NANDA International

Clinical nursing assignments: are we teaching the most important skills?

One of the most interesting things about my role as Executive Director of NANDA International, is that I get a lot of questions from nurses and students who are working with NANDA-I nursing diagnoses. Many of the questions seem to revolve around the same general theme: the students are given a brief history of the patient they are to see the next day in clinical, with the assignment: develop a plan of care based on that data for the following day's clinical unit.

This is common practice in many universities – I know I had to do this same exercise as a student, and I had to assign such exercises as a clinical instructor in a variety of settings. I understand the intent of the exercise: get students thinking about what they need to do in clinical the next day. But – get ready – is it really as important for them to think about what they need to do, as it is for them to think about what they need to know?

If we focus our students on what they need to do, based on the “Care Plan," but don’t really help them tie in the assessment, the data from the patient history, from progress notes of their colleagues in nursing and other disciplines – is it really any wonder that the Care Plan becomes a thing to check off a list, without having any real tie-in to the “real world” of nursing?

Here is the real kicker for me, though - often, the data students are given is too vague to really select nursing diagnoses on which to base a plan of care. At best, they might be able to walk in to clinical with a list of potential diagnoses, and ideas about what additional data they need to collect to rule out, validate and/or prioritize diagnoses once they assess the patient. If that were the assignment, I would applaud it – it would get students thinking about potential nursing diagnoses, and they would need to review them, think about what data is missing in order for them to validate (or not) the diagnoses on their list, and think about how these human responses might be impacting their patients.  HOWEVER, when students are asked to come to clinical with a plan of care developed – based on as little information as the medical diagnosis, list of medications and diagnostic test results – what are we really teaching our students?

Based on the inquiries I receive, the following is what many of our students are perceiving from this clinical exercise:
1. Medical diagnoses determine the nursing diagnoses,
2. Medical conditions, medications and diagnostic tests are the main things they need in terms of assessment data, and
3. Nursing diagnosis doesn't really require clinical judgment, because you just pick something off a list based on the medical diagnosis.

Is this really what we want our students to think? Is it any wonder we hear nurses say to them, “don’t worry – you won’t have to do this once you get out of school?” If the exercises we give our students in clinical practice settings fail to develop their clinical reasoning skills, what is the point? If we are teaching them to rely primarily on medical diagnoses, diagnostic tests and pharmaceutical agents as the key points for determining appropriate nursing care….well….didn’t we lose nursing in there, somewhere?

Yes, we need to know all of those things to provide nursing care – but we could know all of those things and provide care without being a nurse, because the essence of our discipline doesn’t reside in those things, does it?

If we do not support our students in developing clinical reasoning abilities, and support them in considering, validating and prioritizing their clinical judgments that reflect their own domain of practice – nursing diagnoses – do we really need nurses at all?

T. Heather Herdman, PhD, RN, FNI
Executive Director
NANDA International

What is Nursing Diagnosis - And Why Should I Care?

One of the most frequent questions we get goes something like this….”My patient has Congestive Heart Failure. What is the highest priority/most likely nursing diagnosis?”

There is no right answer, because it’s the wrong question! Assigning a nursing diagnosis based on a medical diagnosis skips several steps essential to optimal and safe patient care. A medical diagnosis is only one piece of the puzzle; it does not by itself, provide the depth of information necessary to make an accurate nursing diagnosis.

WHAT IS A NURSING DIAGNOSIS?
Maybe the easiest thing is to start with what a nursing diagnosis is NOT.

A nursing diagnosis is NOT:

• Merely a label that you make up that “sounds like” it explains what you are seeing in your patient.
• Another way of explaining the medical diagnosis, or of renaming a medical condition.
• Something that “goes with a particular medical diagnosis”.

Nursing diagnosis is defined as “a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.” (Herdman, 2012, p. 515). 

In other words, a nursing diagnosis is a judgment based on a comprehensive nursing assessment. The medical diagnosis provides one important piece of data, but it does not provide anywhere near the depth of information necessary for making an accurate nursing diagnosis.

WHY SHOULD YOU CARE?
Because an accurate nursing diagnosis based on a thorough assessment results in more effective and safer patient care. Period.

Let’s take a look at an example:

A man is admitted through the Emergency Department with a medical diagnosis of Viral Pneumonia with the following profile:

• Age 78;
• Dyspneic and demonstrating very shallow breathing;
• Pulse oximeter is showing 90% on 4L of O2;
• History of COPD.

What is the primary nursing diagnosis? Did you think of impaired gas exchange? Seems obvious, doesn’t it, considering the data and medical diagnosis? However, the question the nurse should ask is this: “What is causing the low SpO2?”

After completing a thorough assessment, the nurse discusses her findings with the patient, including the very shallow breathing. She learns the patient is breathing shallowly because he’s in pain. He’s suffering from posthepatic neuralgia as a result of a very painful course of shingles. In this example, the assessment-based, primary nursing diagnosis is chronic pain.

Consider these two scenarios:

Nursing Diagnosis Linked to the Medical Diagnosis
A care plan is developed to address the nursing diagnosis of impaired gas exchange, based on the medical diagnosis of Viral Pneumonia. The posthepatic neuralgia as a cause for shallow breathing is not identified and overlooked in treatment.

OR

Nursing Diagnosis Linked to Nursing Assessment and Critical Thinking
A care plan is developed to address the nursing diagnosis of chronic pain, with treatment designed to resolve this as the primary cause of the shallow breathing, and to prevent recurrence.

Which scenario provides the best patient care and outcome? What do you think the relationship is – or is not – between medical diagnosis and nursing diagnosis?

LEARN MORE
NANDA-I 2012 Conference: May 23-26, 2012
NANDA-I Nursing Diagnoses: Definitions and Classifcation 2012-2014
NANDA-I Frequently-Asked Questions
NANDA-I Fact Sheet