Truth about Nursing diagnosis

VickyRN, MSN, DNP, RN · Oct 28, 2004

A gentle reminder to keep to the subject at hand and avoid personal attacks. it is perfectly fine to disagree, but do so without attacking on a professional or personal basis.

been there · Oct 28, 2004

vickyrn said:

A gentle reminder to keep to the subject at hand and avoid personal attacks. it is perfectly fine to disagree, but do so without attacking on a professional or personal basis.

I apologize if it seemed I made a personal attack on anyone. it was not intended but, reading my post again, it does read as if I did. I truly am sorry for the misunderstanding and hope the reader will forgive me. thank you for bringing this to my attention.

Dixielee, BSN, RN · Oct 29, 2004

Darn, guess I was attacked and missed it. I'd better pay closer attention!

girlfromtx · Oct 29, 2004

hyperstudent said:

Amen! I just finished 8 weeks of my second medical surgical rotation. The hosital was wonderful, the nurses were as helpful as they could be, and I learned a great deal about patient care. BUT today I learned I only earned an 89 in the class because, as my clinical instructor said, "I know you can do better work on your care plans!" Crap, isn't nursing, the actual hands on interaction with a real live patient more important than the fact that my client goal was too wordy, or not wordy enough??? The last 8 weeks the clinical instructor loved my client goals. The grading is so, so, so, subjective.
There were students not doing a dang thing, no patient interaction, no critical thinking, no running around trying to see and do every skill possible, yet they can write (or copy) a care plan so they deserve a higher grade????

O.K. I am finished blowing off steam. Onward and upward.

that is how I'm feeling right now! My Care Plans are decent, but I'm getting slammed on them. Yet you take other members of my clinical group that can't even take a manual blood pressure, are sitting on their butts, with hardly any client contact, but are loved by the prof. b/c apparently they know what they are doing simply because of their Care Plan! :angryfire

It's amazing I saw this post b/c this has been bugging me since day one.

mamabear · Oct 29, 2004

A few thoughts:

The other day, I met a member of my RN graduating class and we talked about this very thing (mind you, this was back in the day of glass I.V. bottles, all white uniforms, etc.: 1982 :rolleyes: ). Neither of us could recall any mention made of nursing diagnoses, but we both groaned over the killer-attack care plans we were required to write. I'm talking 5-6 pages, type-written.

Somebody mentioned in an earlier post something about MD care plans. I don't mean to be flippant, but I didn't realize such a thing existed. Is it different for psych?

The care plans we RNs are required to do are a joke! It's all on the computer and we have 3 problems from which to choose: altered thought processes, ineffective coping, and potential for harm to self or others. I think it's rather lame, but, where I work, you don't dare rock the boat.

magicman · Oct 29, 2004

I agree with you totally. We don't use the formal format that we agonizingly learned in school in the real world. We did, however, learn by using the format. I'm upset about this issue because I sense an underlying resentment against learning them in these posts and having them touted as "useless and a waste of time". It is well known that you improve with practice. Our care plans must differ from MD care plans because we take care of the patient in OUR area of expertise. It is no less important than an MD "plan". There are many older experienced nurses in teaching hospitals who have had to inform the MD of what a patient may benefit from, or has had to remind that MD that the patient has had adverse effects from a procedure or medication years ago simply because that MD didn't ask or , as happens in the real world, doesn't spend but a few minutes with a patient. We are the guardians of our patients' health and welfare and we must have the basic knowledge of knowing what should be done because of what is happening to him/her. It is tiring and cumbersome but so is working an extra shift when all hell has broken loose that day. Every facility or organization that hires nurses have different forms and requirements for us. The higher we go in management the more responsible we are for what those we supervise do. For me, I would prefer a nurse who gripes about doing care plans but does them anyway, and with thought added to the process. "Bring toys from home" for children may seem stupid but think about it. I always forgot this intervention in school.

First, I think the resentment comes more from the fact that CP's, while serving a VERY useful purpose in school, serve no REAL purpose in the "real world" as they are structured today. As an example, have you ever used "Energy Field Disturbance" in a CP? It could, realistically, cover EVERY possible thing that could be wrong with a patient if you think about it.

Second, ND's and CP's were developed to give nursing a "separate body of knowlege" and "a language all our own". Now, while I agree nursing DOES have a specific realm of influence and specific body of knowlege, was this truly the BEST way of proving it? I liken it to doing proofs and theorems in Algebra. They aren't fun, but they do make you think about the steps involved in an equation and teach you logical thinking, etc. BUT, you don't USE them in the real world unless you're in a field of research. CP's might very well work great in a teaching environment so the student can learn critical thinking and what he/she needs to be aware of with certain medical diagnoses, but what purpose do they serve in the "real world"? Again, I challenge anyone to prove they are a better picture of the patient than the rest of the medical record. They are written in such archane language with so many long winded medical deifnitions that NO ONE reads them except nursing. Is that the point? To make them so cryptic to anyone else that ONLY nursing uses them? Is that not a waste of resources and time? You speak of them being tiring and cumbersome.......why should they need to be? And while I agree we are the "guardians of our patients health and welfare", and that we "must have the basic knowledge of knowing what should be done because of what is happening to him/her", what does writing the long definition of a medical diagnosis have to do with that? In school, yes, it is imperative we learn what the medical diagnosis means and what the possibilities are for our plan of care. Once you HAVE that knowlege, as a professional, what is the purpose of writing it all out again? Who are we trying to impress or prove that we have the knowlege? As a licensed professional and a graduate of an accredited school of nursing, does THAT not prove we have the knowlege in and of itself (medico-legal, law suits, etc. asside).

Last but not least, you state "Every facility or organization that hires nurses have different forms and requirements for us.". Since when does a profession NEED a facility or organization to make their paperwork for them? We are licensed to practice nursing jsut as a physician is licensed to practice medicine. That means we can work independently and not FOR anyone but the patient. That would mean the profession should set up our own requirements for documentation, not the company who hires us. Once again, we (nursing) becomes subservient to another for our existence. We aquiess and give away what others worked so hard to achieve -- the independence and acknlowlegement of nursing as a profession.

been there · Oct 29, 2004

First, I think the resentment comes more from the fact that CP's, while serving a VERY useful purpose in school, serve no REAL purpose in the "real world" as they are structured today. As an example, have you ever used "Energy Field Disturbance" in a CP? It could, realistically, cover EVERY possible thing that could be wrong with a patient if you think about it.
Second, ND's and CP's were developed to give nursing a "separate body of knowlege" and "a language all our own". Now, while I agree nursing DOES have a specific realm of influence and specific body of knowlege, was this truly the BEST way of proving it? I liken it to doing proofs and theorems in Algebra. They aren't fun, but they do make you think about the steps involved in an equation and teach you logical thinking, etc. BUT, you don't USE them in the real world unless you're in a field of research. CP's might very well work great in a teaching environment so the student can learn critical thinking and what he/she needs to be aware of with certain medical diagnoses, but what purpose do they serve in the "real world"? Again, I challenge anyone to prove they are a better picture of the patient than the rest of the medical record. They are written in such archane language with so many long winded medical deifnitions that NO ONE reads them except nursing. Is that the point? To make them so cryptic to anyone else that ONLY nursing uses them? Is that not a waste of resources and time? You speak of them being tiring and cumbersome.......why should they need to be? And while I agree we are the "guardians of our patients health and welfare", and that we "must have the basic knowledge of knowing what should be done because of what is happening to him/her", what does writing the long definition of a medical diagnosis have to do with that? In school, yes, it is imperative we learn what the medical diagnosis means and what the possibilities are for our plan of care. Once you HAVE that knowlege, as a professional, what is the purpose of writing it all out again? Who are we trying to impress or prove that we have the knowlege? As a licensed professional and a graduate of an accredited school of nursing, does THAT not prove we have the knowlege in and of itself (medico-legal, law suits, etc. asside).
Last but not least, you state "Every facility or organization that hires nurses have different forms and requirements for us.". Since when does a profession NEED a facility or organization to make their paperwork for them? We are licensed to practice nursing jsut as a physician is licensed to practice medicine. That means we can work independently and not FOR anyone but the patient. That would mean the profession should set up our own requirements for documentation, not the company who hires us. Once again, we (nursing) becomes subservient to another for our existence. We aquiess and give away what others worked so hard to achieve -- the independence and acknlowlegement of nursing as a profession.

Bravo and well said. You got my point across better than I did! Yes, we learn from doing CPs and, I agree, why should we continue to have to use them in the "formal" language? We do spend extra time writing "Alteration in metabolism r/t inability to effectively use natural insulin production" when we admit a diabetic. I would prefer to state "Patient is diabetic, not controlled with BID PO Glucophage 1000mg" This is straight, to the point, and anyone completely understands the problem. Medicare, JACHO, etc., etc., as nauseum seem to believe that if we don't put any ND down on paper then we must not have known about the problem. Putting it down, creating interventions, documenting the patient's response to the interventions, notifying the MD of issues not only protects our licenses, if it comes to that point, but lets others know what has already been addressed. I agree. I too am a graduate of an accredited school of nursing and expect to be accepted as having a brain. I did state that going to a supervisor might help. In some areas where I have worked we were able to change the paperwork to fit our needs and I have yet to use a formal ND when I wrote care plans. I agree with the entire situation but we use them as tools only for learning. Maybe we need to approach the nursing boards with this issue since the boards have decided that they are the "accepted" nursing diagnoses ???? I am glad to be able to discuss this with others outside my little town !! GO NURSES !!

Drysolong · Oct 30, 2004

I'm an inexperienced nursing student, but in my estimation, the discussion of the pros and cons of CP's resemble the discussion between an experienced cook who disdains cookbooks and written recipes and a novice who is trying to learn how to cook and become experienced. The experienced cook will claim that they don't use a recipe, but if you ask them how to cook something, they give you ingredients and instructions. (a recipe):)

been there · Oct 30, 2004

I'm an inexperienced nursing student, but in my estimation, the discussion of the pros and cons of CP's resemble the discussion between an experienced cook who disdains cookbooks and written recipes and a novice who is trying to learn how to cook and become experienced. The experienced cook will claim that they don't use a recipe, but if you ask them how to cook something, they give you ingredients and instructions. (a recipe):)

You are so cool ! The real problem is simple. As students we had to choose 3 patients each at 3:00 pm with as many tubes in them that we could find . Then we had to review the charts and MARs, go home and write either 7 problems with 10 interventions for each problem,(or 10 with 7, can't recall). By midnight we were probably finished, had to turn them in to our instructor at 6:30 am for "editing" before we went on the floor. The MDs tied up the charts when they made rounds and we had to wait to complete our documentation which made us late starting patient care or late to post-clinical meetings. As a working nurse with as many as 35 patients, all with tubes everywhere, there is no time to sit and write even 2 problems/2 interventions on each patient. This is the issue. The time it takes to document versus the the time to care for a large number of patients with tubes, machines, emotional needs and families with the loss of support personnel exceeds the shift time. Add this to the stress of having seriously ill patients staying 2 or 3 days before they are sent home, still ill ( because of the DRGs) and you don't know whether your care (of machines) made a difference in their outcome. If one works in ICU one can't tie up much time charting. Many studies have been made on nurse documentation. The time can take as much as a quarter, or more, of the shift. I'm glad you younger nurses are starting to question why trained nurses don't " seem to have a brain" nor can seemingly be "trusted to do what needs to be done". I don't think it is mistrust. It is proof that the nurse knew the problems and knew the interventions, in the nurse realm, that were done. You've heard "If you didn't document it you didn't do it". I recall when a nurse had to give up her chair and stand when an MD entered the nurses' station and I've seen many changes in nursing. Maybe it is time for another one. In spite of documentation requirements we still put our patients first. We are nurses. Stay in nursing forever. You will experience wonderful things that outweigh the bad ones. No other career can match ours.

MicahSmithRN · Apr 22, 2010

Well as tedious as they are, like it or not, the nursing diagnosis is what makes nursing a profession. No they are not used in real life AS MUCH as nursing school (just like care-plans/maps) but they are important to teach people off the street how to think like a nurse. NANDA legitimized nursing in many ways. However, even NANDA will tell you on their website statement that they will not provide a list of nursing diagnosis because it limits the nursing process by narrowing interpretation.

http://www.nursing-care-plans-911.com

occhealthforever · Apr 24, 2010

Nursing diagnoses are a crock. Care plans the same. Critical thinking! What the H. I am an occ health nurse and have never and hope never to have to use one. My critical thinking stems from the immediate needs of my pt. If you fell off a 40 foot scaffold I sure do not need a care plan.

talaxandra · Apr 24, 2010

well as tedious as they are, like it or not, the nursing diagnosis is what makes nursing a profession.

whether nursing is considered a profession or not depends on the definition being used. nursing meets, for example, the requirements listed by bullock & trombley (the new fontana dictionary of modern thought, london: harper-collins, 1999, p.689); they state that trades and occupations become professionals when they develop or require "formal qualifications based upon education, apprenticeship, and examinations, the emergence of regulatory bodies with powers to admit and discipline members, and some degree of monopoly rights" (source: curry guide).

other authors, however, have more extensive requirements, which separate trades from professions more cleanly. while nursing is certainly regulated, requires specialist knowledge and skill, has professional associations and extensive education, ongoing education requirements, examinations required prior to admission by the organisation, codes of conduct and ethics, licensing and self-regulation, legal recognisition and monopoly, and mobility, all of which some scholars in professionalism describe as attributes of professions, we fall short in several key areas. these include, but are not limited to: being accorded high status, high financial recompense, being in control of remuneration for members, and professional autonomy.

this is obviously a contentious issue. two articles that i think are particularly interesting are brown, knight & patel's 1987 but still relevant journal paper, and andrew heenan's more recent discussion on the topic.

i believe nursing diagnoses are a great way for students and novice nurses to hone their critical thinking skills. however, if we use the first set of criteria listed above to define what constitiutes a profession then nursing has been a profession, at least in some countries, for the better part of a century. if we use the latter, it may never achieve professional status. in either case, i contend that nursing diagnoses are not what has or will tip us from one classification to the other.