The Wisdom of Nursing
When I was in nursing school there was always a lot of eye-rolling when it came time to discuss “Nursing Diagnosis”. This was mostly because nursing diagnoses were followed by book-length “Nursing Care Plans” which we had to produce for various imaginary patients. There was also a faction, including myself, who thought a Medical Diagnosis was just fine, thank you, no need to reinvent the proverbial wheel. For example, for a patient with Congestive Heart Failure (medical diagnosis) patients have trouble breathing, less ability to take care of themselves, loss of independence, and confusion about what congestive heart failure is. Nursing diagnoses might be things like Altered Respiratory Status, Decreased Ability in Activities of Daily Living, Altered Self-Image, Knowledge Deficit related to diagnosis, etc. Kind of seems like silly semantics, doesn’t it? To my knowledge nursing diagnoses are no longer really used in practice, much less those endless care plans.
I’m here to suggest, however, with the perspective of age and experience, that there is profound wisdom in the nursing diagnosis format that can be used not only for illness but for the problems of everyday life.
Let’s take Job Dissatisfaction. That will be our Medical Diagnosis. Treatment: Find a New Job. Now, a nursing diagnosis is structured as The Problem (diagnostic label) Related to (the etiological factor or what is causing it) As Evidenced By (assessment data or clinical markers). A nursing diagnosis addresses the actual experience of the individual. “Job Dissatisfaction” is not a nursing diagnosis, because job dissatisfaction affects each sufferer differently and is caused by different factors in each person. We want to address the human response to job dissatisfaction.
Say your experience is boredom. Boredom is a common response to working at something that doesn’t interest us.
So if boredom is the problem, what is it related to? Maybe your work is too repetitive, or you feel like you never get anywhere.
And if you’re bored, how can you tell it is because your work is too repetitive as opposed to dis-satisfactory in some other way? Because, as you are now noticing, you make shopping lists and compose sonnets in your head while the rest of you follows well-worn paths. Your nursing diagnosis is thus:
Nursing Diagnosis: Boredom, related to the repetitive nature of your work, as evidenced by your ability to do your work while thinking about something else.
But that is not your only diagnosis. You also feel like a bad parent because you snap at your kids every night after work. This is also a human response to the disease of job dissatisfaction. So the nursing diagnosis is Ineffective Parenting, perhaps. What is it related to? Are your kids particularly irritating? No, because you love spending time with them on the weekends and on vacation. If you tell a friend “The kids are driving me crazy” and she asked you why, do you always say “I’m so tired after work?”
Nursing Diagnosis: Ineffective parenting, related to fatigue, as evidenced by your ability to enjoy your children when on vacation.
Now you have a new diagnosis: Fatigue. But wait. Maybe fatigue is the evidence of something else. If you don’t know what the problem is, try structuring the diagnosis backwards.
Evidence – I’m tired all the time.
Related to – work
The Problem – I don’t know, work makes me tired
Actually, having done the work above, you do know what the problem is. Your work is boring and repetitive, and it drains you instead of energizing you.
But now you have a new problem – you’re drained and tired and don’t have the energy to carry out the doctors prescription of “get a new job”. You have Inability to Follow Treatment, related to fatigue, as evidenced by the fact that you’re still in the same job one year later.
This approach to problem-solving can, in effect, help you to nurse yourself. Now you are not paralyzed with thoughts like “I hate work, I’m stuck forever, There’s no way I can quit, I have no idea what I really want to do, I’m just whining and I should suck it up, it’s hopeless” circulating uselessly in your brain. Now you find ways to make the work less boring or to distract yourself. You know why you’re impatient with your kids and get your mom to come over and help between 5PM and 8PM. Having help makes you less tired, and you’re able to find an online course in a subject that has always interested you. You still have job dissatisfaction, but you feel a whole lot better. That’s nursing.
medicine for real 
I had to smile as I recalled the buzz words from my nursing undergraduate years, ‘wholistic’ ‘biopsychosocial care’ ‘art of nursing science’ we even studied ‘instinct’ (can’t recall was it proven to be worthy of being referred to as a science?)….yet if I reflect on my 20+ years nursing career, whilst those care plans have long since ceased to be on paper, I reckon they continue to resurface within my day to day thinking. I wonder about the value of this teaching that encouraged health care planning, really looking at your patient and reflecting on the outcomes of the care provided. Is nursing care on busy hospital wards more and more focused on the completion of tasks with time for little else?? When doctors refer their patients to me, beyond my first 5 minutes of reviewing their lab results, medications, chronic disease screening status so that I am up to speed in their care…I may still have another 20 minutes with the patient!! (what a luxury for many primary care physicians!). So it’s my job and the hope of the doctor making the referral that I may cut to the deeper layers ….’’So Mr Smith I can see your glycaemic control is getting worse, you started a new medication a few months back’….’’Oh, you have not been taking that medication, ok why is that’’…. But how do we measure interventions such as goal setting, small gains in patient knowledge, a shift in patient apathy or their not feeling judged for a short while. Nurses need to continually strive to measure our interventions, in a robust way such that it ‘talks’. We all know each of us is entirely responsible for justifying our time and position under the shrinking health care dollar! There is some good evidence that the success of the Chronic Care Model lies in the strength of the medical model, together with what nursing and other allied health can bring to the table, with the patient at the centre of what should be a big dynamic feedback loop system.
Jen – nice response! I think that nursing diagnosis and theory is a little like physics in pre-med: You don’t use it but the process of figuring out the answer trains the mind. Nurses, like doctors, ARE more buried in tasks these days, because tasks result in measurable outcomes and measurable outcomes translate into money. I’d like to think that maybe the theory is still under there, though.
There is not a process in life that does not require this kind of incremental thinking. I think life experience causes us to problem-solve this way, if only subconsciously. Those of us who do not learn to do it either become overwhelmed with the complex problems of the day or succumb to intense boredom and/or dislike for what we do. To follow our passion (composing sonnets while we mindlessly follow the well-worn path gives us a clue as to what that interest is) is to delight in the intricacies of a lifelong choice that requires the imagining of constant “care plans” that energize and propel us forward. When I took nursing courses while in my 30s, I wrote a brilliant nursing care plan with 86 incremental steps. The faculty were overwhelmed with its thoroughness (so they waived the 3 other plans required for completion of the course). It was an exercise in logical thinking as far as I was concerned. C.