What's your diagnosis?

Nursing, Jan 2000 by Christensen, Robert A, Taylor, Cynthia M

ARE YOU FOR OR AGAINST NURSING DIAGNOSIS?

ONE OF THESE NURSES' OPINIONS MIGHT CHANGE YOUR MIND.

Taking a stop backward

BY ROBERTA. CHRISTENSEN, RN

Many years ago, nursing leaders and educators developed the concept of nursing diagnosis and instituted it nationally. When I was in nursing school, I learned that nursing diagnosis was important for planning patient care and would differentiate nursing from medicine because it incorporated a body of knowledge unique to the nursing profession.

During my career as a practicing nurse, I've discovered that nursing diagnosis neither helps in care planning nor in differentiating nursing from medicine. In fact, it's a giant step backward in the history of nursing.

BLURRING OUR PURPOSE

Members of a profession are involved in maintaining the profession's standards and usually a forum exists for input on needed changes. I believe direct caregivers should be asked the following questions:

* Does nursing diagnosis help you provide better patient care?

* Does nursing diagnosis help you focus your patient care plan?

* Is nursing diagnosis an efficient use of your time as a bedside nurse?

* Do you believe that nursing diagnosis benefits or harms the nursing profession?

No profession has a body of knowledge unique to itself. Nursing knowledge comes from various disciplines: nursing, medicine, psychology, sociology, and religion, to name a few. Nursing diagnosis eradicates all forms of medically oriented concerns and misrepresents the definition of nursing and what nurses really do for patients.

As a critical care nurse, I find that the American Association of Critical-Care Nurses' definition of critical care nursing accurately reflects what I do for patients: "Critical care nursing practice is a dynamic process, the scope of which is defined in terms of the critically ill patient, the critical care nurse, and the environment in which critical care nursing is delivered; all three components are essential for the practice of critical care nursing. The critically ill patient is characterized by the presence of real or potential lifethreatening health problems and by the requirement for continuous observation and intervention to prevent complications and restore health."

Most nursing diagnoses emphasize psychosocial concerns, such as anxiety, inability to cope, fear, hopelessness, high risk of injury, noncompliance, posttrauma response, low self-esteem, spiritual distress, and potential for violence. I agree that we must take into consideration these concerns with all our patients, but the range of nursing diagnosis issues doesn't reflect what we really do.

Each nursing unit has its own focus based on the kind of patient population it serves. Nursing diagnosis ignores the special focus of each unit and, thereby, makes itself marginal in importance to the nurses. The more acute the clinical setting becomes, the less nursing diagnosis reflects what those nurses really do.

Strikingly, the medical aspects of what nurses do have been left out of nursing diagnosis, but the psychological and sociological aspects remain heavily represented. Why exclude the discipline most closely related to nursing (medicine) but include disciplines (such as psychology and sociology) that play an important but decidedly less prominent role in what nurses really do for patients in most hospitals? Why choose the medical term "diagnosis" when the practice of medicine doesn't exist in nursing diagnosis? In our unit, nurses are prepared to do many things traditionally performed by physicians, including interpreting arterial blood gas analyses and 12-lead electrocardiograms. By ignoring these medically oriented skills performed by nurses, nursing diagnosis, when used to define the nursing profession, places nursing outside the real world of health care and misrepresents what nurses really do.

REDUNDANCY?

Nursing schools consider nursing diagnosis a valuable learning tool. But its value decreases once a nurse has performed the same activities hundreds of times over the years. Consider this example: Education and experience dictate that a nurse should assess daily each patient's bowel elimination. This assessment could appear as one entry under nursing diagnosis, yet any conscientious and experienced nurse would make this entry in the patient's chart without thinking twice about it. The experienced nurse doesn't need to spend time writing up a nursing diagnosis to deal with a problem, should it arise. The nurse knows what needs to be done, does it, and documents the activity in the nurses' notes.

ALTERNATIVES TO NURSING DIAGNOSIS

I offer the following as alternatives to the current nursing diagnosis system:

* Include all the elements of which nursing is composed (such as nursing, medicine, psychology, and sociology) and the procedures and skills nurses perform, medically oriented or not.

* Categorize nursing diagnoses by specialty. For example, under the intensive care area, a topic could be "hypotension related to hypovolemia:'

* Delete the word "diagnosis" and replace it with a word such as "guidelines" that reflects the nursing profession, not the medical profession. Specialty-- specific labels would be even better; for example, nursing guidelines for intensive care.