We celebrated our 40th anniversary this year, at our conference in Houston, Texas. At that event, we had the opportunity to acknowledge and thank several who were among the 1973 founding members of our original organization, the North American Nursing Diagnosis Association. Nurses who worked at the grassroots level to establish our mission and develop an initial terminology and associated taxonomic structure. Nurses who did this work without any payment or funding, and without the technology we have today.
Since 1973, our terminology has grown to 216 nursing diagnoses, published in NANDA International Nursing Diagnoses: Definitions and Classification, 2012-2014.
DIAGNOSIS SUBMISSION AND APPROVAL PROCESS
Then and Now
Our process of proposed diagnosis submission, review by our Diagnosis Development Committee (DDC) followed by Membership vote has not changed in 40 years – we remain true to our belief that our body of work should be developed, grown and improved by the nurses who use it. We also remain a volunteer organization – those who submit diagnoses and those who serve on the DDC are not compensated for their time or paid for their work.
Our cycle of submission and publication remains basically the same as well: approved diagnoses – and those identified for retirement – are reflected in our book on a 3-year cycle.
A major change to our process took place in 2001 with the implementation of our Level of Evidence Criteria (LOE). Changes to these LOE criteria have occurred twice since that time, with a tightening of requirements for acceptance. Any new diagnosis accepted into our terminology must meet these criteria.
Impact of Changes to Criteria for Development, Evaluation and Inclusion / Exclusion
Nursing science, as with other health care disciplines, continues to evolve – and with that our knowledge of research methodology and design improves. What was considered good science 20 years ago may not have the rigor that would be expected today, and we must continually strive to update our terminology to reflect new scientific knowledge and ways of understanding, explaining and measuring that knowledge. What we were willing to accept as support for a diagnosis prior to the 2001 implementation of the Level of Evidence Criteria would not necessarily meet the level of evidence required today.
Implementing the Level of Evidence Criteria was an essential and appropriate step to take in the evolution of our work. However, that step resulted in three major challenges for our organization and our terminology:
1. Published diagnoses in need of update to meet the new criteria;
2. Volunteer-only resources through which to complete this work; and
3. A publishing cycle which updates only every 3 years.
Our leadership determined the best course of action was to begin the process of a systematic review of older diagnoses, understanding the process would require several years to complete. Optimally, all diagnoses accepted prior to 2008, when the most recent changes to LOE criteria were accepted, should be reviewed to ensure that they are brought current with those criteria, or are retired from the taxonomy, as appropriate. We have retired eight diagnoses in the past two cycles, due to lack of evidence to retain them in the taxonomy; 23 diagnoses have been revised to bring them current with our required levels of evidence.
OPPORTUNITIES FOR ORGANIZATIONAL LEARNING
Good intentions and best efforts can fall short when viewed from the perspective of those using our terminology. As a result, we occasionally receive negative comments. We are open to this feedback, appreciate it and always learn from it.
A recent example has to do with the diagnosis: Disturbed Energy Field (00050), which was accepted into our terminology in 1994 (prior to implementation of the level of evidence criteria). In 2011, we received concerns about this diagnosis from members in Sweden who were concerned about the lack of evidence and the direct linkage to therapeutic touch (TT), which they did not believe met the requirements for evidence-based nursing intervention criteria. These members were encouraged to provide a review of literature with a recommendation for revision or retirement of the diagnosis from the taxonomy. Unfortunately, they were unable to do this, but the DDC itself has begun the process of reviewing older diagnoses in the taxonomy to evaluate the level of evidence and revise/retire them as necessary. Disturbed Energy Field is one of those diagnoses under review.
We recently received an email from James Randi, who in his own words, “has an international reputation as a magician and escape artist, but today he is best known as the world's most tireless investigator and demystifier of paranormal and pseudoscientific claims.” Mr. Randi’s question was this: “Does NANDA-I still officially accept the term "Energy Field Disturbance" - as it is used in the practice of ‘Therapeutic Touch’ - as a diagnostic term for its members to use?”
My response to him was as follows:
"The diagnosis does still stand, and although NANDA-I does not indicate what interventions are most appropriate for its diagnoses, many TT practitioners do use this diagnosis. I should note, however, that this diagnosis is currently under review due to concerns raised regarding the scientific level of evidence available to maintain it within the taxonomy, so it may or may not remain in the next edition (2015-2017), depending on that review. When the diagnosis was accepted, we did not have Level of Evidence Criteria, and we are reviewing all diagnoses that were grandfathered in to the taxonomy at the time that those criteria were adopted. This is a large project, so it takes us a few cycles to get through all of those diagnoses." In our further communications, Mr. Randi commented:
"Be assured that if NANDA-I chooses to change their [sic] opinion on TT, and I'm able to include that before my book goes to press, I will certainly mention that fact. In my opinion, it verges on being a criminal act for nurses to mislead their patients into thinking that they have special powers. NANDA directly contributes to this mis-education of patients and is damaging the nursing profession."
Mr. Randi misquoted NANDA-I in his initial draft of his book chapter, which he shared with us, and despite that, we have tried in good faith to clarify for him what is and what is not the NANDA-I position:
1. NANDA-I does not endorse any particular interventions and holds no “opinion” on TT, nor do we stipulate its use is required with this diagnosis;
2. We are reviewing older diagnoses to ensure that they meet our newer level of evidence criteria and determine whether or not they should remain part of our terminology; and
3. The Disturbed Energy Field diagnosis does not make any claim of a nurse’s “special powers” and can, as with nearly all nursing diagnoses, be based on a patient’s own perception/report.
Rather than await our review of scientific literature for this diagnosis, Mr. Randi’s same criticisms were then posted on our Facebook page. After extended discussion we have removed these Facebook postings, due to concerns of members who have emailed to ask why, and with what authority, an organization outside of nursing (the Museum of Scientifically Proven Supernatural and Paranormal Phenomena) is commenting on nursing science.
We have published this blog post for two primary reasons:
1. To acknowledge that, despite the aggressive approach, we believe Mr. Randi raises a valid concern.
2. To provide clarity and transparency about our strategic direction regarding the older diagnoses in our terminology.
As a science, nursing must determine for itself what is and is not within its own body of knowledge. As a professional organization, NANDA-I must respond to that body of knowledge, and to its members – professional nurses around the world.
However, just as Mr. Randi would, we think, be opposed to us accepting a diagnosis without taking the time to review the current state of the science – we must oppose random retirement of a diagnosis without that same review, despite criticisms from inside or outside of the organization.
Personal opinion aside, we have policies that require that any changes to the terminology must be based on a review of scientific evidence. And so, that is what is occurring – a review of this concept, disturbed energy field, is underway – along with review of a number of our older diagnoses. Recommendations will be made to the DDC members, who will make a determination that will be sent to the Board of Directors and to the organization’s members for their vote, prior to dissemination in the next edition of the text, NANDA International Nursing Diagnoses: Definitions and Classification, 2015-2017.
It is a slow, methodical process – with the intent of ensuring that new diagnoses and diagnosis revisions and retirements are based on the most current level of scientific evidence. It can mean that we do not always keep pace with evidence – an unfortunate reality that is not unique to nursing science.
We would certainly like for such review to happen more rapidly, but without funding for this work, we rely on the dedication and volunteer efforts of those who believe in the importance of an evidence-based terminology to represent the knowledge of nursing.
We encourage all members / professional nurses to each consider choosing one of the older diagnoses to research and review the scientific literature that has been published since the diagnosis was accepted into the taxonomy, and to submit recommended revisions along with the supporting scientific evidence to the DDC. This is how we progress, and we need to continually clarify, revise and/or retire diagnoses as appropriate.
Dr. Bernie Garrett
Having a NANDA diagnostic statement of "Disturbed Energy Field" is about as much use as a diagnosis of "Feeling a bit under the weather." Come on, this makes nurses look ridiculous.
Time that NANDA got a grip on this situation.
Dr. Bernie Garrett, RN, PhD, BSC. (Hons)
As a nurse returning to practice after a 10 year absence, I was shocked and appalled to see this non-scientific nursing diagnosis in my 2011 nursing fundamentals textbook. I am glad to see that it is being considered for removal, and respect Nanda's structured process. Why, though, it was ever adopted in the first place is beyond me.
Robert Glickman RN CRN
The Disturbed Energy Field diagnosis does not make any claim of a nurse’s “special powers” however, there is no evidence for the Human Energy Field (HEF) and not one single Therapeutic Touch Practitioner (TTP)can prove that they can detect one. Therefore, in order to use this diagnosis, the TTP are using special (or supernatural) powers that humans do not have. Not only does the TTP detect the HEF, the practice & diagnosis requires differentiating between “warmth,” “coolness,” “spike,” “hole,” “bulge,” “tingling,” “flowing,” and “dense” sensations within that field.
Nurses are informing patients that they can feel the HEF and gaining their confidence while misinforming and misleading them at the same time.
The $1 Million Challenge to any TTP who can detect the Human Energy Field which was to be held on April 20, 2013 in Philadelphia at the Franklin Institute did not receive a single inquiry but is still available/
While accepting and agreeing with RN Glickman's important comments, I'll simplify the situation somewhat. The James Randi Educational Foundation offers our $1 million dollar prize to anyone - TTP or not - who can simply show that they can detect the HEF. It's that easy. No arguments, no fuss, no scientific or supernatural theories required. Do it, and walk away with the $1,000,000 prize. My experience in the quackery field tells me that NANDA-I will never come to grips with the HEF situation, but will continue to promote this attractive-but-false delusion.
Please prove me wrong.
As a second-year nursing student learning about care plans, I was concerned when I saw the "Disturbed Energy Field" diagnosis in the back of my text book.
EBP is the backbone of modern nursing, and this type of thing undermines that, in my opinion. I completely understand that reviewing and (hopefully) removing it from NANDAs list of nursing diagnosis'. That being said - I would be curious to know how it got there in the first place.
Mr. Randi's approach may seem heavy-handed, but I'm glad someone is fighting the good fight.
Lucas Cummings SN
James Randi how would someone go about proving you wrong? Simply show that someone came detect HEF with no scientific or supernatural theory. How would it be determined HEF is proven by a individual TTP or not? Should there be a panel of non partisan people to cast votes after hearing an individuals testimony or personal theory to decide whether or not HEF is valid? How will this be judged?
I would invite all to go to http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3907587/ to gain more information about energy fields and the role of nursing practice in the field of oncology nursing. I beg to differ with opinions expressed above. Caring Science, and Energy Field therapies can play a significant role in Nursing.
Do not wear blinders when it comes to integration of complementary modalities into nursing. This is the 21st century, and HIGH TECH DEMANDS HIGH TOUCH if it is the human being we are truly caring for. I ask NANDA to reconsider and keep "Energy Field disturbance" as a NANDA diagnosis.Thank you.
"...due to concerns of members who have emailed to ask why, and with what authority, an organization outside of nursing is commenting on nursing science..."
NANDA, no offense here, but we should be encouraging those outside of nursing to comment and question nursing science. We should also be ready to defend it, with rational, logical, scientific data. That's how nursing becomes acknowledged as a real, professional field, which should be all our goals.
The NDx of 'Disturbed Energy Field', which has no scientific backing, should not take 'cycles' to remove. It's scientifically wrong, and is a target for ridicule in nursing schools and beyond. Needing to debate this to make a decision is equivalent to debating what bucket to use to put out the fire.
Matter and energy... That is the human being. It is not about special powers... It is about sensitivity and good intentions for an excellence in nursing care. I also ask NANDA to keep "Energy Field disturbance" as a NANDA diagnosis.Thank you.
Ms. Hall and Ms. Hervas:
If there is no scientific proof of human energy fields, then there is no reason to keep this nursing diagnosis in the age of EBP. This relegates nursing to roles equivalent to pillow-fluffing and defeats the advances our profession has made toward a truly science-based practice. If there are nurses that believe in the validity of Energy Field Disturbance as a real human problem, they should initiate a scientifically rigorous study of the subject and publish it in an authoritative, peer-reviewed journal. Once it has been proven and investigated thoroughly (and scientifically), that nursing diagnosis can be reinstated. Until then, NANDA-I owes it to the profession to immediately remove this unsupported and somewhat spurious "condition" from its books. Nursing has come too far to have such an error in its guides. Good intentions, sensitivity, and human kindness are fabulous characteristics, Ms. Hervas, but they are not the end-all be-all of nursing. They are personal traits that make a nurse's scientifically sound practice that much better.
I request that NANDA not overlook the work of Martha Rogers, a nurse theorist, who defined energy fields in relation to nursing practice over 30 years ago. The Society of Rogerian Scholars actively researches these ideas as a means to better understand and explain Rogers' Theory of Unitary Human Beings. I also remind NANDA that an increasing number of nurses are certified in Healing Touch (a nursing intervention) or other traditional energy healing practices such as Qigong. Also, hospitals are beginning to integrate these services into their treatment plans. Please do not remove the ability for these holistic nurses to accurately reflect the care they offer patients. Thank you.
Claire Billings, HTCP
I request that NANDA keep Disturbed Energy Field. See the study below on biofield therapies which help to balance the disturbed energy fields.
"Biofield therapies: helpful or full of hype? A best evidence synthesis" study
RESULTS: Studies overall are of medium quality, and generally meet minimum standards for validity of inferences. Biofield therapies show strong evidence for reducing pain intensity in pain populations, and moderate evidence for reducing pain intensity hospitalized and cancer populations. There is moderate evidence for decreasing negative behavioral symptoms in dementia and moderate evidence for decreasing anxiety for hospitalized populations. There is equivocal evidence for biofield therapies' effects on fatigue and quality of life for cancer patients, as well as for comprehensive pain outcomes and affect in pain patients, and for decreasing anxiety in cardiovascular patients.
Also, many other cultures have been using energy based practices for hundreds (thousands?) of years such qi gong, acupuncture, so since they have withstood the test of time and people have found benefit (unlike the Western medical practice of bloodletting), how can we say that there is no such evidence for disturbed energy field? There are special devices to show the electrical fields and measure it.
The ability to assess the energy field is a skill that many (not all)can develop over time with training and practice. Just because, you have not trained to run a marathon, does not mean it is impossible.
Mary Jo Frey
I am a registered nurse and have been practicing for 41 years. I was introduced to Reiki and Healing touch about 4 years ago at a nursing seminar. A nurse with a Masters Degree in nursing presented the topic of Healing Touch and Reiki along with some other forms of integrative medicine. She also presented some science to support the concept of energy fields. I was skeptical of course, after all I'm old! and this "new fangled, new age,magic" stuff has got to be crazy right?, but this set my mind to thinking. The only way to learn and grow is to explore and question. Why not open my mind to new things. I've asked many people and there are several that have found a great deal of help after under going Healing touch and Reiki sessions. They were also very skeptical about this and went for the sessions not expecting much,but felt it wasn't going to hurt. They even payed for their session and had something to lose if the session wasn't helpful. I tried a session of Reiki thinking I was crazy, after all, they just rested their hands on different areas of my body while they just kept talking with one another about things going on in their lives. At the start of the session,I'd told them of issues I'd been having and thought if it worked those issues might be resolved. I got off the table and the some of the problems were resolved, but I hadn't mentioned one other issue, the biggest. As they talked among themselves during the session, one of them mentioned a problem in the spot I'd not mentioned and they went to work on that area. I said nothing, it was resolved.I did not pay for the session and had nothing to lose if there were no positive results. These are people you'd meet anywhere that are not "weird" as you or I might have thought. At present I do home health and one of my clients was offered and given a session of Healing Touch in the hospital during very critical episode. Parents and she were very skeptical but felt there was no harm. She suddenly was relieved of her problem. Since then she's had other amazing responses to the sessions. This convinced me that there truly was something to all this energy medicine. I would also point out that many hospitals and centers have incorporated these energy medicines into their care. Why would they do that if they didn't respect this as another form of treatment? Also, in the European countries Essential oils, and energy medicine are routinely used and are very effective, often before care that we here in America usually use to start with. They recognize that this care is effective. This not not replace many of our current medical practices. If there is an infection, then an antibiotic would be the choice. Why should energy medicine not be introduced to medical practices here? Why not find some experts that can fully and scientifically explain the use of energy medicine? It is not fair to nurses or physicians not to be made aware of this. Not all treatments work on everyone. The more ways we have available to treat and diagnose those we care for the better. Our goal is to heal. If we don't accept newly introduced forms of care we would never have progressed in Medicine as far as we have. I worked in an NICU that participated in the blind trials of what later became Surfactant. Wow, putting this greasy looking stuff into the lungs of a neonate was pretty questionable, but now look what it's done! Then, just looking at intralipids and putting them in IV lines was scary. Now look how they are used! There have been many questionable things intorduced in medicine that I,in my 41 years of nursing, have seen first hand work amazingly well. Energy medicine is just another way to diagnosis and treat problems.It, again, does not replace the care we give now. It offers us one more weapon to fight disease. It is very close minded not to introduce all forms of treatments even if we don't agree with them or accept them. Many forms of care that have been used for centuries have been found more and not to be as "old fashion" as we first thought. Inventors either in Medicine or anything else would never get anywhere unless they explored everything available to them. Please reconsider offering Energy medicine in your Publication. Written by true experts in the field and introduced with the correct description from the experts that first introduced the topic.
I am a newly graduated BSN and HT student practitioner. I ask that Disturbed Energy Field remain in NANDA and direct you to the comments of Amanda Cook on 11/5/2014. In support of Ms. Cooks comment, Martha Rogers is one of the nurse theorist in our nursing textbooks and is relevant to modern nursing practice.
Ines Hoster< MS, HTCP/I, QM
I so much appreciated the forward thinking of NANDA when the diagnosis of Disturbed Energy Field was added. The energy field can be measured in many different ways including with instruments such as the SQUID and cameras, as evidenced by Dr. Virginia Hunt, Kirlian Photography and the writings by Dr. Jean Watson on Caring Science, etc.
As am instructor for Healing Touch program I have had the privilege of training many students over 15 years in becoming sensitive to the energy field. When I see over and over that students already in the first course are able to point to areas of disturbance in a person's energy field, whether they sensed it as heat, thickness or heaviness or were able to see it, that is a lot of evidence! One can observe this over and over- observation is one of the best and oldest scientific tools.
I also know that many nurses have never taken a course that teaches them to become sensitive to the energy field - therefore it does not exist???
Please keep the diagnosis and stay committed to 21st century nursing knowledge.
I am very much gratified that NANDA has seen fit to reconsider acceptance of the Disturbed Energy Field matter. I hope that my efforts may have suggested that decision. However, the million-dollar offer also applies to such matters as acupuncture, energy field detection,energy medicine, healing touch, kirlian photography, qigong, and reiki. I eagerly await applicants.
Respondents to this page should know that the million-dollar prize will be offered for proof of any "disturbed energy field," "human energy field," "healing touch," "qigong," "acupuncture," "reiki," "energy medicine," or "kirlian photography" phenomena. I am pleased to see that NANDA has reconsidered their acceptance of the DEF as once embraced. Now, where are the claimants for these other bits of quackery, please?
James Springer, RN,
I'm happy to see that this Nursing Diagnosis was removed. I only hope that the FDA would begin to review the claims of homeopathic medicine and other snake oil salesmen.
Bernie Garrett, PhD, RN
Bravo for removing this non-Evidence-based practice (although I am not sure the rationale given actually makes much sense)!
If nursing is to remain credible as a professional body, we really need to move away from metaphysical therapies, Rogers, Watson Parse, and other postmodern nonsense. Although these theorists have promoted valuable discussion, in reality these ideas have done nothing to advance the profession in meaningful terms. The anti-science agenda this sort of thing promotes is damaging the profession, and it is a good time to refocus on the practical approaches that actually impact health, rather than magical remedies that don't WORK (at least any better than listening to some music, talking or enjoying a relaxing moment with a beverage. The fact this has been on the books since 1994 was a PR disaster for nursing, akin to having a label saying "we don't believe in science"
Carolyn Ewell MS, APRN, FNP-BC
Thank you for removing the disturbed energy field diagnosis. I have long been mystified as to why it was ever entertained. It is the only nursing diagnosis that seems to lack any basis in reality. Thank you.
Linda Rosa, RN
It is, indeed, good to hear that the "energy field disturbance" nursing diagnosis has been removed from the NANDA classification.
Nursing researchers have long been remiss in not first establishing the plausibility and existence of the "Human Energy Field" (HEF) BEFORE conducting clinical trials.
This basic research, after some decades, was taken up by a 4th grader, who tested TT practitioners to see if they could reliably detect the HEF when not looking. They couldn't. And nurses have been doubly remiss in not replicating this simple and inexpensive experiment.
This experiment, plus an extensive literature review, justified, according to JAMA reviewers, this key statement:
"To our knowledge, no other objective, quantitative study involving more than a few TT practitioners has been published, and no well-designed study demonstrates any health benefit from TT. These facts, together with our experimental findings, suggest that TT claims are groundless and that further use of TT by health professionals is unjustified."
"A Close Look at Therapeutic Touch" Rosa, et al, JAMA, 1 Apr 1998.
In my many years of nursing, I must say that generally nurses are one of the most superstitious lots I've ever encountered. All should refer to the book "What We Know That Isn't So." We expect, as professionals, to base care on verifiable EBP. However, most nurses still encourage patients to hold on to mystical beliefs because such beliefs make the patient "feel better". I find this sort of deception appalling. Prayer is a prime example, and most nurses fervently believe in it. That, despite the fact that there is not one shred of scientifically verifiable evidence to support it. We need to decide if we support science and reality, or if we should be a profession that supports selling fairy tales and wishful thinking as useful treatment for our patients. As for those who actually believe that prayer works, I have one simple question. Why bother to go to a doctor at all? Rely on your prayer, and accept it if the deity your are sending your wishes to decides to ignore them. You can't have it both ways. Rely on reality and science, or mysticism. Choose.