Nursing Diagnosis in Action: What Every Nurse Needs to Know | 002

Heather Herdman: 00:00:00

Hello and welcome to the Nanda cast. I'm your host, Dr Heather Herdman, Chief Executive Officer of Nanda International. Today we welcome Dr Rita Gengo to the Nanda cast. Dr Gengo is the inaugural scholar in the Marjorie Gordon program for clinical reasoning and knowledge development, which is a global initiative between Nanda International and the Boston College, Connell School of Nursing. The aim of the program, which began in 2017 is to advance, educate and disseminate nursing knowledge internationally and to foster a deeper understanding for the articulation of nursing contribution to patient, family and community care outcomes through clinical reasoning and the testing and refinement of nursing language and nursing diagnosis. Dr Gengo is an assistant professor at the Christine e Lynn School of Nursing at Florida Atlantic University, and a fellow of the Nanda International Association. She's a member of the nursing diagnosis Research Network and a researcher at the nursing diagnosis interventions and outcomes study group at the University of Sao Paulo, School of Nursing in Brazil. Her research interests focus on nursing classification, assessment and clinical reasoning, aiming to advance nursing knowledge and enhance evidence based practice and the quality of nursing care. She's also dedicated to promoting symptom science from a nursing perspective, particularly in the field of cardiovascular nursing. Over the past few years, Dr genkow has secured national and international funding. She's published extensively in her field, as an active member of Nanda international for many years, Dr Gengo advocates for the use of standardized language in both nursing practice and education. So Rita, I think we could spend all night just talking about all of your accomplishments. But welcome to nandacast. It's so lovely to have you here.

Heather Herdman: 00:02:00

Dr. Rita Gengo: Thank you. Thank you for this lovely introduction. It's a pleasure being here.

Heather Herdman: 00:02:06

We've known each other for a long time. I think we've been probably hanging out at Nanda conferences for a while now. So it's always great to talk with you. There's so many things we could talk about, but today, I'd like to kind of try to focus us on a couple of particular issues. So maybe just as a start, if you could tell us a bit about your experience working in a hospital setting and how you saw nursing diagnosis helping to direct care in that setting. Okay,

Heather Herdman: 00:02:36

Dr. Rita Gengo: that's a nice question to start with. You know, I love talking about my clinical experience and how I've learned over the years from my own experience, but also from the many, many nurses I worked with. But I want to start, you know, my I started my career back 2000 right after I graduated from nursing school, but my interest in nursing diagnosis began earlier than that, while I was to a nursing student, and I remember that, and I think it's interesting saying that, because you know, That makes a lot of sense throughout my career. So I remember I was choosing some electives that I needed to complete that year. I was in my sophomore year, and then I saw a course on nursing diagnosis. Then I was looking and thought, What is this? And I talked with some of my colleagues, and they were all like, ah, we don't know what that means. But then I looked who was teaching that course, and it happened to be a person who is my mentor to this day. And then I said, you know, I'm gonna go ahead and register for this course, and let's see what's you know, what I'm going to find out. And that course was instrumental for all my decisions. From starting at that point, I understood that nursing diagnosis was something that nurses needed to learn, and they need to, you know, practice from that particular lens. So when I so actually, before I graduated in Brazil, we have to complete, like a thesis to graduate. And of course I, I chose to study nursing diagnosis, so it was my very first work with nursing diagnosis and function of our patterns. And then I published that. And that was such an accomplishment for me at that time. And I was, I'm very proud of that work to this. Day. So then I graduated and went to work in the hospital. And at that time, they didn't have nursing diagnosis as a requirement. So we did, we did do the assessment, patient assessment, but we didn't need to document nursing diagnosis. There was, you know, everything was on paper. There was a space to document. But, you know, if we didn't complete that, then there was no problem. And that was the only place where we could document nursing diagnosis. There was no other place so and then I started thinking, you know, there's not much sense in documenting nursing diagnosis right after I assess the patient. Do the nursing assessment, but then I don't talk about nursing diagnosis until this patient is discharged. So when I was that for working, I was always talking in nursing diagnosis language. And, you know, I think it was something that kind of, I don't know, it stimulated my colleagues, or made them excited about that too. And you know, my colleagues wanted to know more about nursing diagnosis, and we start talking. And there was a group at that hospital. It was a group that we specifically looked at what we call in Brazil, at that time, called nursing system accident, which is nursing process. And I was invited to be part of that group, and that was I see that as a turning point. We started discussing the importance of looking at nursing diagnosis and see how nursing diagnosis informed everything we did with in terms of patient care. And of course, I wasn't alone everything I'm talking here. Of course there was, you know, there were a lot of people involved. But then we started discussing how we were going to implement nursing diagnosis in the electronic health record, and we did that work, and we didn't use a particular classification, but most nurses at that hospital were familiar with men to diagnose. So that was the language that we were we were using, and so I remember us. At the time, I was working at the hospital as a bedside nurse. That's what we need. We did, and like I said, we talked nursing, diagnosis language. And then I was invited to go to a kind of a nurse educator role. And when I went to this when I went to that position, my role was to oversee a residency, nursing residence program. So in what I did, one of my main things in that role was to go to the units where the residents, the nursing residents, were so called nurses, and we discussed patient care. And my questions always I began with the question, why does this patient need you as a nurse today? Oh, it's a great question. Yeah, because with that, I wanted to know what, what was the unique contribution that the students or the nurses residents, they were going to bring to the patient and, you know, to the team. And based on that, they had to plan the care based on nursing diagnosis. So from the nursing diagnosis, they would choose the interventions and outcomes that were sensitive to nursing care. So that was an exciting time, and I have I stayed in contact with many of these nursing residents, and they remember that vividly, like I do. So I think it was a great time. I think that's proof that

Heather Herdman: 00:09:31

how we were exposed to this content completely can shift how we feel about it. If you have a good experience like that, where you can actually start to see that, you know, wow, I do have a unique contribution. This is what the nurse brings to the table that can kind of reset somebody's thinking in a way that, if you don't see it that way, it's just documentation Exactly. So that's great that you're able to do that for other people as well. I'm curious, just as a follow up listening to you talk about talking nursing diagnosis language. Is it something that you shared or today share outside of the nursing group? Do you share this with colleagues and other disciplines? Do you share it with the patients?

Heather Herdman: 00:10:17

Dr. Rita Gengo: Yes, so that's interesting, because when I was doing my master's and PhD program, I was at the medical school. So my chair, my chair for my master's thesis, she was a physician and she and a biologist, and my PhD chair was a physician too. And interestingly, my thesis and my dissertation were both a nursing diagnosis, so and I remember people telling me, how come you're going to have physicians guiding you in a, you know, in research with nursing diagnosis, they don't know anything about that. And I said, yeah, they don't know that, but they know about research. And then I had other mentors who guided me in the nursing diagnosis area. So one of the things that, you know, I carry with me to this day is something that my PhD chair told me the day I defended my dissertation. She said, You know, we're I was thinking that your dissertation was going to be very simple, but it ended up, ended up being something very complex, and most, most importantly than that, your findings about nursing diagnosis also changed my practice. Oh, interesting, yeah, and I thought that that was like a testament of how, you know, everyone can benefit from nursing diagnosis. And I have another example, like I said, I was responsible for this nursing residency program, and we invited other professionals, physicians, psychologists, to come and speak with the nursing residents. And I remember we invited a physician, he came to talk about with the nursing residents, about heart failure. And he started, and I was there. Nobody told me this, so I I heard from him, and he said, You know, I can spend all the time we want me here to talk about her failure. But the thing that nurses need to know to be good nurses is one thing that I learned is called nursing diagnosis. Oh, wow,

Heather Herdman: 00:13:06

that's great. Yeah.

Heather Herdman: 00:13:07

Dr. Rita Gengo: So yes, I have shared, and I shared, you know, I've always shared nursing diagnosis outside nursing, and I do believe that it is important not only for us nurses, but to show to other healthcare team members what we do and why we're doing that,

Heather Herdman: 00:13:28

I agree with you. I think it's really important, and I was able to see that in a multidisciplinary team too, when I was in school and in my graduate work, where the nurses, you know, kind of led this multidisciplinary patient rounds, and they always started with the nursing diagnosis. And I was shocked when I first started working there, that physicians would jump in and ask questions or make comments or say, Oh, well, then you're gonna, you're probably gonna do this and this and this, because they knew what they were talking about. And I had where had gone to school myself for undergraduate school, we never talked about nursing diagnosis, except amongst ourselves. So I was really surprised that the respiratory therapists knew what it was, the social workers knew what it was, and it became a really good way to communicate between the team that and it makes sense, because, as you said, why a physician? Why would a physician be able to help you with a dissertation on nursing diagnosis, but they know diagnosis. They know the diagnostic process. So the clinical reasoning process is the same, the focus is different, exactly you know. So that's interesting. And what about with with your patients? Do you share diagnosis with your patients? Yes,

Heather Herdman: 00:14:44

Dr. Rita Gengo: I did. Now, I I, I'm not practice, practicing clinical practice anymore, but when I was working as a bedside nurse, most of the times, yes, if I thought that they were able. To understand, because one thing that I was always concerned is that I didn't want to scare them. They had very complex clinical conditions, and I always thought, well, I don't want to make things worse for them. But you know, especially when we had some diagnosis that were more psychosocial, where their validation of what I was thinking, that they might be might being experienced was important. I always ask them if my interpretation was correct. So let's say. I'll give us a simple example, let's say I was thinking that the patient was anxious. So anxiety is pretty easy. Everybody understands, or most of most people understand what anxiety is. So I would say, you know, I am saying you were saying this, and you're saying that my impression is that you might be anxious. Do you think I am I am right? Do you think I'm thinking correctly about what you were experiencing? There are some situations where the label of the diagnosis might not be readily understandable for patients. Then, you know, I was I use other words to try to explain and double check if my my conclusions were correct, and

Heather Herdman: 00:16:31

that makes great sense. I mean, our colleagues in medicine do the same thing, right? We have a heart attack, not a myocardial infarction, but that validation with the patient, I think, is so important, and they don't have to know the label, per se. But I remember sometimes working with students, and I would have them do this kind of validation check with the patients, and sometimes the patients would kind of look at them funny and say, Well, I didn't know that. Nurses thought about that kind of thing, you know. And so it was a kind of a teaching moment, too, for the patient to say, No, this is what nurses are looking for. We're looking at how you're responding. And sometimes we could have some really interesting conversations. So, you know, you're you're talking about working with students, and kind of the your colleagues in medicine makes me kind of think about the difficulty sometimes that I think nurses seem to have, or students seem to have, sometimes differentiating between medical diagnoses and nursing diagnoses. And you know, although for us, it's probably pretty crystal clear what the difference is. You know, are there times that you've seen nurses in practice struggle with that, or students struggle with naming something or giving, giving a label or a term to a response that they're seeing and trying to figure out what's medicine and what's nursing and and, can you maybe give us a good example of how a nurse might represent knowledge that is of our discipline, using terminology? Okay, yeah, that's a great question. Yes, I heard

Heather Herdman: 00:18:16

Dr. Rita Gengo: loves nurses, experienced nurses asking and debating, what is nursing diagnosis, or what is a medical diagnosis? And you know, from my from my teaching experience, teaching nursing diagnosis now for so many years now, I think that I see magical diagnosis as pretty straightforward. Now everybody is used to medical diagnosis, even though, if we are not in the medical field, we hear all the times, so and so has hypertension, so and so was diagnosed with diabetes. So we somehow, we are used to that terminology and and that's not true for nursing diagnosis. Uh, like I just said, patients don't have idea that nurses diagnose. Sometimes, you know, members of the multi professional team does they don't have idea that nurses diagnose. And I think that today we can say that nurses know that nurses can diagnose, but until a couple of years ago, that wasn't true. Some nurses didn't. Were not exposed to nursing diagnosis in nursing school. So I think that one thing is that the what I just said, medical diagnosis, are pretty straightforward. We we are used to that terminology, and we kind of know what that terminology means. You know, if you have a medical diagnosis, it means that something is not going well. With your help, right? We know that, but we don't know exactly what nursing diagnosis mean. When we look at the definition, the definition says that it's a human response. But what is a human response, right? And, and this is a conversation that I had with my mentors back in the day, and once they told me, Well, maybe medical diagnosis are also a human response. And then I said, Wow, that confused me. Now I knew what nursing diagnosis were. But anyway, you know, I think that there is this kind of blurry thing in the definition of nursing diagnosis that is difficult to understand what human responses are. And I think that this term is going to be clear as we work with nursing diagnosis, as we learn to think about nursing diagnosis, as we learn to think like nurses, then I think that term knowledge becomes clear. I think that also in other cases, what happens is that nursing diagnosis are far more complex than medical diagnosis, and I think that also contributes to the confusion, especially when I think students are trying to learn how to diagnose, how to make nursing diagnosis. What they think is that okay, if my patient has heart failure, then they will have this nursing diagnosis, that nursing diagnosis, that other nursing diagnosis. It's like equivalent, equivalence list. So Exactly, yep, and that's not true. You know, that's when I say that nursing diagnosis are much more complex. And I always mention an example, like, if we think about a person with hypertension, well, they have hypertension because they have consistent blood pressure, high blood pressure, that is, you know, in several appointments, they were found to have a high blood pressure, and they were diagnosed with blood pressure, and that's the medical diagnosis. But then when the nurse goes and talk with them, the nurse might find out that this patient, you know they have, they are ready to learn more about the diagnosis. They are willing to change their lifestyle. They want to do everything they can to comply with the treatment and things like that, then they have a specific nursing diagnosis. I might not say the name correctly now, but I think redness for or enhanced self management or something like that. I don't have my classification right in front of me now, but they have this diagnosis, nursing diagnosis, and another person with the same medical diagnosis of hypertension, we might see that this person has difficulties in, you know, adapting their lifestyle to To the treatment that's necessary, or they don't understand what that really means. So then we might think, no, this is a different nursing diagnosis. Now they might have risk for ineffective health self management or something like that. So the same medical diagnosis, but two different nursing diagnosis that will require different actions if we want to make a difference in that person's lives. Absolutely,

Heather Herdman: 00:24:06

I think that's, that's a great, great example.

Heather Herdman: 00:24:10

Dr. Rita Gengo: So I think that exemplifies the complexity and how, like I said, it's not nursing diagnosis are not really straightforward. It requires the nurse to really come to know the patient. You cannot make a diagnosis just based on what you heard from the physician or for from the psychologist, or you need to talk to the patient. We need to come to know that person. Yeah, and you

Heather Herdman: 00:24:42

mentioned earlier that you you also studied functional health patterns, and so I'm interested in how you think about that coming to know the patient, because we hear it all the time, you know, oh, the nurse knows the patient, that the nurse is the person who really understands. Ends the patient. And when I, when I kind of try to think about, well, why is that? What is what does that mean? I always kind of come back to, it's the way we go about assessment, you know, rather, you come from a theoretical model, you know, Margaret Newman or Martha Rogers, you know, Wanda hoard that, or if it's if it's from a framework, a nursing framework, like functional health patterns, that helps you think about the patient. So how do you how do you think that kind of assessment leads to knowing the patient

Heather Herdman: 00:25:35

Dr. Rita Gengo: Well, having a nursing framework to guide the way you come to know the patient, for me is the, you know, it's ground zero. We start building our relationship as a nurse with patient based on, you know, bringing the nursing perspective into that relationship. If you have nursing framework, like the functional health patterns, you've got your questions your or you're going to ask questions that are relevant for you to know the different like if you're talking about functional health patterns, to to understand how the different health patterns might or might not be affected or dysfunctional, what areas are okay, and you might want to, you know, leave that the way it is, or maybe do something to improve That pattern. But also, I think especially with the functional health patterns, it's very clear to me that one pattern influences the other pattern. Although we can look at the different patterns in isolation, they actually are not isolated because they they are going to give me, I don't want to see a picture, but I would say a movie of what that patient is experiencing. And I don't want to see a picture because it's not static. So the functional health, health patterns gave me an idea of how that patient is experiencing. It is manifesting these patterns when they are facing a situation, medical diagnosis and a life process, not a nursing diagnosis, I'm sorry, a medical diagnosis, a life process, or something like that. So I do believe that when we use the framework from a nursing perspective, that brings us to practice nurse with nursing with that patient, no we can use to choose. We can choose to to use other frameworks. But are we really practicing nursing when we use different I would say head to toe to toe assessment. Is that really nursing?

Heather Herdman: 00:28:13

Yeah, no, I would argue not. But yeah, it's a very good point. Yeah, yeah. So, you know, it makes me think about where we give power. You hear people say, and I've seen this on online chat groups and different discussion boards around nursing diagnosis that, oh, we don't need those. We have medical diagnoses. That's all we need. We know what the medical diagnosis is. We just go and intervene. And and so there's this expectation or understanding that somehow medical diagnosis are really important, but sometimes a lack of understanding of that nursing diagnoses are important. And so I'm just wondering if there are some lessons you've picked up along the years in practice, or as you've taught, done your research that you could use to help explain to people who maybe aren't believers as to why nursing diagnosis really are important.

Heather Herdman: 00:29:11

Dr. Rita Gengo: Well, I think that it goes back to how we teach nursing diagnosis. You know, I think that our curriculum is heavily based on medical diagnosis. So when you are teaching med surg, you have a Lacher on COPD, right? And then you briefly mentioned, maybe at the end of your lecture, what the possible nursing diagnosis are and what interventions you might want to choose, but we don't put emphasis on the importance of. Of the nursing diagnosis, how nurse diagnosis will guide everything we do, and how nursing diagnosis can be also a measurement of our effectiveness as nurses, as we deliver nursing care, because if a patient comes with a nursing diagnosis and they spend, I don't know, sometimes they don't spend too much time in the hospital anymore, right? Hospitalizations are very, very short. Yeah, are fast now. But you know, if they come with a nursing diagnosis and they are living with the same nursing diagnosis, did we do? What we are supposed to do. How effective was our care? How much that everything that we did cost to the healthcare system, to the hospital, and were were we really doing what we were supposed to do? So I think that when we go back to your question, I believe that my and I discussed this with some colleagues, and we try to do this in the past in another institution, and there is a lot of resistance, because usually faculty teachers teach the way they were taught. Right? So it's easier for me to think about my med surg course organizing by disease, because that's the way I was taught. That's the way med surg books are organized, most of them, but I am not sure that's the best way for us to teach nursing students how to think like nurses. So I was saying that we tried once to teach students using nursing diagnosis, and I believe that experience was very good, because I remember students enjoying because they were now learning our language. And of course, they need to know what COPD is, what heart failure is. They they need to know that. But I don't think that the medical diagnosis should be the stars. No, yeah, I totally

Heather Herdman: 00:32:22

agree with you. I just was reading an article that was published by a group of researchers in Turkey who had done a qualitative study with students asking about their experience with with nursing diagnoses. And I was really struck by it, because the student responded. The students responded that they really liked the diagnosis. They liked that it gave voice, that it directed care, but they wished their professors would teach more, because they didn't feel like they got enough information, enough understanding to in particular, they talked about differentiating diagnosis or prioritizing diagnosis, and for me, it made me think about how we set up our curriculum exactly as you just said, like we go in and we teach respiratory distress syndrome in the neonates, where we teach thermo, you know, hypothermia or hyperbilirubinemia. And why instead aren't we teaching, you know, about ventilation or respiration, or, you know, thermoregulation, these broader concepts which underlie our diagnoses, but it but if you understood the concept, and then we could teach what a normal pattern looks like, and then how you would know when it's abnormal. You get to the diagnosis, the nursing diagnosis, and then from there, we could start to talk about, when might you see this in a hospitalized patient, you know? So we tend to see this in neonates. Why we tend to see this in people who have congestive heart failure? Why? Versus putting all that focus on here's the medical diagnosis that we can't diagnose anyway, yeah, and,

Heather Herdman: 00:34:01

Dr. Rita Gengo: you know, I think that brings also a sense of autonomy, because I can decide what nursing that not. I don't have that much power, but, you know, together with the patient, we decide what nursing diagnosis that patient has, right? As nurses, we don't depend on anybody else, any other professionals, to help us to make decisions about nursing diagnosis. And like I said, we cannot make medical diagnosis, right? You know, based on the nursing diagnosis, we can decide what care plan we are going to put in place, right? Is this one better? That one better? Then comes into play evidence based practice, so everything is kind of integrated. And yeah, I think that brings this sense of autonomy as well.

Heather Herdman: 00:34:58

Yeah. Which is a great segue into my next question, which is, you know, today we hear a lot about interdisciplinary care. I used to think that was a more of an American phenomenon, but it's, it's kind of becoming a worldwide thing, where now we're talking a lot about interdisciplinary care. And sometimes it's, it's just a word. It's still a very physician driven, yes, everybody sits at the table, but it's the physician telling us what we're going to do, and then everybody goes off and does their role per se. So if you could think about your perception of kind of the knowledge of nursing and the importance of nursing diagnosis as part of that interdisciplinary team. What advice might you offer to nurses in practice, in terms of the importance of representing nursing knowledge within that interdisciplinary practice model?

Heather Herdman: 00:35:54

Dr. Rita Gengo: Well, the thing that comes to my mind is making nursing visible. Of course, we need to think like nurses. We need to learn about we need to learn about that. We need to discuss with, you know, with the interdisciplinary team, what we bring to the table in terms of our unique contributions. This is really important when we are thinking about cost of care, right? Because if nurses are there to do something that any other professional could learn to do, like I'll give you an example, put an IV. You don't need to be a nurse to put an IV. Anybody that you train can do that absolutely right. So this is not nursing per se. So what is our contribution to improve nurse to improve patient outcomes, to collaborate with other team members to make that patient to improve the quality of life, quality of life of that patient now. So when I think about your question, one thing that comes like I said, comes to mind is make making nursing visible. And to make nursing visible, we need to bring to the table. What we do is what is unique to our to our discipline, to our profession, and that is represented in nursing classifications, Nanda and also the classification nursing intervention classification, the outcome classifications. But I also think that the way we think is important, how we guide our thinking so our disciplinary knowledge, not only in terms of our classifications, but you know, the theoretical perspective that guides how we think about a particular situation, about in a particular context, because that may vary from, you know, depending on your particular view. So if we are able to articulate that to other health care team members, I think they are going to appreciate our contribution. I think we'll be able to show or to demonstrate why we are there, right, our unique contributions. And, you know, I think that, yeah, I think that the importance of being integrated. One thing that I want to mention about this is that we need to be careful not to disappear in the interdisciplinary team. And that's very easy to happen. Very, very easy, because and nurses often complain. Sometimes I hear some colleagues say, you know that discipline is taking this particular thing from nursing. Now, nurses don't do this anymore. It's that profession or now we cannot do this other thing because it's doing anybody who learned that technique or will be able to do it, and that's not what nursing is. That's what nurses do. But it's not what nursing is.

Heather Herdman: 00:39:33

It's that dichotomy between the role of the nurse exactly the things we do and the discipline of nursing, the things we know, yes, and, and it's really easy to identify the the doing things, yeah, you know, we put in IVs, we put in catheters, we do wound dressings. It's much harder to articulate, I think, the thinking part, the reasoning part that people don't see. Mm. Hmm, that leads to maybe some of those role things. But as you said earlier, and I used to tell my students this, when they would get all excited because they were going to put in their first IV, you know, I'd say I could probably teach a monkey to do that. This is not, this is not the nursing This is not nursing knowledge. This is a task. Anybody that has good dexterity can do this. They can't think like a nurse. Not everybody can do that. And that's it's a big difference between role and knowledge, I think,

Heather Herdman: 00:40:32

Dr. Rita Gengo: yeah, and the good news is that we can learn how to think like nurse. And I'm repeating this free. I don't know why, but I think that's important to think like nurse. That's what differentiate us from everybody else.

Heather Herdman: 00:40:47

So now you have me excited, and I think we should, we should write a curriculum guide in our spare time. Okay, well, Rita, this is delightful. It's always wonderful to talk to you, and I always leave our conversations with 100 ideas of things that that we should do. So I want to thank you really for joining me here today on the Nanda cast. And for those of you listening, I hope you've enjoyed my conversation with Dr Rita gango, and if you liked what she had to say, you might want to know that she's going to be one of the presenters at a pre conference seminar at our upcoming 2025 conference in Lisbon. So we hope to see you there in June. And don't forget to sign up for our newsletter@www.nanda.org and you can follow us at LinkedIn, Instagram and on Facebook. And I think it's also important to say that if you go to the Nanda website, you can find links to our publishers, or you can find our textbook, Nanda, international nursing, diagnosis, definitions and classification in I think, 22 languages now, so you can find links to the different publishers there, and hope to see you next time here on The nandacast. And in the meantime, let's continue defining nursing one concept at a time. Thanks for listening.