i've been an adn for 16 years. recently, i finished my bsn and now am through my first year of a dnp program. like most students, i struggled with learning to understand a nursing diagnosis during my adn schooling. since that time the term has cropped up in various situations but usually as a passing comment. it has in no way benefitted my practice as a nurse. in fact, when i bring up the subject with colleagues i often get a smirk or an eye-roll!
the subject of nursing diagnoses happened to come up in one of my grad school classes the other day. i decided to take a stab at this sacred cow and suggest that maybe they are burdensome and irrelevant to a working nurse that they simply aren't utilized. my professor's response was a textbook explanation that i've only heard repeated on a college campus. "if you say your patient has pneumonia, you are using a medical diagnosis which is outside your scope of nursing practice. you must have a nursing diagnosis to be able to implement and evaluate your interventions." i may be wrong, but i'm pretty sure i've been able to implement and evaluate my nursing interventions without needing a nursing diagnosis.
personally, i believe the idea for a nursing diagnosis comes from the ongoing and hard-won independence from the thumb of the medical community. i am all for the continued growth of nursing science. however, on this point we overshot the mark. there is simply no justifiable rationale for calling pneumonia something like
"impaired gas exchange related to effects of alveolar-capillary membrane changes. or
ineffective airway clearance related to effects of infection, excessive tracheobronchial secretions, fatigue and decreased energy, chest discomfort and muscle weakness. "
why not just say the patient has pneumonia? because it a medical diagnosis and we don't practice medicine? baloney! its a pathologic condition. call it what it is. we dont need to reinvent the wheel.
why do we hang on to this? we need to eject it from nursing and maybe realize we don't use it like we thought we would. a lot of time and energy is wasted on this topic in nursing programs that could be better spent elsewhere.
I agree with thr Op. Nursing diagnosis is not significant as most nurses get by without it.
Not to talk about fitting numerous diseases to just 99 standard Nanda chosen diagnosis. Ineffective airway clearance and impaired gas exchange could be for any airway disease or ailment but asthma is asthma anywhere to the doctor. Why do we have to make it harder on ourselves.
Wow. That's interesting. Perhaps, historically, nursing had performed say physical therapy functions. However, I can assure you that they would reject the idea that they fall under our authority or for that matter even know what a NANDA care plan is. Yeah, sorry, I can't swallow that one. Each of those specialties have their own governing boards/licensure and practice with more autonomy than we do.
Nursing is a stand alone profession. We are developing our own body of science with our own research. We are beginning to prove our economic value to healthcare too. As you know, Medicare will no longer pay for hospital acquired infections. At our hospital, nursing led an initiative to dramatically reduce catheter-acquired UTIs by 40% with only nursing interventions--no doctor orders. This means saving DRG money for the hospital.
They would reject that idea, sure. In reality though we delegate to those specialties, not the other way around. Remember that we are the patient's advocate, no other profession can say the same.
You have not answered my question, "What is the difference between nursing and medicine?"
What would you have NANDA replaced with? Give me an example of how a careplan would be designed, or would those go away too?
Doesn't matter if we contribute or not, if we cannot prove our contribution and bill for it we are toast.
You don't like NANDA, fine, then provide an alternative!
I agree with thr Op. Nursing diagnosis is not significant as most nurses get by without it.
Not to talk about fitting numerous diseases to just 99 standard Nanda chosen diagnosis. Ineffective airway clearance and impaired gas exchange could be for any airway disease or ailment but asthma is asthma anywhere to the doctor. Why do we have to make it harder on ourselves.
Because we (theoretically) are not concerned with the actual disease but the patient's response to it. Subtle but significant difference. In addition to that the NANDA diagnosis are supposed to provide the basic interventions that accompany the Dx in a holistic fashion.
Did she mention how she would resolve the problem of differentiating nursing from medicine, how to articulate nursing tasks in a billable manner, unify the nursing language, or guide interventions?
Can't just say "she said it was bad" without endulging us with her resolutions. If not NANDA then what?
BTW Benner, although an esteemed theorist, is slightly controversial and while a leading educator is certainly not the foremost...giving a little too much credit me thinks.
Nursing Practice by definition does not fit well into an ICD code type system. This is because, unlike Medicine, we don't place patients into one-size-fits-all categories, we see patients as a complex mix of various factors that affect their overall health. Where we went wrong, was thinking that what we should do is redefine Nursing as a practice which also places patients into broad categories, even broader than Medical Diagnoses, effectively trading what makes Nursing so important so we can be more like Doctors. It is true that providing a foundation for a billing structure was one of the purposes of NANDA, although I have no idea how you would bill for "impaired tissue perfusion" given the exceedingly wide variety of interventions and activities that could include. So how can we bill? Simple; by the hour. Hourly billing has been shown to be most effective and fair way of billing for healthcare and is hopefully the direction CMS will continue to move towards for Doctors in the future.
In terms of guiding interventions, NANDA does not guide interventions. NIC and NOC existed for quite some time before attempts were made to tie NIC/NOC to NANDA. Take "impaired tissue perfusion" for instance. This is the NANDA description for an MI, a stroke, PAD, diabetic neuropathy, hypertension, hypotension, raynauds, the list goes on and on. Because of this, the NANDA/NIC/NOC care planning guide I used in Nursing School gives you over 150 NIC's and over 1000 associated activities. This is why, to be useful, you need to start with the specific Medical condition involved, making the NANDA step of the process completely useless.
I agree that the field and practice of Nursing is difficult to explain to the general public, although NANDA does not in any way help to clarify what we do to the general public, it's barely understood by Nurses.
Both CMS and the Joint Commission are opposed to NANDA and for a very good reason. The single largest factor that impairs patient safety is communication barriers. As nurses, using a language which is intentionally meant to be different than that used by other members of the trans-disciplinary care team should be considered criminal and is an embarrassment to a profession that claims to support patient safety.
In terms of if not NANDA, then what; Medical Diagnoses, patient specific problem statements, and NIC/NOC.
Who would you say is the foremost Nursing educator. I'd say Linda Aiken a close second in terms of being well known, although I'd say Benner is more respected. I don't think I could do her book justice with a simple summary, but it's well worth the read if you're interested. Essentially, basing one's view of patient care on a broad generalizations does not benefit learning or practice, and essentially has to be unlearned in order to progress in your practice.
They would reject that idea, sure. In reality though we delegate to those specialties, not the other way around. Remember that we are the patient's advocate, no other profession can say the same.
You have not answered my question, "What is the difference between nursing and medicine?"
What would you have NANDA replaced with? Give me an example of how a careplan would be designed, or would those go away too?
Doesn't matter if we contribute or not, if we cannot prove our contribution and bill for it we are toast.
You don't like NANDA, fine, then provide an alternative!
We didn't use NANDA in our care plans in my nursing program, care plans work fine without them and actually even better.
"They would reject that idea, sure. In reality though we delegate to those specialties, not the other way around. Remember that we are the patient's advocate, no other profession can say the same.
You have not answered my question, "What is the difference between nursing and medicine?"
What would you have NANDA replaced with? Give me an example of how a careplan would be designed, or would those go away too?
Doesn't matter if we contribute or not, if we cannot prove our contribution and bill for it we are toast.
You don't like NANDA, fine, then provide an alternative"
I actually do not delegate to other specialties. They receive a doctor's order to initiate their interventions with the patient. As a nurse, I parallel their care, not above or below. Our practices are independent of each other.
The differences between nursing and medicine are extensive and do not in any way hinge on NANDA. We did not differentiate from medicine with the advent of NANDA.
As I've said, the careplan is useful. It's not that difficult to imagine one without a nursing diagnosis as that is in fact the case in the working world of nursing. Again, it has been pointed out repeatedly on this thread that they simply aren't relevant to a nurses' practice.
As for billing, I admit I'm lost and probably ingorant here. Who exactly am I billing for my services? It's my understanding that my hospital receives a set amount based on ICD-9/DRG codes. My economic value is in assisting that patient to recover as quickly as possible with zero complications to minimize cost and keep as much of the DRG money as possible. As far as I know, there is no separate billing for nursing services. Am I wrong?
I just read a book called 'Nursing against the odds' Wonderful book that i believe every new grad should read... anyway i digress.... In the said book, they author addressed Nursing diagnoses...
Her approach made me really think....
She said, that Nursing diagnosis actually do the Nursing profession a disfavor because:
1. Other members of the health care team think its ridiculous and they don't want to bother trying to navigate through all the useless fluff to arrive at the fact that the pt has Asthma. (whereas MD/PT/OT notes are consise and to the point for easy navigation)
2. Said fluff is time consuming and obsolete...
3. Its ridiculous that nurses with an extensive amount of knowledge to know that it is asthma (plus have taken countless classes on bio/anatomy/patho/micro ad nauseum) have to go round and round and round in an effort to say that its asthma....
Wow. That's interesting. Perhaps, historically, nursing had performed say physical therapy functions. However, I can assure you that they would reject the idea that they fall under our authority or for that matter even know what a NANDA care plan is. Yeah, sorry, I can't swallow that one. Each of those specialties have their own governing boards/licensure and practice with more autonomy than we do.
Nursing is a stand alone profession. We are developing our own body of science with our own research. We are beginning to prove our economic value to healthcare too. As you know, Medicare will no longer pay for hospital acquired infections. At our hospital, nursing led an initiative to dramatically reduce catheter-acquired UTIs by 40% with only nursing interventions--no doctor orders. This means saving DRG money for the hospital.
They would reject that idea, sure. In reality though we delegate to those specialties, not the other way around. Remember that we are the patient's advocate, no other profession can say the same.
You have not answered my question, "What is the difference between nursing and medicine?"
What would you have NANDA replaced with? Give me an example of how a careplan would be designed, or would those go away too?
Doesn't matter if we contribute or not, if we cannot prove our contribution and bill for it we are toast.
You don't like NANDA, fine, then provide an alternative!
"They would reject that idea, sure. In reality though we delegate to those specialties, not the other way around. Remember that we are the patient's advocate, no other profession can say the same.
You have not answered my question, "What is the difference between nursing and medicine?"
What would you have NANDA replaced with? Give me an example of how a careplan would be designed, or would those go away too?
Doesn't matter if we contribute or not, if we cannot prove our contribution and bill for it we are toast.
You don't like NANDA, fine, then provide an alternative"
I actually do not delegate to other specialties. They receive a doctor's order to initiate their interventions with the patient. As a nurse, I parallel their care, not above or below. Our practices are independent of each other.
The differences between nursing and medicine are extensive and do not in any way hinge on NANDA. We did not differentiate from medicine with the advent of NANDA.
As I've said, the careplan is useful. It's not that difficult to imagine one without a nursing diagnosis as that is in fact the case in the working world of nursing. Again, it has been pointed out repeatedly on this thread that they simply aren't relevant to a nurses' practice.
As for billing, I admit I'm lost and probably ingorant here. Who exactly am I billing for my services? It's my understanding that my hospital receives a set amount based on ICD-9/DRG codes. My economic value is in assisting that patient to recover as quickly as possible with zero complications to minimize cost and keep as much of the DRG money as possible. As far as I know, there is no separate billing for nursing services. Am I wrong?
I was typing a long post about this very thing. Those allied healthcare professionals (such as PT/OT) receive a physician's order to initiate their services, not a nurse's order. I have yet to hear of a PT or OT initiate care to a patient based solely on an order from a Nurse. I would actually expect that such an order would be effectively ignored as an invalid order. If I were a PT or an OT, I wouldn't put my own License at risk...
I just read a book called 'Nursing against the odds' Wonderful book that i believe every new grad should read... anyway i digress.... In the said book, they author addressed Nursing diagnoses...
Her approach made me really think....
She said, that Nursing diagnosis actually do the Nursing profession a disfavor because:
1. Other members of the health care team think its ridiculous and they don't want to bother trying to navigate through all the useless fluff to arrive at the fact that the pt has Asthma. (whereas MD/PT/OT notes are consise and to the point for easy navigation)
2. Said fluff is time consuming and obsolete...
3. Its ridiculous that nurses with an extensive amount of knowledge to know that it is asthma (plus have taken countless classes on bio/anatomy/patho/micro ad nauseum) have to go round and round and round in an effort to say that its asthma....
People have spoken a lot about care plans in addition to diagnoses. What does a care plan really do other than take time away from actually providing care?
Do nurses really get out of report, and say: "Let me read my patient's plan of care before I take another step?" If so, you have much more leisure than I've ever had on a given shift...
People have spoken a lot about care plans in addition to diagnoses. What does a care plan really do other than take time away from actually providing care?
Do nurses really get out of report, and say: "Let me read my patient's plan of care before I take another step?" If so, you have much more leisure than I've ever had on a given shift...
To put it simply...without care plans, you won't get paid.
honeykrown, MSN, NP
385 Posts
I agree with thr Op. Nursing diagnosis is not significant as most nurses get by without it.
Not to talk about fitting numerous diseases to just 99 standard Nanda chosen diagnosis. Ineffective airway clearance and impaired gas exchange could be for any airway disease or ailment but asthma is asthma anywhere to the doctor. Why do we have to make it harder on ourselves.