Navigating the Evolution of Nursing Diagnoses in an Age of AI

Heather Herdman (: 00:02

Hi, welcome to the NANDA cast. I'm your host, Dr. Heather Herdman, Chief Executive Officer of NANDA International. Today, my guest is Dr. Jane Flanagan. Dr. Flanagan is a department chairperson and associate professor at the Connell School of Nursing and a nursing scientist at the Massachusetts General Hospital, Yvonne Lund's Center for Nursing Research.

She holds appointments as a member of the board of directors at the Sherrill House in Boston. She is voluntary faculty in the School of Nursing at the Health Science Center at the University of Tennessee, Memphis. She is an associate clinical scientist at the Phyllis Cantor Center at the Dana Farber Cancer Institute and a nurse practitioner at the Foxhill Village Assisted Living Facility in Westwood.

Dr. Flanagan is editor of the International Journal of Nursing Knowledge and serves on the editorial board for the International Journal for Human Caring. She is an appointed fellow in NANDA International, the National Academy of Practice, and the National Academy, Jesus, and the American Academy of Nursing. Dr. Flanagan's work is focused on lifestyle interventions to improve the health of those caring for people with chronic health conditions. Dr. Flanagan, thank you so much for joining me today.

Jane Flanagan (: 01:21

Thank you for having me.

Heather Herdman (: 01:23

Now you have such an interesting background because you are very clinically grounded. You have this body of research that includes patients experiencing cancer, needs of informal caregivers, including those with dementia, systemic challenges of caring for chronically ill children with high complexity care needs in the home, and examining the lived experience of healing from liver transplant surgery.

You've been a NANDA member for quite a long time, and yet you are also very involved in nursing theory that would be considered a holistic approach to patient care. Your research includes the integration of nursing knowledge related to unitary transformative caring science into the practice setting. So I wondered if we could start this conversation with a very simple question, talking about how you see the difference between a label, such as a nursing diagnosis label.

as a way of describing or some would say labeling a patient on the one hand and the use of nursing diagnosis as a reflection of the nurse's clinical judgment on the other. Because I think that since the beginning of the use of diagnoses, some nurses have felt that the practice of using diagnosis is reductionistic and therefore they oppose it because it's not considered a holistic representation of the human being receiving our care.

So, so I'd like to hear your perspectives on that.

Jane Flanagan (: 02:47

Thank you for the question. And it's one that is a very interesting one coming from where I do come from, because I do believe that nurses do approach the patient in a way that is much greater than the body parts, right? And that's kind of when we say holistic. A lot of people can say across professions, I'm holistic. But what does it really mean from a nursing perspective to be holistic?

And I think that is grounded in a theoretical perspective. It is how we actually come to know the patient. It is certainly based on how we then turn around and advocate for the patient, their family, and their needs. And I think that our approach is just very different from others. We see ourselves in that role. I might work with physical therapists or respiratory therapists, and they'll say, there is this issue. But they don't have the language that we have in order how to address that. And that does come from our conceptual basis of

basically coming from our theoretical frameworks, that when we think about a unitary caring framework, which is kind of where I live in that world, I am looking at the whole of the person, but I'm also thinking to myself, how am going to communicate this to somebody? So there is that in the time moment of in practice where we need an efficient way to be able to say to someone, this is what I'm seeing. And I think that our nursing language

You know, it's always evolving. You know this better than anyone. You write the textbook. But it's always evolving. It's always changing. And I think one piece of it is how do we capture how nurses think to then capture what it is that they're trying to convey to somebody else? I also think there's a second answer to that in some ways, too, because I think as new nurses, we sometimes go in and say, what's the problem I need to fix? And, you know, we all remember this day, like whenever it might be, you just don't want to kill me.

Right? Like you want them to get through and you want to do the right thing by them for that shift that you're on and whatnot. And if that even means peaceful dying, you want to do peaceful dying well. So I think what's important for us to think about is nurses do come from a problem perspective, but we also think in a process oriented way. So we think about what are the things that they're going to need if I do get them through this day.

Jane Flanagan (: 05:02

We might not be thinking that as a brand new nurse or in a brand new scary situation where you're just trying to, like I said, get through the moment, but we do eventually get to that place where like, okay, we've got over the hump, but there's a whole lot of other things that have to be put in place for this person to be successfully healing and doing well outside of this environment. And, you know, we know from, I know this from my own research, but from multiple research that's out there, transitions of care go really poorly, whether it's coming into the hospital.

being in the hospital or going back out of the hospital and that might involve two or three steps before they actually even get home and that's if they go home. So I think that this whole trajectory of care that nurses are always thinking, how do I make this a little smoother? How do I make that a little better? Why did this even happen to this person in the first place? So we may not have language that captures all of that in that one moment and that is the unitary caring perspective, but it's also.

necessary for us to put in that moment in time for somebody else caring for that patient, what are the priorities? What do we need to address now? And so to me, it's looking at it from that perspective because we can't ignore the priorities of care because we're out here in a world saying like, you know, this wouldn't be great if all these things happened. Those are health care problems. Those are societal problems. Those are equity issues that like need a much bigger scope for us to be able to deal with it.

but I don't think we let them go. I think as nurses we kind of hold on to them and you know, there's always this expression of what keeps you up at night. It's sometimes those things that keep you up at night. What can I do to make those things better? So I don't think that they're incongruent. I think they're very complimentary and it's really important for us to keep in mind that when we're thinking about that holistic caring perspective from a nursing point of view, that unitary caring perspective from that perspective is considering the whole picture. It is considering all those things.

and it's not stopping at that. And it's one of those things that nurses then, you know, there's wonderful work to be done at the bedside, but then there's wonderful work that needs to happen outside of the bedside. And that's why nurses get involved in organizations like NANDA or whatever other organizations, because they can take it to the next level. You can't move the policy at the bedside. And if anything, we're the probably least heard.

Jane Flanagan (: 07:22

oddly enough, at the bedside. So you do have to move outside of your comfort zone to get to a place where you can say, this is what nurses do, this is why we need to be heard. I was just at a conference where I heard someone speak and they basically pushed their way onto this patient care committee, basically. And they were the only nurse on the committee and basically had to push their way on and then said, well, it didn't really come out that representative of nurses, this is their own reflection.

because they were the only nurse out of a group of, I don't know, about 50 people. And so everybody else's perspective was heard, the finance people, the policy policy, the people we consider policy people, everybody else's perspective, the insurance companies was heard, and the nurse's voice got a little bit in there because of this one person pushing their way in. But it's too, that's why we can't rely on the bedside to be the place to make our voices heard. We have to sometimes get out of our comfort zone.

Heather Herdman (: 07:53

Hmm.

Heather Herdman (: 08:15

Yeah.

That's a fabulous answer and it raises so many questions for me. I love that the fact though that you talked about, first of all, that what's happening in my mind or what's going on in this interaction with myself and the patient as I'm interacting at a bedside is not necessarily what I'm able to document.

And, you know, there can be a wonderful conversation and a lot of information that goes back and forth between patients, families, nurses. But how do we encapsulate that for a handoff? We can't spend an hour on each patient explaining what we just did. And so to me, is, I don't see a disconnect either because to me, theory is what is the underlying basis in how you approach the patient.

Jane Flanagan (: 08:53

Yeah.

Heather Herdman (: 09:08

and it drives your thinking. But Nando or standardized terminology gives you a way of saying, are the priorities of care for today. So you said that much more eloquently, but I really liked that. I also wonder, what do you see, thinking about handoffs in particular, because this is always, I was a former quality person, this is always the big problem, certainly in hospital settings, but I think in any setting or handing off between settings.

Jane Flanagan (: 09:16

Mm-hmm. Mm-hmm.

much of it.

Heather Herdman (: 09:38

How do you think we can best capture those things that we weren't able to, maybe we identified them in one setting, but we didn't have time to get there, and kind of move them on to, hopefully in your piece of the pie, you can now start to address these. Do you see ways that we can use standardized language or use other tools to improve those handoffs so that things don't get lost?

Jane Flanagan (: 09:49

Jane Flanagan (10:07.608)

Right. I think it's a great question and I think we were alluding to artificial intelligence before we got on this call and I do think that's something that we really don't need to fear because I do think if you could really get in the mindset of like, what's it like to think like a nurse? I took this quiz one time and it was supposed to be about, you know, I think your personality overall. And it was a lot of nurses taking it but there were other people as well and nurses all came out hypervigilant.

Heather Herdman (: 10:35

Hahaha!

Jane Flanagan (: 10:35

And not surprisingly, right? Like to anybody who's a nurse, that's probably not very surprising that we're always thinking about like what else could happen, what could go wrong. And our mindset is what can go wrong, right? But it reminds me of like when you go out to dinner in a restaurant, you walk in and you get an immediate feel of what the place is like, right? Nurses have that when they walk into a patient's room. What is the feeling like? So it's this intuitive kind of feeling that you know something's right or wrong and you...

you know, not going to necessarily document that, but you know immediately something's to be sensed. But then you think about, you know, ordering what it is you want to order. And I'm one of those people, like, I'd like the dressing on the side and then the dressing comes slopped all over it. And I'm like, hmm, what part of them wasn't listening? So there is a part of where the delivery of care does need to meet the person's needs. And that's what documentation gives us, right? That really clear documentation, labeling it, saying what it is that the person wants.

It can change the experience greatly, right? So if someone says they have an allergy to food and they don't get that allergy addressed, right? So that's a whole piece of like what we need to be thinking about. But I honestly feel like if we could track from the minute a person, nurses walking in the room to what they're thinking and how they're thinking and what their decision making is, we don't capture decision making in the moment. We capture decision making after I've walked out of the room and I've probably done 10,000 other tests in between.

And then I'm not going to sit down and document. And I'm going to sit down and document and tell you what it was I was thinking a couple of hours ago with a lot of interruptions in between that not being in the moment of that is part of our barrier, right? And it's part of why the handoff doesn't happen the way the handoff could happen because you're like, this is the best I can remember at this point. You're probably hungry. I probably haven't been to the bathroom. I mean, a little few other things, right? And you're thinking, here's the best I can recount. And it's always going to be

Heather Herdman (: 12:15

Absolutely.

Heather Herdman (: 12:21

Right.

Jane Flanagan (: 12:31

what's the most critical issue that you don't wanna forget. there's a whole host of other things that make the experience just like going out to dinner, really, really good or bad to that patient's experience. And sometimes it's those little things or what seems like little things, like the dressing being on the side or not, feels like a little thing. But you know what, to the person paying for that meal and having that meal and having that experience, it's not a little thing. So we can't lose that. I just, there's gotta be a way with.

Heather Herdman (: 12:54

It's not a little thing.

Jane Flanagan (: 13:00

Artificial intelligence or sometimes you have transcribers. I'm not sure if I completely have seen that in action. I'm not sure that that quite captures it either. But I do think we need to think about not being afraid of it and embracing it and having it work with us and being a voice.

Heather Herdman (: 13:13

It's kind of those things that you're lying in bed at night thinking, my God, did I remember to say this? Did I remember to say that? Right? Yeah, exactly. So, you know, when you're working with younger nurses or nursing students, how do we help them to kind of get a sense of using standardized language as a tool rather than as a documentation issue?

Jane Flanagan (: 13:18

Yeah, right, exactly.

Heather Herdman (: 13:40

we're not really looking to reduce patients. Our goal is not to somehow take all of this information we've had and now reduce them to this little label, but that we use the label as a way of trying to explain the patterns that we pick up on when we walk into the room and say, how do you help new nurses or students kind of get that?

Jane Flanagan (: 13:56

and

Jane Flanagan (: 14:02

I think that's a great question because I remember when I was in school, one of the things was to think about as many labels as you possibly could. And I actually think that's counterintuitive to what our actual goal is. So rather than listing, it was almost like, could you almost memorize the NANDL list and be able to document everything that you thought might have possibly happened in any risk, right? And I sort of say just the opposite. I'm like, what is it that you want to convey about this person? And for students, that's a really hot thing because it is, they're not always even sure

Heather Herdman (: 14:12

Thank

Heather Herdman (: 14:16

Yeah.

Heather Herdman (: 14:22

Okay.

Jane Flanagan (: 14:32

What is the scariest thing that could possibly happen, right? And they're not in that mindset. That is a learning curve that happens over time. So I think for helping students to think about when you walked in, don't be afraid to reflect on those experiences. First of all, think it's really important nurses reflect on their experiences, period, anyway. And we do not spend enough time, but I think it's really critically important to students to think, tell me about what that was like for you. And probably they're not going to be that aligned.

Heather Herdman (: 14:33

in words. Ready?

Jane Flanagan (: 15:00

from what was different for the patient, right? If like I was really uncomfortable doing X, Y, and Z for this person, do you think maybe they might've been feeling the same way? I never thought of it that way. So I think it's helping them to think not only about, you we're all about me when we're first nurses. What am I not doing? What have I forgotten to do? But then if you sort of say, help me think about what the person might've been experiencing.

Heather Herdman (: 15:10

Mm-hmm.

Heather Herdman (: 15:16

Right?

Jane Flanagan (: 15:24

And allowing that humanization of the experience, again, getting back to that theoretical perspective, we say we're a part of humanizing the experience. Well, we have to help students understand that too. So if we bring it to that perspective of helping them see what is humanizing about the experience, not only for them, but for their patient, it helps them to think about those labels a little bit differently. And I think it conveys very importantly, what are the patient priorities? And so I think it's just helping them to feel comfortable.

to express that. And too often we kind of, you know, I think there's a diagnosis like a risk for inappropriate grieving or I'm not sure if I have the right label on that. but my point being, is it what you're feeling or is it what they're feeling? You know, sometimes I think some of the labels we need to think about who's actually experiencing that. Is it that grief experience, my discomfort with what's happening or is it they're just, are they really experiencing that?

Heather Herdman (: 16:05

think it's maladaptive. Maybe. Right.

Heather Herdman (: 16:18

Yes.

Heather Herdman (: 16:23

which kind of speaks to validation, right? So how do we validate our ideas or our hypotheses about what's going on with this patient with the patient whenever possible? Because it's been kind of interesting to me, both as I've been a nurse, but then taking care of my mom as she was toward the end of her life and listening to what people would say to me. And I'd be like, did you ask for that? Because I don't think that's what she would tell you.

Jane Flanagan (: 16:24

it helps.

Jane Flanagan (: 16:34

Right.

Jane Flanagan (: 16:52

Right.

Heather Herdman (: 16:52

and realizing that they weren't necessarily reflecting her, they were reflecting themselves. This was a woman who was kind of like, don't want to die badly. So what are the steps? Tell me what the steps are. They would get uncomfortable. Like, oh, don't talk about that. We shouldn't be talking about that. And she's like, but I'm going to die. And so we validate with her. Listen to what she's saying, not what you're feeling, but what she's feeling.

Jane Flanagan (: 16:57

Right.

Jane Flanagan (: 17:06

Yeah.

Jane Flanagan (: 17:13

I am going to die and that's my concern, right? Yeah.

Heather Herdman (: 17:21

and her better nurses, it was wonderful to watch that interaction with them. And she would tell them things she had never told me. And then I would say, well, she's never told me that. No, she said that because she doesn't want you to worry about it. And was so interesting that she would feel really comfortable talking with the ones who were reflecting her experience to her.

Jane Flanagan (: 17:29

Right.

Jane Flanagan (: 17:41

Right, right. And that's what patients, know, nurses get credit for doing that all the time. Do we do it all the time? Not necessarily, but what nurses need are good coaches and good role models that help them understand, go to the places that are challenging, go to the places that are difficult. If you're feeling discomfort, imagine being the person in the bed that's vulnerable and can't really go anywhere. And like, that's the person that really needs us to sort of say, this is what I'm feeling or seeing with you. Is that, is that?

Heather Herdman (: 17:46

Yeah.

Heather Herdman (: 18:03

Absolutely.

Jane Flanagan (: 18:11

possibly true, you know, in being able to ask those tough questions because nurses do it very well. And then we don't document it, you know, so, so, and then we don't necessarily role model for someone else to see it. But when we have those role models and we do try to document it, I think, I think the documentation is really lacking in that area, though. I think, you know, we have the diagnosis to support doing that. We just don't necessarily have the medical

Heather Herdman (: 18:17

Mm-hmm. Yes, yes.

Jane Flanagan (: 18:40

electronic health records. You know, I love that we call them health records because it doesn't feel like it's so nursing oriented. I remember Elizabeth Barrett said to me, Jane, make sure you never use EMI, use EHR. And, you know, saying don't use electronic medical record, use electronic health record. And I thought, oh, that's great. I agree with you. And then I thought, is it really? Is it really? You know, I agree with what she was trying to convey.

Heather Herdman (: 19:07

to do right.

Jane Flanagan (: 19:08

But I'm not sure that the record actually does that. it becomes very much a, if people think Neander's labeling things, I think the electronic health record does that even. It's really a safety checklist sometimes. Cover things up. Make sure you said what you were gonna do.

Heather Herdman (: 19:22

Yeah.

Yeah, you know, it makes me think about how nurse's voice gets heard within this huge record and does it even get seen within the huge record? And, you know, that kind of makes me think about this whole notion of interdisciplinarity, which has been the buzzword for the last decade or so.

Jane Flanagan (: 19:36

Mm-hmm.

Heather Herdman (: 19:47

You hear people saying all the time on television commercials to articles that multidisciplinary teams or interdisciplinary teams, transdisciplinary teams, of different words, but they're all important and we really need to have everybody involved in them. And what I tend to see is that these are teams that have many disciplines in them, but there's really not necessarily any inter happening.

Jane Flanagan (: 20:15

Right.

Heather Herdman (: 20:15

And I think that it seems to be to me sometimes because nurses don't know what it is that they should or don't know how to share what it is that makes their knowledge or their perspective on patients unique. And it made me think about a couple of years ago, you had written an editorial in the International Journal of Nursing Knowledge. And in that, you...

Jane Flanagan (: 20:26

Right.

Jane Flanagan (: 20:32

Mm-hmm.

Heather Herdman (: 20:43

He made a comment that the nurse in practice and in some team-based science is completely obscured. And then you go on to say that this type of work is critical to advancing knowledge. It's important. And it's essential that nurses bring their perspectives to the forefront. And I couldn't agree with you more. So I'd love to hear your perspective on what you think that core disciplinary knowledge is and how that should be embedded into curriculum and practice and research.

Jane Flanagan (: 20:49

Mm-hmm.

Jane Flanagan (: 20:55

Jane Flanagan (21:07.8)

Mmm.

Jane Flanagan (: 21:12

So I love the question because I think that, you know, what I see more and more of is what I would call our colleagues in that interdisciplinary, transdisciplinary world using things that are really embedded in nursing practice. And so one of the things that I can think of is the what matters most, you know, and I'm like, that's interesting. What matters most is to me, Margaret Newman.

Heather Herdman (: 21:23

Thank

Jane Flanagan (: 21:39

you know, tell me about the significant people and events in your life, right? So that is, tell me about that and then what's important to you. So like that is a framework that is grounded in nursing. And now, you know, people sort of say, well, you know, that's what that's what I do as a physician. And I'm thinking, well, you're practicing nursing without a nursing license. And that's we know that the other way couldn't happen, right? You know, no nurse would be practicing medicine without the medical license.

Heather Herdman (: 21:59

Alright.

Okay.

Jane Flanagan (: 22:08

But I do think what's really important is for us to be clear about it because I don't think that we've been clear that that is what it is that we're doing. And I do think that again, we're not documenting it. So then no one knows that we're actually doing it. We basically document all the, to your point, the critical things in the handoffs so nothing happens, that a quality issue, a safety issue doesn't happen. But all the other really good things we do, we do not document.

And then when we get at the table with an interdisciplinary team, we don't say what it is that we do that's different. And I have found more and more that when I've been part of teams, think that physicians are being educated a little bit differently about the concept, at least, of what it means to have other people at the table. And I do find our voices more welcomed to be able to express that. But we just have to be comfortable speaking up and doing it.

You know, I mentioned and you mentioned it about introducing me that I'm interested in lifestyle interventions. Those are, you know, broadly holistic interventions, but they're preventative interventions. No one owns those. No one owns like healthy eating, healthy exercise, all that. That's anybody can, anybody can say that's my thing. I think nurses approach it differently by saying to the patient, let's talk about where you are, but this is what I see. What do you think? What's a priority for you?

We do go about it in a very different way and it's not a prescriptive list of here's the things rather than a prescription pad of pills, I'm gonna give you a prescription pad of activities I expect you to do and let me know how it goes and if you don't then you failed, right? That is a little bit and with all due respect to my physician colleagues, a little bit their model, right? That these, I gave you a list, you didn't do it, I don't know what to do with you. You know, I work with people with chronic illness and you know, they have the best intentions but.

Heather Herdman (: 23:36

Great.

Jane Flanagan (: 23:55

things get in the way, including just the cost of their medications and keeping up with taking them and just trying to get through the day sometimes. So you really have to scale that back to where they are and what they're able to do. And basically, nurses do this very well, like rewarding the small incremental changes and being with the person through the journey and recognizing not every day was going to be a perfect direction going this way. Some days do a little bit of zigzagging and.

Heather Herdman (: 23:59

Smart.

Heather Herdman (: 24:12

Mm-hmm.

Jane Flanagan (: 24:20

we're with them on that journey and accepting of who they are on that journey. I think that's the nursing perspective and we can't be afraid to say that. So when I have my physician colleagues saying like, I do that, I'm like, yes, but this is what I do differently. And I do hear more recently an acceptance of that, but you can't sit at the table and be quiet. And what you have to do is be able to have your own language of how you're saying it. And I do think

Heather Herdman (: 24:29

Yeah.

Heather Herdman (: 24:35

Yeah.

Jane Flanagan (: 24:49

going back to the theory question, our theory doesn't form our language and how we are with our patients and with our family members that we're dealing with as well. Like we're dealing with the whole and it's not just that, you know, when sometimes I see some of my physician colleagues like, I did a good job talking to the family. I'm like, yeah, talk to the family. didn't talk to the patient. They talked to the patient and then came out and told the family what happened. It's not really everybody in the same room at the same time, right?

Heather Herdman (: 25:16

Yes.

Jane Flanagan (: 25:17

We don't want to role model that. We want to role model like, okay, let me maybe get each individual story, but now let me bring it together to hear what I heard that was discrepant or congruent or whatever it might be. That's what we do differently. We need to own that.

Heather Herdman (: 25:28

Yeah. I think too, like you had a whole piece about meeting the patient kind of where they are. There are some things that patients are going to say to us, I'm not going to do that. I am not giving up my Coca-Cola on Saturday nights. I don't care. Or I'm going to have a piece of pizza, you know, whatever, when I watch a ball game. And so how do you work around that? Because there is something to quality of life, right? And so

Jane Flanagan (: 25:40

Right. Yep. Yeah. Right. Right.

Jane Flanagan (: 25:53

Right.

Heather Herdman (: 25:57

kind of not saying, this is a non-adherent patient, but saying, okay, this is really important to the patient, so how do we work around that so to kind of mitigate as much as possible any of the negative effects and allow them to have some joy in life?

Jane Flanagan (: 26:06

We're not.

Jane Flanagan (: 26:12

Right, Like how do we tailor the interventions? And I think we're very good at tailoring, not documenting that we tailored, but tailoring the interventions to say, okay, if you want that pizza on Saturday night, like let's talk about like what that does so you are knowledgeable. We don't want to just say, just have it. Let's make sure you know what it's doing to your blood sugar and your cholesterol and all of that. Here's the information. Now what else can we do the rest of the week? Can Saturday be special? We might ask that question, right? So.

Heather Herdman (: 26:34

What's the answer?

Heather Herdman (: 26:39

Right? Yeah. And allowing them to make an informed decision. So not just, okay, well, you want to do it, go do it, but okay, if you do it, you realize this, yes, I do. Okay. And then, you know, I might be one of those patients. We're all like that, right? Yeah. So, so to kind of change the tax a little bit, I just came back from the Ascendio Conference that was held in Rotterdam.

Jane Flanagan (: 26:44

Exactly.

Jane Flanagan (: 26:49

Right. Right. Exactly.

Yeah, yeah, I think the reality is we all are.

Heather Herdman (: 27:08

And for anybody who was there, I know you know it was a wonderful experience. And if you weren't, recommend you try to go two years from now and they have their next one. But it was filled with ideas, but also with examples of how people are starting to use big data. And often combining advances in artificial intelligence with that big data and looking at how we could or already are.

transforming healthcare in just many, many ways. during the pandemic, or right after the pandemic, I think, you wrote an editorial for our journal and you discussed the need for nurses to ensure that big data captures what it is that nurses do to provide humanistic care during people's lives. And I remember reading when I read it and thinking, see, theorists do actually think about data.

Jane Flanagan (: 28:02

You

Heather Herdman (: 28:03

So sometimes you'll hear people who don't think of themselves as being very theoretical saying, they don't really, they're not really, they're not really realists. They're not really thinking about what's happening at the bedside. And so it kind of made me smile when I read your editorial thinking, you know, well, here's one who clearly does and you know, people pay attention. So talk to me a little bit about what you think we need to ensure that gets captured in the electronic health record that can make the voice of nursing contributions.

heard and maybe can help nurses to better articulate what it is that they know, which I think they have trouble sometimes articulating, versus what they do, which they can easily explain.

Jane Flanagan (: 28:46

I do think nurses are very good at describing what it is they do and terrible about describing what it is they think and why they think the way they do. So it's that it really is that, you know, clinical reasoning process that's going all along. I mean, you might go in a room and think one thing and then you're like, let me reevaluate that. And you're changing your mind as you go. Capturing that would be incredibly important. You know, why, why you're thinking differently than you did just five minutes ago.

what it is that nurses see isn't really important. I mean, we do use all our senses when we go into a patient's room. I don't think that that's captured in any way. So I think that is that part of the piece is really important. And when it's not captured in the documentation, it just completely gets not noticed in one way. sometimes I see a lot of that diagnoses that come through the journal and it's definitely much more that very almost

a little bit more prescriptive than I would like to see because it doesn't capture what I'm seeing in the big picture. And I think that something like artificial intelligence could really help us to be able to think about what is happening in that moment of what a nurse is thinking. I think if we capture that well, then I think then it will be in the data set and it would be part of the electronic health record we were referring to earlier. It doesn't necessarily capture nursing knowledge.

Heather Herdman (: 30:10

Yeah.

Jane Flanagan (: 30:13

And so I think that if we pay attention to why we think how we think and then capture that in some way, you know, again, going back to when I was educated about nursing diagnosis, you my notes probably were four pages long. No one could write a four page long note. I copied everything. I captured everything I was thinking and I got an A in everything. But that doesn't mean it's realistic, right? That's like that's so far removed from what you can really do.

Heather Herdman (: 30:31

Get ready to have

Jane Flanagan (: 30:41

But yet if a social worker was to go in and talk about a patient family dynamic, which again is a very different perspective than our dynamic of what we're looking at, that would be an okay note to read and write. And their notes would capture it, our notes wouldn't. So what's wrong with that picture? And we spend that very close and intimate time with patients more than any other provider, and yet we're not capturing that. And I think if we took away the documentation burden,

Heather Herdman (: 30:53

Mm-hmm.

Jane Flanagan (: 31:08

to capture that in some other way, whether it is artificial intelligence or something else, then it would be beautiful because we'd actually have it there. I remember I had a nurse director and he always just scared people because he'd say, what if a robot replaced a nurse? What would that be like for everybody? And everybody would be like, what's he trying to do? Get robots in here to replace us? And that was the beginning of the robot movement, if you will.

Heather Herdman (: 31:17

Thank

Heather Herdman (: 31:31

Yeah.

Jane Flanagan (: 31:32

And people were like, well, no one could ever do this. And this was a group of operating room nurses. And he was like, so they couldn't count the sponges? Like, help me understand what would they be paying attention to differently? And people got really visibly upset by it. But what he was trying to say is, what are you as a human bringing to that interaction? And why is it different that a human do that? So yes, a machine can do that. But are they paying attention to everything that's happening in the room, the whole environment?

Heather Herdman (: 31:41

Yeah

Heather Herdman (: 31:52

Great.

Jane Flanagan (: 32:02

And are they capturing that other thing? And we better have language for that other thing to be able to say, that's what's different and that's what I bring to the interaction. And one nurse captured it beautifully. said, I went in the room and I sweep the environment of whatever happened in the previous case and bringing a new energy and a new vibe to that new environment so that everybody can feel calm and relaxed. so like literally, I feel like I'm sweeping the room between patients. And I thought, now where's that captured?

Heather Herdman (: 32:29

Wow. Right?

Jane Flanagan (: 32:31

Right? It's not. But that to me is part of what needs to be in big data. Big data needs to capture that as well.

Heather Herdman (: 32:40

It's interesting, at Ascendio they talked a lot about the use of what they call ambient listening. So that, you know, as the nurses are talking, whether it's to a patient among themselves or just talking to oneself, that data can be captured and then sifted through, you know, using AI tools, et cetera, to identify things. And so maybe, you know, it kind of is exciting to me to think about the possibilities of what we might find.

that yeah, this is what we've known all along nurses are thinking and doing, but wow, we're actually seeing it now in the records. That doesn't scare me at all. think that's one of the reasons.

Jane Flanagan (: 33:14

Right.

And you know, what's interesting about AI is it's still, I mean, from my understanding or limited understanding of it, it doesn't capture the emotion. But if you were to see this is what I was thinking and then add what you're emotionally were thinking to that, that really puts the human component in it, right? So, know, nurse expressed, you know, dissatisfaction. No, actually, I was really quite emotional hearing what that person had to say and didn't know how to respond. Like capturing those moments as much as because it's...

Heather Herdman (: 33:23

Right.

Heather Herdman (: 33:29

Yeah.

Absolutely.

Heather Herdman (: 33:41

Yeah.

Jane Flanagan (: 33:47

Do we always know how to respond to what patients bring up? I know I have not, I mean, I don't care how long I've been a nurse, someone's gonna catch me every time I'm practicing to say, you have me go, huh, I don't have the answer for that, right? And what do you do with that? And those of those moments that you do wanna capture that, no, I don't have the answer for that and I'm gonna have to look that up or I'm have to think harder about how I would approach that type of problem, you know, so.

Heather Herdman (: 33:59

Yep.

Heather Herdman (: 34:13

Thank

Jane Flanagan (: 34:15

You know, I had someone recently say to me, what do I do? My daughter recently died and my son's not speaking to me. He has mental health issues and he's challenged. Now what? And it's sort of like, hmm. So how do we do patient family-centered care in that situation? Right? Not exactly an easy situation.

Heather Herdman (: 34:27

Yeah.

Heather Herdman (: 34:37

People are complex. Well, I mentioned a couple of your editorials. So it seems like a good segue into a question about the Nanda Journal itself. And as the editor of the International Journal of Nursing Knowledge, it is the official journal of our organization. And I should tell people for those who may not know, it's a peer-reviewed publication for professionals that are committed to discovering, understanding, and disseminating nursing knowledge.

Jane Flanagan (: 34:38

Right.

Jane Flanagan (: 34:47

Uh-huh.

Heather Herdman (: 35:05

you know, this journal used to be called Nursing Diagnosis. And I really love that we changed the name. And I love that we went for nursing knowledge as a whole because, you know, I think as we've talked about today, obviously, diagnosis is one piece of the clinical reasoning puzzle. It isn't the clinical reasoning puzzle. But I thought it would be nice for our listeners to get some insights from you as its editor as to what are the types of papers that you are looking for and that you would like to see.

in terms of publications in the journal.

Jane Flanagan (: 35:34

That's such a great question. One of the things that I probably have written an editorial about is what I sometimes what I don't necessarily want to see, which is sometimes how nurses feel about nursing diagnosis, because, you know, it's here and it's the reality and, you know, let's move past that, you know, that piece of it. But moving past it actually is exactly some of the things that we've been talking about today. What is nursing knowledge? How do we explicate that? And

those are the types of papers that I really would love to see in the journal, like making those linkages between what it means to think like a nurse and what it means to actually be with the patient, and then how do you then document that? So to me, pushing those, like pushing our organization to be able to think in that, you know, I know you're on board with this, like how do we capture all of that? It's not, people are complex, our caring is complex, what it is that we do every day, thinking about so many different.

types of things around the patient situation. How do we capture all that? And it is driven by the way we think as professionals and how do we then mentor a new generation? So we have to start writing papers saying, this is how I think like a nurse, this is the theoretical perspective that does guide my practice. And this is the best way I can document it for now. And that will evolve our language, which will be a good thing, right? We always wanna be moving in a...

know, a direction where we're capturing the bigger picture. And to me, that's the connection I would love to see in the papers that come forward. Sometimes I have to say, you know, I get one of those papers and I'll send it out for review and people say, well, this isn't anything to do with nursing language. And I'll say, so please read our aims and scope because it is beyond that. We do want to be capturing papers that are around nursing knowledge. And I welcome those papers for sure.

Heather Herdman (: 37:20

Yeah.

Heather Herdman (: 37:31

Great, great. Well, Jane, I really want to thank you for your time today. It's always a pleasure to speak with you. I always leave with all kinds of questions. And if our guests have enjoyed today, I should also say that Dr. Flanagan is one of the keynote speakers at the upcoming NANDA International Conference in Lisbon, which will be in June of 2025. So I hope that you can join us there. You can find more information about that on our website at www.nanda.org.

If you have enjoyed the conversation, give us a review on the platform you're using for your podcast. And we're very interested in topics you would like to hear about, as well as maybe individuals you might want to hear from. So drop me a line at ceo at nanda.org. Thanks to all of our listeners for tuning into this episode. Please see our website while you're there. Don't forget to sign up for our newsletter. You can follow us on LinkedIn and on Facebook.

And you will also find links to purchase the NANDN nursing diagnosis definitions and classification text on our website. So we hope to see you next time. And until then, let's keep defining nursing knowledge, one concept at a time.

Jane Flanagan (: 38:38

Thank you for having me, this wonderful experience.