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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.

NANDA International BlogThis 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?

NANDA International BlogBased 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?

Dr. T. Heather Herdman, PhD, RN
Executive Director
NANDA International, Inc.
Comments
Anjali Katdare
7/14/2013
As per my experience, the students require minute to minute guidance , evaluation and encouragement to make accurate nursing dignosis using their critical thinking skills and use their common sense.
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