How Nursing Language Transforms Patient Outcomes

Heather Herdman: 00:00:00

Hello and welcome to the nandacast. I'm your host, Dr Heather Herdman, Chief Executive Officer of Nanda International. Today I'm going to dive a little bit into a topic that's been on my mind lately, the breakdown of the nursing process. We all talk about the nursing process, assessment, diagnosis, outcomes, interventions, but we often teach and implement them in practice as a cookie cutter plan of care that has nothing at all to do with the nurses, assessment, her judgment, her decision making. You know what I mean, pre developed care plans that link to a medical diagnosis rather than the nurses assessment. Well, what if I told you there's a better way? When I was a student, we were given assignments for clinical practice rotations with the patient's name, their age and their medical diagnosis. We'd usually get these about five o'clock in the afternoon, and then we were to go back to our rooms and develop a care plan before we ever walked onto a clinical floor, before we ever met a patient. And what I mean by the beginnings of a care plan was depending on our instructor identifying at least three to maybe six diagnoses and developing a full plan of care with outcomes and interventions to address this patient's needs. Now I don't know what the faculty thought was happening, but the reality is that we sat in dorm rooms, scrolling through nursing care planning books, trying to find something that sounded like it might be related to patient's medical diagnosis, and frantically copying down interventions and outcomes that those care plan bulk authors had identified. It was, in my opinion, an exercise in frustration and futility. And you know, a common conversation in our dorm rooms might go something like this, I have a 75 year old male patient with a stroke. What's the right diagnosis? And then the three or four of us that would be sitting in the room would start paging through books to see if we could find something that sounded like it might have something to do with someone who had a stroke. The conversation would continue as we were looking for the books, you know, along the lines of, how am I supposed to know the condition this patient is in? I don't even know if this patient is alert and oriented. Does he have the family? Is there a support network? Does he have other conditions that might be affecting him? This is so ridiculous. How am I supposed to do this? And generally, after spending all this time trying to make up what might be possible for this patient, we would arrive on the clinical unit the next morning to find that sometimes half or even more of what we had identified was completely irrelevant for this patient. Now our instructors would argue that it wasn't so much about this particular patient as the care planning exercise was to teach us about underlying causes of the nursing diagnosis, we selected how they might relate to having a stroke and what we would do about it if it was identified. But honestly, for me, it never made sense. In our nursing fundamentals class, we had learned that nursing diagnoses were reflections of how an individual or family or community experienced a health crisis or perhaps a change in developmental stage or life process. So simply having an age and a gender and a medical diagnosis told me absolutely nothing. And I'm afraid to say that this type of teaching technique, in effect, left me feeling that the nursing process was perhaps a nice idea, but something that would never be useful in clinical practice. And unfortunately, when we would talk to nurses on the clinical units, they often had learned to use nursing diagnosis in their school, and so they told us, just don't worry about it. You won't have to do this when you get out real nurses don't deal with nursing diagnosis. This led to even more frustration amongst us, as we started to feel that the exercises we were given were busy work, rather than learning important strategies to help help improve our abilities to be good nurses. So fast forward a few years to when I was working in a hospital and I started to see interdisciplinary teams discussing patients with nurses leading these rounds. I was really surprised to learn that these team meetings were led based on nursing Guide. Diagnosis, the primary nurse would identify the patient, give a brief history of what had happened during the previous shift, and then would identify which nursing diagnoses they would be focusing on during their upcoming shift. Now members of other disciplines might comment or ask questions, and sometimes they might identify how what the nurse was seeing or was treating was interrelated with something that they themselves were focusing on from their perspective, over my weeks of orientation, and then moving into being a nurse practicing on my own in that unit, I started to realize that although each discipline might consider the same phenomenon, let's say anxiety, whether it was a physician, a nurse, a respiratory therapist, we all looked at that phenomenon of anxiety from a different lens, from A disciplinary lens, so the respiratory therapist was mostly concerned with how anxiety was maybe causing the infant to fight the ventilator, or how how efficient the ventilator was able to be, and the physician might be concerned about how it was affecting Cardiovascular or respiratory parameters. And while as a nurse, I was also interested in those things, I was looking at how anxiety might affect neuro behavioral changes in the infant, or how it was affecting the parents, as they observed and tried to care for their infant. And this led me to start thinking about how different disciplines could assess a patient and arrive at perhaps the same term anxiety in this case, yet we all arrived there by looking at different data, whether through observation or physical exam or parent interviews, And we might arrive at different parameters to monitor and different interventions. This was the beginning of a revision of my thinking about the nursing process, and specifically about nursing diagnosis. Over the years, what I've really come to realize is that assessment is the most critical step of the nursing process, and today we have a new problem in connecting the dots between assessment and the plan of care. It's always been there, but I think it might be a little worse in many, if not most, of our electronic health record systems, the assessment data is collected in one location or set of screens in the electronic health record system, and then the plan of care is developed or approved somewhere else. It's very rare that I see a linkage between the data the nurse takes the time to collect and what she considers, and that is critical for arriving at diagnosis and the space where they must document the actual diagnosis, outcomes and interventions. This is frustrating for the nurses. It leads to an increased amount of time, because often they have to go back and forth between the assessment screen and the care planning tool, or in the worst scenarios, they have to re enter same data over here and over here. Now, systems have tried to find a way around this problem by producing these standardized care plans that the nurse can select and implement. In other words, we've come up with an electronic form of what we did back in our old dormitory rooms when I was a student, as we flipped through pages of standardized care plans, it didn't work then, and it doesn't work now. And although vendors will counter that nurses can select or unselect interventions or outcomes or diagnoses, and they will often boast about how wonderful it is that these systems can be customized by anyone, so that you know, every unit in the hospital can have a different Care Plan or different terms in their care plan. They are losing the purpose of standardization of terms, and they are often still being linked predominantly to medical diagnosis. This linkage, that is without evidence in most cases, reduces the patient to being labeled an individual with a particular medical condition.

Heather Herdman: 00:09:49

It takes away the importance of the nurses clinical reasoning, and it doesn't support care planning based on the data that has already been collected by that nurse and. So what if there was a different way? What if, as the nurse did a structured assessment using a framework that's based on nursing knowledge, the computer system was able to help link that collected data to potential diagnoses? If you think about what defining characteristics are. They are the signs and symptoms that we as nurses collect when we are conducting an assessment, whether that's the initial intake assessment, the more in depth assessment or ongoing assessments that continue as the patient continues to receive care, so as the nurse is documenting the data she collects, information systems are completely capable of linking that data using the defining characteristics identified by Nanda International to potential nursing diagnoses. The defining characteristics and related factor are the diagnostic indicators. They are the things that should be present in a patient if we're going to diagnose something. So as we find these characteristics, as we're doing assessments, computer systems can help us to show those linkages to support our critical thinking, not to do it for us, but to support it. And so this would enable the nurse to consider appropriate diagnoses based on assessment of this individual, patient or family or community, not on a medical diagnosis, or not, based on some pre programmed care plan that a group of people came up with in a room somewhere. If this sounds like science fiction, it really isn't. This technology already exists. We just aren't harnessing it within nursing practice. Now, what we often hear is there isn't money in the budget for nursing informatics or for nursing terminologies, but this is such a short sighted way of looking at things. There are studies out there that document that length of stay and return to hospital is directly related to nursing diagnoses. But who is advocating for the importance of the nursing process and of the tools we need to support it? We need to call on our nurse executives to take a step back, forget maybe what they learned or how they learned about standardized languages in the nursing process, and really look at the potential of standardized terminologies that are eminence based, and that is critically important, a term without a definition and clear diagnostic indicators is just a term. But when we have that wealth of information that is based on literature, based on research studies underneath those terms, they give us the potential for improving quality care and patient outcomes. More importantly, we need to be looking at methods to decrease documentation time burden on our nurses, while still enabling collection of the important information that they obtain from patients every single time they interact with them. We need to put as much emphasis on the quality of the nurses diagnostic abilities as we do on how efficiently they're able to pass medications. Think about that just for a second. If we thought about how well do you diagnose and are you actually selecting interventions that have been proved through research to be the most effective given the human resources and the the physical resources that you have in your institution, which of those interventions are most likely going to get you to the outcome that you want. Isn't that what we want nurses to be focused on? I would argue, and I know this is controversial, but I would argue that we could train personnel to safely pass medications. In fact, there are hospitals all over the world where patients already self medicate, or where unlicensed personnel are able to distribute medications, stay with the patient while it's taken, and document that it has been given. But those same personnel, no matter how well they perform that task, are not able to keenly observe, assess, develop hypotheses and then arrive at a diagnosis which can direct care. This is because diagnosis is not just a task. It is not just a documentation tool. So. A diagnosis requires disciplinary knowledge, so it is far more than a skill or a task. It is the culmination of application of the knowledge of the nursing discipline to a set of data collected from a patient or family or community, which ends in a judgment about the response of that individual, family or community, and which can direct treatment that's not a skill, that's knowledge, accurate application of the nursing process goes well beyond diagnosis, intervention and outcome. It provides a professional voice for our discipline. You know, today we hear a lot about interdisciplinary care, but it's often just a buzz word for physician driven care that is assigned to other disciplines to do the use of an assessment driven diagnostic process, which then leads to outcomes and interventions, can provide a roadmap for other disciplines to understand the uniqueness that our discipline brings to the care of the patient. Going back to my days in the hospital that I spoke of earlier, I remember being surprised to realize that the physicians and social workers and respiratory therapists who sat around that table discussing our patients understood what the nurse was focused on and why, and then what she was going to do about it when she used standardized terms. I had never heard nurses use diagnostic terms with anyone other than themselves, but by doing so, these nurses were able to communicate to other disciplines what it was about their care, their judgments that was different from the medical judgments or the judgments of the other professionals. And you would hear these team members say to the nurses, oh, okay, and you're going to be managing that piece, right? Because they knew that whatever diagnosis the nurse had just mentioned was within the domain of nursing practice, and I didn't have to describe what I meant by ineffective thermoregulation or Parent Infant separation. They knew what that meant, because the nurses used those terms all the time, and so all the disciplines were aware of them. So to my nurse educator colleagues out there, I would recommend a reconceptualization of how we deliver content to our students. Why do we continue to this day to have chapters in nursing textbooks on how to diagnose congestive heart failure or respiratory distress syndrome, when in fact, nurses do not diagnose these things unless they're nurse practitioners. Would it not make more sense to have chapters that focus on ventilation or breathing pattern, on thermo regulation or resilience, and really explain the importance of those concepts, how nurses can address them, in terms of identifying patients who have a normal pattern and those who have an abnormal pattern or are at risk for an abnormal pattern, and what can we do about we could, then, after explaining the concept of ventilation, for example, identify how we would recognize normal ventilation and how we would know we had a problem with ventilation. What would it look like if the patient was having a problem? What would it look like if the patient was having a normal ventilation? Because we have to understand the normal before we can understand the abnormal, and only once we understand those things could we then bring in the medical conditions where we might be most likely to see these types of responses occur if we turned on its head the way we teach now, and we focused on the phenomena of concern to nursing and the nursing discipline, and really help students and nurses understand those critical concepts, nutrition, sleep pattern, ventilation, thermal, regulation, resilience, coping, just to name a few, they would be able to apply that knowledge across multiple medical diagnoses Whenever those signs and symptoms and etiologic factors appeared. You know, nurses are always credited with knowing the patient. But what does that mean?

Heather Herdman: 00:19:51

I would argue that the reason patients will tell us that it was the nurse who heard me, it was the nurse who figured out something was happening or something really bad, was. Going on, and called in a team to figure it out is because those nurses are looking at patients in a way that allows them to synthesize data they are collecting from each and every encounter, and they arrive at judgments based on the nursing discipline, and those concepts are phenomena of concern to the discipline, but we have to find ways to make this easier. We need systems that are developed for the nursing process to support the thinking, the critical reasoning and clinical reasoning underneath the nursing process, not just to tick a documentation box. We need our IT developers to really understand what nurses know and how they use that knowledge to develop plans of care, and stop seeing treatment plans as some cookie cutter documentation tool that can easily be inputted into a system that a nurse can just check off as she goes through her day, not quite sure if those same people were the patients they would want to be seen as a unique human being with unique responses deserving of the highest level of evidence practice that is the essence of nursing. So I think my point here today is that we really have to rethink how we're doing things, whether that's teaching or practice or developing and using electronic health records rather than care plans. They're just really an exercise in futility from the perspective of the nurse or a way to pass inspection on behalf of healthcare systems and information technology companies. We need informaticists who are willing to work with us to develop interactive systems that capture the nurses judgments about each individual patient in a way that can be standardized across systems, across countries and across locations and sites. So we can continue to research these responses and better understand how to identify them when they occur and what interventions are most helpful when they do occur. So I'd like to ask our listeners to share some stories about educational methods that they have found useful in honing clinical reasoning skills in making the nursing process really come to life, and maybe some of our students can talk about things that they have found helpful or not so helpful. And most importantly, to our nurses. In practice, we need to find our voice and make it known to our administrators and our Information Technology colleagues, but the use of standardized terms is essential for decreasing documentation. It can facilitate research because of the standardization and improve patient outcomes, but only when it is done in a way and it supports the individual nurses clinical reasoning for each individual patient, family or community. So with that, I want to thank our listeners for tuning in to this episode of the nandacast. I hope you'll join us at our international Nanda conference in Lisbon, which is held this coming June. You can find all the information on our website@www.nanda.org and while you're there, don't forget to sign up for our newsletter. Follow us on LinkedIn, Instagram and Facebook. You'll find links to purchase the Nanda I nursing diagnosis, definitions and classification text on our website as well. I hope to see you next time. Until then, let's keep defining nursing one concept at a time. You.