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During a recent afternoon at a coffee shop, I overheard  exam quizzing going on among a group of students sitting nearby. I quickly realized they were nursing students studying for finals. Another customer asked the group how far along they were in their studies, and they answered they were due to graduate in a week. How exciting!

I began to pay more attention to what they are discussing. It was, in a word, pathophysiology. They were quizzing one another on normal ABGs and lab values, signs and symptoms of congestive heart failure and chronic obstructive pulmonary disease. There seemed to be a strong consensus among them as to what the most likely exam questions would revolve around: common medical diagnoses.

I heard them talk about medications, lab and diagnostic tests, and basic pathophysiology for those medical diagnoses that they expected the majority of questions would involve. Never once - not once - did I hear them talk about patient (human) responses to treatment, ethical concerns, caregiver stressors or anything that might even remotely resemble a nursing diagnosis. There was no discussion of nursing assessment criteria, prioritization of care, educational strategies for patient/family teaching, or even patient safety/quality concerns.

I began to realize my blood pressure was rising: nurses of this generation will be my caregivers someday, but are they even learning what it means to be a nurse? I couldn't help myself - I caught the eye of one of the students and started a conversation:

Me: What is nursing all about?
Student 1: What?
Me: I see your nursing textbooks - if you had to describe your profession, what would you say? (There are a few quizzical looks around the table before I get a response.)
Student 2: Well, we work with the doctors to care for patients. (This was not the response I was looking for, and noted my blood pressure was continuing to rise.)
Me: So, you work under the doctors, then? (They weren't quite sure how to answer this, either.)
Student 1: Well, kind of, but we do our own things, too.
Me: Oh, what kinds of things? (Surely, I thought, they will talk about assessment, designing treatment plans, discharge teaching, coordination of care - something that I consider to be integral to nursing!)
Student 3: We give medications and monitor how patients respond to them.
Student 4: Yeah, and we do dressing changes for wounds and we monitor hemodynamic stability with patients in intensive care.
Me: What do you find most exciting about what you do? (I thought, perhaps, if I approached them in this way, the human interaction component would come alive.)
Student 2: I like the emergency department, there is so much that happens and the day goes by fast because you always have something to do.
Student 4: I like working in labor and delivery, because it is always such a happy place. The people are nice because they are excited about having a baby and they appreciate you helping them.
Student 1: I like anything but med-surg (laughs), but I'll probably have to work there first for a couple of years. (They all seemed to agree with this statement, and none seemed very excited at the prospect. I tried another strategy.)
Me: So, what made you choose this profession?
Students: Jobs! (laughter)

Most of these students are older, and they began to talk about the job market, having been laid off (or husbands having lost jobs). One was recently divorced and never worked outside of the home, others had worked in retail, education and information technology. Most said they chose nursing after considering job prospects and what careers had the least likely chance, in their opinion, of having layoffs in the future.
They also said that they thought the pay is better than many professions. Only one said she always wanted to be a nurse, because she had a very sick sibling who had been hospitalized frequently, and it was the nurses who made her feel comfortable, explained what was happening, sat with her sister, talked with her parents.

Me: So, you chose to be a nurse because you wanted to help individuals who were dealing with difficult health problems, to be that support person, that teacher, that trusted person?
Student 3: Yes, but now I see there really isn't much time for that. Hospitals don't value that, so the staffing is short all the time and nurses don't have time to do those things anymore. Most of the shift is passing medications. (She says this sadly, but when I looked around the table, I didn't sense this was a problem for any of the other students.)
Student 1: Nurses have too many important jobs to do, such as meds, treatments, dealing with the doctors and their orders - we just don't have time to sit and hold patient's hands anymore.

One of the students asks me what I do. I explained to them that I work for NANDA-I and that I have been a nurse for a long time. They were a bit thrown by this, I think. They were surprised to learn that NANDA-I is headquartered in Wisconsin, where they live - but even more surprised to realize that NANDA-I has an international membership.

Student 4: Our instructors don't seem to like it or really know how to teach it. (They all agreed with this, saying that with every teacher they have to learn a new way to use NANDA-I, NIC and NOC, and that they never thought of it as anything other than a way to chart something to pick off of a computer pick list. In fact, they said that this is how they were taught to use NANDA-I.)

Student 2: Each health care organization has NANDA-I in problem lists, but some have them already set up for you, so you just pick the medical diagnosis and everything else populates. Others require you to pick the diagnosis, the outcomes and the interventions. That is a pain. It takes too long to do the whole NANDA-NIC-NOC thing, and it really isn't that important because we know the medical diagnosis and that is what we are taking care of, really. I understand we have to chart, but it should be a lot simpler. (This seemed to be the consensus.)

I talked with them about assessment and the detective work that nurses do to try to figure out what is going on with a patient. I asked them if they ever listen to the physicians when they are rounding with residents or students. They told me they don't - instead, they leave the room. I asked them if they thought the physicians would ever say that diagnosing would be something they didn't have time for, and they laughed at this.

Student 2: Of course not, that's what physicians do! They have to diagnose, so the rest of the health care team knows what it is treating. We work as a multidisciplinary team now, you know? So we all work on the same thing. (Listening to this, it seemed she thought nursing has evolved because it is now multidisciplinary.)

Me: But what it is that you, as nurses, bring to the multidisciplinary team, if you don't bring your own base of knowledge, your own ability to assess, diagnosis and treat the responses our patients have? They have no answer for this.

As I left the coffee shop that day, I was overwhelmed by sadness and wondered just what is it that we are really teaching our students about nursing? And if our profession has become a magnet for people who are simply looking for job security, is this really what we want to promote? I have had some unfortunate experiences with nurses who have been responsible for my own family members in the last few years;  nurses who never spoke to my father or mother, never placed a stethoscope on a chest or asked how the family was doing. They just came into the room, wrote down numbers from all the machines, hung IVs, and left the room. This is not nursing and this is not the type of care that I want when I need to be a care recipient.

I think these students felt they were talking with a remnant of times gone by, and that their world of nursing is completely different. I frequently hear this from nurses who are working in clinical areas in my country, and from university professors as well. We seem to be so focused as a profession on expanding the role of nurse practitioners, that I wonder if we have forgotten the primary purpose of the profession: the nurse in clinical areas, who should be the hub of the health care system, the coordinator/care manager, resource person, educator, health care provider and, yes, the diagnostician for human response.

What are we teaching our students?

Dr. T. Heather Herdman, PhD, RN
Executive Director
NANDA International, Inc.

Mary Hostetter, RN, BSN, CCRN
Today I was looking for information on Orem and her involvement with nursing diagnosis when I discovered this website and blog. Although I'm not an educator, I have been at the bedside for 29 years and have precepted countless students and newly minted nurses. My experience is that they all enter the profession for a myriad of reasons, but most will become indoctrinated with the uniqueness of nursing practice. In fact I love to tell them that soon they will realize that without their role ( the
Maria Müller-Staub
Hi Heather very well done, thanks and congratulations! Maria
Anita Collins
Nursing diagnosis is becoming the center of our nursing education in the college, I am in. We are promoting it in our parent hospital as well, on request to develop the caring aspect of nursing among nurses. We found teaching nursing diagnosis to staff nurses greatly helps in it. Presently we are encouraging our students to draw up the care plans and ask the clients to choose which aspect of the planned care they would want addressed first so that clients do not feel powerless in hospitals.
James Griggs RN, MBA, NE-BC
The entire concept of the nursing "dx" is so obviously irrelevant to actual nursing practice that students realize it very early. Nurses do in fact work for doctors(gasp)! Again, nursing students understand this but PhDs just can't seem to come to grips with it. And lastly, folks become nurses primarily so that they can get paid (double gasp). Why is this a bad thing?
Barbara Sternitzke, RN, MS, HNB-BC, CDE, CHES
Heather, thank you. That was inspiring and sad at the same time. Holistic nursing provides care that recognizes the interconnectedness of body, mind, emotion, spirit, social/cultural, relationship, energy, and environment. How an individual is perceiving an illness cognitively and emotionally is of primary importance to nursing. We are the ones in the healthcare system who CARE. What happened to nursing?
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