Speaking the Same Language: Go beyond the label!!

Imagine your mom has been admitted to the emergency room for shortness of breath and chest pain. She has her tests done, is assessed by her nurse and her doctor, and they come in to tell both of you what they think is happening. You tell them both you and your mom are nurses, thinking that will help them to explain things more completely.

The doctor says to you, “well, your mom has an alteration in cardiac rhythm” and the nurse says, “we also have assessed that you are suffering from altered anxiety management." Would you have any idea what they were saying? Or you might wonder, “What kind of alteration in cardiac rhythm? What do you mean by altered anxiety management???”

Sound ridiculous? Possibly….but isn’t that exactly what happens when we decide it is okay to create labels for nursing diagnoses/patient problems for ourselves – with no literature support, no basis in research, no consensus around the terms? If one nurse calls a patient’s problem “Pain," the second nurse stipulates “Acute Pain” and the third nurse chooses “Chronic Pain” – do we really have any idea what the patient is experiencing, or why the nurse chose to use the label that she did?

How frustrated would we be as patients or nurses if each doctor who saw a patient changed the medical diagnosis – how would we know what was going on with the patient? How would we know how to intervene or to set appropriate outcomes? And yet, we are often content to do just that with nursing diagnoses.

The primary problem with this is patient safety – if we do not have nursing diagnoses with clear definitions, and with diagnostic indicators (assessment data – the things NANDA-I calls defining characteristics, related factors or risk factors), then how do we know that we are making the correct diagnosis in the first place? And how do we know the interventions we choose are going to be effective? Chronic pain and acute pain, for example, require very different interventions and have different underlying etiologies. If we do not know how the diagnosis was made (by referring to the indicators used to make the diagnosis), and we do not have a clear definition, then we do not have a way to ensure that we are providing the best care to our patients.

Nursing is so much more than following doctor’s orders, isn’t it? Then don’t we need to have one terminology that allows us to identify and communicate our knowledge about our clinical judgment – to one another, our health care partners, and our patients?

Is the terminology within NANDA-I perfect? Absolutely not! Does it need clarification, revision, expansion? Most definitely! But if we do not have it, we either have to go back to the days that we wrote paragraphs in our patient charts – which meant very little of what we knew (our judgments) about our patients was ever seen by other care givers – or we will be relegated to showing the things we do (the tasks of nursing) in an electronic record, which could lead administrators / financial leadership to determine that “we don’t need nurses because non-licensed personnel can be taught to do these tasks."

Is that really in the best interest of our patients?