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.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
. . . I absolutely agree to the value of learning nursing interventions. That's the fundamental skill set of nursing. The nursing care plan is useful also to a certain degree, but I think that could use some revision. The argument is often made that the nursing diagnosis helps the beginning student understand the nursing process.
I find that most often students understand the nursing process and waste lots of time in a dither over whether or not this vague NANDA dx or that one is correct, and lacking the big picture at that point, are often filled with anxiety about getting a failing grade if they doin't pick the right one.
It adds an extra layer into the care-plan process that seems to me more akin to driving to your destination through a muddy or slushy road, and there is an abundance of nursing history and theory about "who we are and what we do" before and after the NANDA implementation I recall very clearly in it's incipient stages back in the early eighties.
I find lots of people aren't aware that nursing care plans existed before NANDA and since nursing education itself is those interventions and implementations that reflect where we are so far, the addition of a nursing dx that no other discipline understands is very counterproductve. As I've bored people to death with here many times :) our careplans were dynamic, easily accessable and understandable, and could be contributed to by a CNA in some areas he or she would normally be more involved in than would the LPN or RN.
This hospital clearly recognized nursing as a stand alone profession, because the Progress Notes contained notes from the doctors, nurses, CSWs etc on the same page. We used an abbreviated SOAP note format - and for routine notes all concerned would address a problem from the care plan/MD dx the professional judged to be of priority for that shift.
This approach worked well because it meant a greater cohesion (translated meant the doc had a note in his or her face so more likely to read it). The NANDA system made this process obsolete - and took a large chunk of valuable information that could be gleaned from our input into a murky realm most people either laugh at or ignore.
In any other discipline an unworkable idea is promptly jettisoned and/or revamped, but this seems to me almost a sentimental attachment to, because it's original goals were and still are laudable. I can't mock too much because I remember the excitement and fanfare reflected in my nursing journals of the day.
I am confused, is it that you do not like care plans or you do not like NANDA?
Whatever we use we must be able to describe what nursing actions we have taken in order to clarify what nursing really is. Nursing is one of the very few fields in health care that is poorly defined and almost impossible to bill for. We have to be able to prove to the world that we touched this patient, we formed a plan, we acted on that plan, and we are worth the cost.
What insurance company do you know of who even knows what the hell a nursing dx is - let alone be satisfied that it has enough clarity to assign a cash value to? It amounts to a foreign language to them.
Since an overwhelming percentage of providers do not use NANDA for that reason, I am satisfied they know we are doing those things we went to a school to learn and are licensed to do. Requirements for documentation have increased, not decreased, the goal to qualify our roles in greater detail.
Why do we not use medical terms? There lays the foundation of the difference between medicine and nursing.
Docs treat disease, nurses treat people. To clarify this, we are concerned with the patient's reaction to the illness, not necessarilly the illness.
That is not true at all, and unfairly slashes the broad brush across the medical community as a bunch of robot borgs when there are hundreds of thousands of docs who" treat the person". Since almost nobody uses them, does that mean nobody is treating "the whole person"?
They are still used in LTC and in Home Health. As an instructor, I was just having this same discussion with my class today. When I went to school and started nursing, there was no such thing as a nursing diagnosis. When I started a job in 2001 that used them I was lost for a long tim, trying to figure out why the heck we were doing it. Well, it's partly for reimbursement. And for being able to treat the patient in a holistic manner. The nursing diagnoses is supposed to cover the WHOLE patient, just as our care does. In the "olden days" we all went to work and did our best nursing care based on the doctor's diagnosis for that patient. But we were leaving out some imporatant areas of need. Plus that - your idea of best nursing care may have been different than the nurse on the next shift. So there was no continuity.
I work in home health and have never seen a nursing dx anywhere. Our recerts have nursing goals just as in the olden days without a NANDA dx in sight. If I were a doctor I wouldn't want to sign something that had a lot of incomprehensible terminology either.
All NANDA did was assign new verbiage with a distinctly 70s new-agey flair. Most nurses who actually provide the care at the bedside don't use them, they are used in LTCs - but does the rank-and-file see/use the nursing dx? Care plans never making it past the office door aren't being used, whereas the care-plans pre-NANDA were at arms length to anyone interacting with that patient.
The treating the whole patient process is done at the macro level in acute care with from OT, PT, social workers, dieticians etc and the maestro of the whole thing in theory would be a PCP as the hub of the wheel. The development of a specialty residency in Family Practice was done for exactly that reason - as very few docs stop at the GP level anymore.
The dirty little secret that no one wants to talk about....Nursing and Medicine are not "philosophically different". Everyone works together in a team to carry out different and sometimes the same roles in order to get the job done. Nursing is "Holistic" while medicine/PT/Social work/etc.. are not, is BS and deep down everyone knows it.
If everyone spends so much time clammering for ways to look independent because we have a inferiority complex about being a physicians "handmaidens" (this is not the 1960's for crying out loud), we are going to miss the real revolution which is everyone working together in a team for the common good of the patient.
I have a thread up about nursing not being a profession. I used the ridiculousness of Nursing Diagnosis as part of my point. Its like the kid in the playground with coke bottle sized glasses, a horse sized overbite and terrible acne...............nursing diagnosis is just too easy to make fun of. But, don't make fun of them in front of the teacher.
I believe exactly what you said, nursing diagnosis is an attempt to reinvent the wheel. We so badly want to be considered professionals, we were willing to put anything on the plate and call it our "unique body of knowledge". Thus nursing diagnosis came to be. Calling a duck an Anatidae doesn't cut the mustard though (I like my duck with orange sauce anyway).
I have not yet learned what I think our body of knowledge does include, but we can do better than this.
i mentioned this during my exit interview from nursing school, i discussed how nursing dx and care plans seem to have no place in real practice. the lead instructor for my program actually made this exact same argument that you did:
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.
my instructor thinks it's ridiculous that we cannot just call it pneumonia. nobody is saying that we want to be the ones making the initial diagnosis of our patients, that is reserved for the practitioners. however, we all should have a basic functional knowledge of disease processes and their interventions- why do we have to rephrase it it our "own words"?
my instructor told me that evolution of nursing diagnoses were basically just a "hey, look what we can do!" kind of thing. get rid of the damn things, they don't serve any purpose.
OMG YES!! Nursing dx are a pain, they have no real value and are a waste of 75% of your time while in Nursing school. If a pt has COPD, lets just learn how to treat/intervene. Not RE-DIAGNOSE!! Makes no sense to me and I do not care how many instructors tell me "nurses use this everyday", I say BS. The nurses I work with and have talked to ALL say it is only used in school. Waste of my time and money as a student, IMO.
Specializes in Infectious Disease, Neuro, Research.
To you, how do you define nursing? What is the difference between nursing and medicine?
Are we simply Doctor assistants or a stand alone profession with unique goals and interventions?
NANDA was in part developed to unify the nursing language, there are 12 OFFICIAL nursing languages, not including the hundreds of non-approved subset languages. NANDA was ment to unify nursing and all the non-medicine health fields.
The reason why those other specialties do not have their own weird language is becuase they all fall under the nurse's care plan. Every single one of those specialties you pointed out (except the Pharms who are in fact a part of the MD group) are sub-sets and off-shoots of nursing. Every one of those specialties derived from nursing and provide a specialized form of nursing care and in fact fall under the nurse's authority and must abide by the NANDA care plan.
What is the difference between nursing and medicine? Zero. Zip. Zilch. Nada.
Physcian assistant? No. Cohort? Yes.
How should we "be paid"? By analysis of the patient's holistic status within the framework of medicine. If nursing notes can stand in court, supporting the care-pathway authorized by the MD, they should be capable of supporting a medical diagnosis, within a limited framework. How is a GP reimbursed when he/she dxs and treats GI, endo, OB, ORL, onc, etc..? By documenting observations that support their hypothesis. We should be doing the same.
Sound like ARNPs, or "baby docs"? It should.
The problem. It would require higher standards from educational institutions. It would require teaching something more substantial than a relatively modernized version of Galen's "humors". In turn, this would require a more developed faculty, and would also decrease enrollemnt. Ahh, here we come to the central problem.
The AMA, in conjunction with a majority of Universities, does not want to waterdown the provider pathway, with its high level of compensation. Because standards are (comparatively) low, there is an excess of both applicants and graduates in nursing. Great for the employers'. How does the University guarantee it's continued tuition flow? How does the ANA prevent mass revolt? Pushing for an artificial SES barrier- making the tuition for at least the 4 year BSN "The Standard". We won't actually increase the level of practice or (demonstrably) competence, but we will ensure that members continue to meet the financial obligations of membership, and that the Universities/Colleges continue to receive FAFSA and private loan monies.
Whilke I can agree with you in general terms, regarding the "new" professions, they do not fall under nursing authority, or under the "careplan". Each of these professions has its own Board-established standards of care(with attendant outcomes) to which they must adhere. Our careplans are an irrelevance which no one other than nursing (and this, only in the vaguest, most academic sense) must achieve.
Not a nurse speaking here, so feel free to mock and chastise me for not getting it.
I can understand having some tool that prompts the nurse to think about what interventions s/he can take to improve the patient's health, well-being, and overall comfort but a nursing diagnosis doesn't seem to add much value to the process. From this lay person's POV, a nursing diagnosis bears a remarkable similarity to the similarly convoluted and puffed up "Objective Statement" that used to be a mandatory component of a resume. And like those Objective Statements, it seems it's time for the nursing diagnosis to be shown the door and instead just get on with telling folks in straight-forward language what the problems are and how you intend to alleviate them.
Instead of using a nursing diagnoses to determine the interventions needed, why can't nurses just use the findings from their patient assessments and create a care plan from there without trying to combine all the problems identified into a nursing dx? If the nurse's assessment finds that a patient is having trouble maintaining their O2 sat above 85 percent on room air, say that and then note what your plan is to address the problem.
Specializes in Infectious Disease, Neuro, Research.
Getting more into some of the previous posts, what you suggest hipcrip, is exactly right. The problem is billing; sepcifically, that if "other people" are able to make medical judgements, on even a limited scale, it decreases the volume of billable evals for the MD, hence the opposition from the AMA.
Granted, I'm suggesting significantly higher thinking for the "average" RN. This is the root of much of the discord between RN/LPN/CNA/CMAs. Currently, we do nothing that any CMA, CNA or LPN, of comparable intelligence (soooo discriminatory, I know!) is incapable of doing. Because the decisional capabilities of the individuals within nursing are so nebulous and ill-defined, it has led to the convoluted system we have. Nursing is direct care- assess the need, address the issue. It has become a check-box administration, middleman (-woman) managerial position.
The ANA cannot effectively out-lobby the AMA, so they are left with defining the profession by (artificial)economic measures.
The practical difference between a medical diagnosis and the findings of a nursing assessment are purely in the differential diagnosis, as taught to med students. In immediate interventional processes, the primary dx will make little difference. Severe sprain or non-displaced fracture(of the ankle, we'll say)? In either case you neuro-check, immobilize in position of comfort, assess vitals and complete secondary survey.
"Impaired LE mobility pursuant to kicking boyfriend" is burdensome irrelevance.
Dx (or in the case of nursing/EMS: "Rule Out/") :
1) Sprain
2) Non-displaced fx
3) Spontaneously reduced joint dislocation
Interestingly enough, since this differential process is what teaching hospitals use with residents, it could be argued that, with appropriate QA/QI measures in place, it would increase the level of care delivered by physcians as well as nurses.
If any of us were called to validate our individual opinion of which of the 3 listed dxs was appropriate, it would cause more careful evaluation of both the patient and our own decisional processes. No one likes to look foolish, and sharp minds in modest competition become sharper.
It is also far more standardized and reductionist, using differentials, than NANDA.
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.
besides we cannot bill for dx asthma.
you've got to be kidding!?! i just took (and passed) nclex. guess what? not one nursing dx, but plenty of medical dx and disease. no one is interested in disease without respect to the patient's response to it. the interventions of nanda are great, but should be linked to something real, like a medical dx. nursing dx is crap. those who insist on the importance of nursing dx are, in reality, trying to insist on their own importance. "see doc, i can make a diagnosis too! you're no better than i am." most of us know that we are medical professionals, just not physicians. pharm, pt, ot, respiratory and nursing are all medical professions with different foci. we work in the medical field. as nurses we handle medical conditions (not nursing conditions) from a nursing standpoint. if you're in the hospital, you have a medical problem of some kind, be it physical or mental. yes, we are holistic in our approach to the patient, but some in nursing are somewhat silly in their approach to the profession.
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...
Working my way through this thread, I have to respond to this with a resounding "Why?" If, as nursing leaders so adamantly declare, a plan of care is crucial, why do we not have time to work on them? If our patient load was such that we could only get some of our meds passed, someone, somewhere, would surely think something needed to be done about it. Probably delegate it to lower paid staff or robots, but something. At my facility, we do have clinical pathways for some medical Dx that amount to pre-fabricated care plans. Most of us rarely have time to look them up, and about half the interventions are medical, anyway. We are also required to initiate goals every dayshift and evaluate them on nightshift. More than once, I have followed one of the best, and best-educated nurses on my floor and evaluated her goal, "safety" on each patient. And too often, I'm doing this evaluation at 0830, because I didn't have time to mess with it, either. Either she or I could have done a better job, but we were too busy keeping people from climbing over the bedrails, taking them to the bathroom, crushing their meds in pudding, and a lot of other interventions that clearly relate to nursing Dx and careplans we don't have time to write.
There have been numerous threads on the dichotomy between professional/academic/theoretical nursing and the real world of actual nursing practice. I'm pretty firmly on the side of the real world, because if we don't do these things, who will? I do a lot more than wipe butts, but it's a rare shift that someone's butt doesn't need wiped and I'm right there, and the person whose butt needs wiped often considers it a fairly high priority. I can't help empathizing with someone in such straits that they need someone to wipe their butt for them, and, of course, it's more fun than charting.
I agree that nursing Dx may have some value as an educational tool. I find them less relevant in nursing practice, although I have to admit there have been a few times being familiar with them has helped me form a plan of care that I have implemented without being able to write. A lot of my pt population is awaiting a medical Dx, but still needs nursing care. A few times, recognizing that a patient may, say, be having anticipatory grieving (actually, family of the patient) has helped me to get some ideas of how to deal with it, and to communicate in report that the family wasn't merely "nuts." Falls have been a big problem on our floor and we assess fall risk on every patient, then implement strategies to prevent them. It would be interesting to know how many falls occur while the nurse is charting. It would be about impossible to measure how many falls did not occur because the nurse was in the room instead of taking time to write more than "safety."
Specializes in Peds/outpatient FP,derm,allergy/private duty.
Another thing to think about is related to the times we are in -- at least in my area the economy and job market are still fighting to keep ground. Is it fair to students to add one unneccesary dollar to their eventual debt burden by hanging on to things of such dubious value?
As a result of the market and other forces it looks like the BSN entry point is becoming a defacto reality, which will put people of limited resources in a precarious position already, I think there is an ethical obligation to take a hard look at what we are mandating people add personal and financial stress to learn, when in the past the demand would counteract the more effluvious coursework.
nursel56
7,122 Posts
I find that most often students understand the nursing process and waste lots of time in a dither over whether or not this vague NANDA dx or that one is correct, and lacking the big picture at that point, are often filled with anxiety about getting a failing grade if they doin't pick the right one.
It adds an extra layer into the care-plan process that seems to me more akin to driving to your destination through a muddy or slushy road, and there is an abundance of nursing history and theory about "who we are and what we do" before and after the NANDA implementation I recall very clearly in it's incipient stages back in the early eighties.
I find lots of people aren't aware that nursing care plans existed before NANDA and since nursing education itself is those interventions and implementations that reflect where we are so far, the addition of a nursing dx that no other discipline understands is very counterproductve. As I've bored people to death with here many times :) our careplans were dynamic, easily accessable and understandable, and could be contributed to by a CNA in some areas he or she would normally be more involved in than would the LPN or RN.
This hospital clearly recognized nursing as a stand alone profession, because the Progress Notes contained notes from the doctors, nurses, CSWs etc on the same page. We used an abbreviated SOAP note format - and for routine notes all concerned would address a problem from the care plan/MD dx the professional judged to be of priority for that shift.
This approach worked well because it meant a greater cohesion (translated meant the doc had a note in his or her face so more likely to read it). The NANDA system made this process obsolete - and took a large chunk of valuable information that could be gleaned from our input into a murky realm most people either laugh at or ignore.
In any other discipline an unworkable idea is promptly jettisoned and/or revamped, but this seems to me almost a sentimental attachment to, because it's original goals were and still are laudable. I can't mock too much because I remember the excitement and fanfare reflected in my nursing journals of the day.
What insurance company do you know of who even knows what the hell a nursing dx is - let alone be satisfied that it has enough clarity to assign a cash value to? It amounts to a foreign language to them.
Since an overwhelming percentage of providers do not use NANDA for that reason, I am satisfied they know we are doing those things we went to a school to learn and are licensed to do. Requirements for documentation have increased, not decreased, the goal to qualify our roles in greater detail.
That is not true at all, and unfairly slashes the broad brush across the medical community as a bunch of robot borgs when there are hundreds of thousands of docs who" treat the person". Since almost nobody uses them, does that mean nobody is treating "the whole person"?
I work in home health and have never seen a nursing dx anywhere. Our recerts have nursing goals just as in the olden days without a NANDA dx in sight. If I were a doctor I wouldn't want to sign something that had a lot of incomprehensible terminology either.
All NANDA did was assign new verbiage with a distinctly 70s new-agey flair. Most nurses who actually provide the care at the bedside don't use them, they are used in LTCs - but does the rank-and-file see/use the nursing dx? Care plans never making it past the office door aren't being used, whereas the care-plans pre-NANDA were at arms length to anyone interacting with that patient.
The treating the whole patient process is done at the macro level in acute care with from OT, PT, social workers, dieticians etc and the maestro of the whole thing in theory would be a PCP as the hub of the wheel. The development of a specialty residency in Family Practice was done for exactly that reason - as very few docs stop at the GP level anymore.