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EDITORIAL: by T. Heather Herdman, PhD, RN, FNI
Editorial initially published in Portuguese and English, in: Rev. Eletr. Enf. [Internet]. 2011 abr/jun;13(2):159-60. Available at: http://www.fen.ufg.br/revista/v13/n2/v13n2a01-en.htm

Years ago, a nurse I admired was kidding me about graduate school. What was a nursing diagnosis (ND), and why did we need them? Wasn’t it enough to know that the infant had respiratory distress syndrome? Why add in this other layer of nonsense? Why spend my time thinking about theory and other ridiculous things that had no context in clinical practice? I hear similar comments from nurses today.

What, then, is the knowledge of nursing practice? Nurses generally do not question the need for medicine to research disease and its treatment – yet many cite as irrelevant research done on human responses and treatment of those responses to achieve nurse-sensitive outcomes. When we neglect to teach, read or implement critical research on nursing knowledge and how it impacts patients – it becomes an afterthought, information that is “nice to know if you have time”. Is this what nursing is – a nice to have but not necessary field of practice? Why do nursing students and nurses in practice often feel they must implement physician orders and then, if they have time, “do some nursing”? I believe that this clinical reality occurs primarily because we do not, as a collective whole, really educate nurses, our peers or our patients about the discipline of nursing.

Nursing curricula heavily emphasize pathophysiology and pharmacology – is this nursing? These disciplines provide important content for nursing practice. But do they define nursing? I believe they do not – nurses need to understand these related fields, but we need to focus on human responses. What is pain? How is it manifested across lifespan, setting, etiology, gender, or culture? How do we differentiate acute pain, chronic pain and impaired comfort? How does a particular medical condition impact the human response of pain or comfort? What makes pain associated with a bone fracture different from pain experienced with diabetic neuro-pathy? Do we really understand the concepts – or do we merely rush to provide pharmacologic treatment of a symptom we are observing? Is that medication the best intervention – or is it simply the easiest? What do we do for the patient who cannot tolerate the medicine, or does not want it? How does the etiology of the pain, the patient’s coping mechanisms and history, impact his pain response? If we do not understand how acute pain and chronic pain differ, or how impaired comfort and chronic pain differ, how do we know what we are really treating? How can we best achieve a positive patient outcome? I believe we cannot.

Imagine a curriculum designed around core concepts of nursing knowledge. Rather than modules based on physician diagnosis (MD) on congestive heart failure or bone fractures, we could have modules on pain, risk for contamination, decreased cardiac output, or acute confusion. Rather than clustering content around medical diagnoses, we could use ND - concepts of importance to nursing practice – and cluster content around them, including related medical diagnoses, psychosocial, cultural and physiological responses, pharmacological treatments and desired outcomes.

This would require many nurses to reframe their concepts of ND. Some recent literature implies that ND were developed for documenting nursing in the electronic health record (EHR). The truth is that ND were (and are) developed to provide language that describes the knowledge and practice of nursing. Just as medical diagnoses are used within medicine – not as a documentation tool, but as a tool for describing what is being treated in a concise, internationally understood language to drive intervention and outcome - if correctly developed as concepts that can be defined, studied, taught and implemented in practice, ND can describe what nurses know, drive what we do and what outcomes we achieve.

I doubt that anyone would suggest that a physician should be allowed to create a medical diagnosis at a patient’s bedside and begin to use it clinically; yet some advocate for this practice in nursing. Simply construct a label and you have ND. But what does it mean? What do we know about this concept? How do I teach it, research it, measure it or share it with other disciplines and patients? How can we be so disinterested in understanding the core knowledge of our discipline? How can we allow what works best in a computer system to drive nursing practice, to mandate how we, as a discipline, develop the science beneath the labels?

Are ND just documentation tools? Unfortunately, that is what they become when we neglect to teach the concepts – really understand these phenomena of nursing practice and the content underlying them. Nursing diagnoses were never meant to be simple terms that could be created at random to describe a condition. Nursing diagnosis labels should describe a concept (including health promotion concepts, not just “problems”) that is clearly and uniformly defined and supported by nursing research and practice literature, identified by signs/symptoms that can be obtained during nursing assessment, review of patient/family history, diagnostic tests and completion of various screening tools. The concepts should be well researched, well developed, and internationally disseminated.

What would have to change to enable students to learn about nursing practice, how it supplements and interrelates with the practice of other health disciplines? We would have to teach nursing – the science of diagnosing and treating human responses to actual or potential health problems or life processes – and we would have to completely restructure, in most cases, how we practice nursing. Are you ready for such a challenge? I believe we must make these changes quickly, before we lose what it truly means to be a nurse.

Comments
Hailemichael G. Yosef
8/5/2013
Great points and excellent thoughts. But, we need to answer the question "How can we be so disinterested in understanding the core knowledge of our discipline?". I would love to know your response.
Josefin Wiking
8/6/2013
Thank you for illuminating and describing some crucial points for developing nursing.
Heather Herdman
8/16/2013
Thank you, Josefin and Hailemichael, for your comments! I think that the question Hailemichael poses is critical! My personal opinion is that nurses often (1) believe there is more power/status in alignment with medicine, and (2) there is some fear in taking responsibility/accountability for our own knowledge, so it is easier to "just follow orders". What I do know is that the nurses who have made a difference in my own personal care, and that of my family, have been those who truly valued nursing - who recognized the medical condition, but who assessed, diagnosed and treated the human responses that nursing considers from its own unique perspective. I already have a physician if I am in hospital, what I need is a nurse who understands the human experience of the patient/family, and intervenes to improve my health, knowledge, coping/resilience, etc.
Asha Bose
9/4/2013
Madam, you are really sharp in thoughts. But todays nurses are working on a string which is controlled by physician.What points you have suggested r good in it. Still have confusion to implement it!
Colleen Leonard RN
9/14/2013
Heather, I read your article with great interest. Many times a physician is only looking at the medical aspect of a patient; he has CHF or diabetes. Nurses look at the whole patient and nursing diagnoses should take into account his support system, his lifestyle, his finances, his belief system, etc. All the factors weigh heavily on how a patient will overall respond to medical interventions. Sometimes our diagnoses determine other problems that directly or indirect affect a medical condition. Education of the condition and treatment is one of the biggest parts that is not always covered by physicians. Doctors are at the core of a patient's medical condition but nurses are the liason to recovery.
T. Heather Herdman
9/16/2013
Liaison to recovery - I love that!!! Thanks for sharing!!
Marcia
9/22/2013
Hello, I am currently an registered nurse and board certified cardióloga technician. I am enrolles in a BSN program and hope to continue on in obtaining a FNP degree as well. First, I want to thank you Dr. Leading this Q&A blog. Second I feel the need to comment no the previous blogs. Pertaining to the fact that only nurses look at the whole picture of the patients situation ludicris¡ I do not know where you work but where I work the Doctors most certainly do look at moré the médical diagnosis. We all are on the same team with the same goal, and that is quantiy, compassionate patient care. Period.
Marcia
9/22/2013
Can you let me know if you recieved my previous blog
Nandy
3/6/2014
Thank you Heather Herdman for the definitive definition of the practice of nursing summed up in the last paragraph of your comments. There is an assault on this science/art approach to the treatment of disease.
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