The Evolution of Nursing Diagnoses

Heather Herdman (: 00:03

Welcome to the NANDA cast. I'm your host, Dr. Heather Herdman, Chief Executive Officer of NANDA International. Today I am honored to welcome Dr. Mary Ann Laven, one of our founders of NANDA International. She holds a diploma from St. John's Hospital School of Nursing.

her BSN and MSN degrees, and her advanced nurse practitioner certificate from the St. Louis University School of Nursing, and a master's in doctorate from Harvard School of Public Health.

Heather Herdman (: 00:38

Her career has included a plethora of things and we could spend the entire day going through them. But I'll just suffice to say three years of public health nursing in La Paz, Bolivia. She was a clinical nurse specialist in coronary care, director of the cardiovascular nursing program at St. Louis University, and an associate professor in both undergraduate and graduate programs at St. Louis University.

, Mary Ann co-coordinated the: 1973

erican Academy of Nursing. In: 2024

ke a step back in time to the: 1970

Tell us why you began to look at what eventually became nursing terminology or what we now know as nursing diagnosis, like whatever possessed you to go down that route.

Mary Ann Lavin (: 02:23

Well, that was the time when I was directing the cardiovascular nursing program and Chris was our mental health consultant. And what started it was that Joan Carter, who later was associate dean at the school, was at the time director of the hospital department of nursing. And she called up one afternoon and said, Mary Ann, how are we going to get nursing diagnoses in the computer?

ing it? And remember, this is: 1973

And I said, I'll get back to you. So I hung up, went across the hall to Chris and I said, Chris, I just promised Joan Carter that we would create a nursing classification. How are we going to do it? And she said, she said, we'll call a conference. And I said, And I said, we'll have it here at SLU.

Heather Herdman (: 03:38

Hahaha!

Mary Ann Lavin (: 03:51

And she said, yes. And I said, how many? And she said, well, let's invite 100. And I said, OK. And she said, but it has to be competitive. And I said, how? And she said, well, ask them to submit an essay. And I said, nursing diagnosis. And she said, yes.

So that's how it all started. Later that night, about two hours later, we were both down in the basement in another office. And Chris said, I just had another idea. And I said, what? And she said, we'll call it the national. We had already decided it was going to be the first conference on nursing diagnoses. Chris said, it'll be the first national conference. And I said, Chris, we don't.

Heather Herdman (: 04:40

you

Mary Ann Lavin (: 04:43

You don't have any authority to call a national conference." And she said, but we're inviting people from across the United States, right? And I said, yes. She said, then it's national.

Heather Herdman (: 04:46

you

Heather Herdman (: 04:53

Hey, if you don't name it, it doesn't happen, right?

Mary Ann Lavin (: 04:58

Right, right. So that's how it all started. Then we went to the dean and she was all in favor of it, Sister Mary Theresa Knoth. And then she went to the authorities at the university and the medical school people said no.

Heather Herdman (: 05:15

Yeah.

Mary Ann Lavin (: 05:18

So then we said, well, we'll still have it. We'll just have it at this old hotel downtown. And sister Teresa arranged for us to move all the office equipment down there because this old hotel did not have a business office. So we created a business office and had the conference in

1973.

Heather Herdman (: 05:51

You know, this strikes me as a wonderful opportunity for nursing students to think about when you think things are impossible, how you just kept going. Well, we can't do it this way. We're going to do it this way. Well, you can't do it this way. You're going to do it this way. And honestly, Marianne, when I think we look at your life, that's kind of the story of your life is you tend not to see barriers. just say, well, we'll just going to go around that barrier and move to the next step.

Mary Ann Lavin (: 06:12

Right.

Heather Herdman (: 06:20

When you were trying to look at these diagnoses, what was the purpose? Why did you need them? Or why did your dean feel that you needed them?

Mary Ann Lavin (: 06:29

Well, the director of nursing at the hospital thought we needed them in order to enter data into the computer. Okay, so that was the...

Heather Herdman (: 06:36

Okay, and with the purpose of what though? What was the purpose of having the data in the computer?

Mary Ann Lavin (: 06:42

So that we would be able to document nursing practice in a manner analogous to the way in which physicians document medical practice. That's not saying that we used a medical model. You know, just because we diagnose doesn't mean that we use a medical model. Plumbers diagnose, you know, architects.

diagnosed. People in climate science diagnose, everybody diagnoses. Diagnosis is just a problem-solving method.

Heather Herdman (: 07:22

Exactly. I love that you say that because I hear people still to this day say, know, nurses don't need to diagnose as if it's a bad thing for a nurse to do that. And, and I think, well, when you listen to television, the car mechanics say, we will diagnose your car's problems. You know, it is, it is the end point of a judgment. And of course, nurses use judgment, whether you want to call it a nursing diagnosis or not. They are determining what's going on with their patients. So.

Mary Ann Lavin (: 07:51

Right.

Heather Herdman (: 07:52

Yeah. So If you fast forward to today, so 50 some years later, and you look at nursing classification, has the purpose for those classifications changed at all in your mind or has it evolved in any way?

Mary Ann Lavin (: 08:10

Yes, absolutely. And I think it's becoming even more exciting today than what it was then. Because nurses are beginning to correlate nursing diagnoses and their respective interventions with specific outcomes. Not just an outcome based on a five scale Likert.

on a five-point Likert scale, but with nursing outcomes that are related to laboratory outcomes, like bioinflammatory markers. And I think this is very exciting because, for instance, the nurses at Johns Hopkins were investigating coping self-efficacy and found that

that bio, inflammatory biomarkers and coping self-efficacy are indirectly related. As coping self-efficacy goes up, biomarkers, inflammatory biomarkers go down and vice versa. Right.

Heather Herdman (: 09:22

It makes perfect sense. It makes perfect sense. So, you know, when I was a student, I didn't really have instructors who understood the point of nursing diagnosis. I was kind of in that early group of people who were learning about diagnoses. And we were often automatically linking nursing diagnosis to medical diagnoses.

honestly from care planning books, which is of course completely wrong. And yet, and yet we still, we still see it being taught this way to this day in some locations and

maybe more concerning, we see electronic health record companies that are providing standardized care plans that have been developed in this way. So standardization has been implemented in many instances as a recipe rather than an application of clinical reasoning or using diagnosis to name those judgments based on assessment and clinical reasoning. So what do you say?

to nurse educators about how they might integrate nursing diagnosis or even clinical reasoning as a whole across the nursing curriculum as opposed to in this one introductory class as many of us get it and then we forget about it along the way.

Mary Ann Lavin (: 10:43

Okay, well.

If we take coping self-efficacy, we could ask nursing students to identify a moment in their own lives in which coping self-efficacy was high and another moment in which coping self-efficacy was low and to identify the signs and symptoms of each and whether or not low coping self-efficacy was associated with other signs and symptoms like

joint pain or fatigue or depression or what have them identified within their own selves, within their own family, within their own acquaintances, the frequency or the prevalence of nursing diagnoses in their own life. I think that's a good beginning way to start.

Heather Herdman (: 11:38

Hmm.

Mary Ann Lavin (: 11:43

and then to transfer to the bedside when they go into clinical practice to find out, to interview the patient in such a way that the patient begins talking about those episodes. And surprisingly,

They will be associated with medical diagnoses, but medical diagnoses I think will be subservient to the nursing diagnoses and not vice versa.

Heather Herdman (: 12:13

I love that. I love that you said start with yourself or start with the people around you because I think one of the things that I notice when I talk to students and even to faculty who are new at teaching diagnosis is we stopped thinking or we don't stop to think about what's the normal.

Mary Ann Lavin (: 12:14

I think, yeah.

Heather Herdman (: 12:38

What does coping self-efficacy look like when it's working? How would we know that, this person has really good self-efficacy? And instead, we tend to start with, well, what's the problem?

Mary Ann Lavin (: 12:42

Mm-hmm.

Heather Herdman (: 12:53

And I always say to students, how would you know? How would you know what an effective breathing pattern looks like if you can't tell me what an effective breathing pattern is? So starting with that normal makes so much sense to me. And then kind of taking those concepts that...

Mary Ann Lavin (: 12:53

Right.

Heather Herdman (: 13:10

we can all relate to, self-efficacy, anxiety, pain, and thinking about how does it manifest in ourselves before we move on to the patient. I think that's a really good tip for faculty. So you talked about medical diagnosis. How do we help colleagues, and especially students, think, to think about

Mary Ann Lavin (: 13:23

Right.

Heather Herdman (: 13:35

diagnosis in nursing, the way that our colleagues in medicine think of diagnosis in their field, not as documentation so much, but as representing the judgments about those things that are primary areas of concern for patients that we as nurses can treat, as well as how it gives maybe a term that others can understand across setting and country. I think that we have a real strong sense that

We all have to know the medical diagnosis, but not so much a strong sense that we need to know the nursing diagnosis. So what would you say to students about why you think that's important?

Mary Ann Lavin (: 14:20

I think nursing diagnoses direct, relate directly to manifestations of human behavior in one aspect or another.

use I'm something related. In: 1968

would come down to the infirmary to get their medicines after supper and they would be chanting, burn baby burn, burn baby burn, burn baby burn. Well, in my mind, the kids were mad at what was happening in society. I was mad at what was happening in society. I assumed from a nursing diagnosis point of view that they needed a safe space.

that they couldn't go around saying, burn baby burn in the dining hall, nor in their village, you know, but they could, they found out they could on the front porch of the infirmary. So this, their behavior was manifested in what appeared to be defiance, but was probably actually just anger.

Heather Herdman (: 15:45

Thank

Mary Ann Lavin (: 16:10

at society. But this little 12 year old boy, very skinny little 12 year old, not at all like the 16 year olds, came in for his medicine and he whispered to me, don't be afraid of them. And I said, what? He said, don't be afraid of them. They're just playing tough.

And I said, because this was a new language for me, you know, playing death. I said, I'm not afraid of them. I said, but what other games are there? And he said, there's playing crazy. There's playing down there, all sorts of game. And I thought this is this is this is he is diagnosing.

He is diagnosing their behavior plain tough, but he's telling me that there are other diagnoses as well. Plus, he's telling me that these diagnoses operate as defense mechanisms. And it's sad that children have to use defense mechanisms like this.

But this was an example from nursing in which a whole plethora of nursing diagnoses developed. And today we talk about inclusivity, but we talk about it in terms of welcoming and belonging. But Bridget Holt, who is a nurse practitioner, talks about it also in terms of respect, in terms of trust, and in terms of

of acknowledging one's agency. This little child was inviting me to, he was including me in his culture. So we often think of inclusivity as us including others in our culture. Whereas my very early experience with inclusivity was this little 12 year old inviting me into his culture and teaching me about

Heather Herdman (: 18:07

Thank

Mary Ann Lavin (: 18:28

the diagnoses that he was making. I don't know, so this whole framework of how people use language and terminology, I think is very, very telling. And I think that what it tells us is that in ordinary language, in ordinary communication, you and I and everybody with whom we relate,

are using diagnoses all the time. Anytime we say, that behavior is such and such, we're diagnosing. Now, we need to develop interventions.

but the little boy already had interventions. He wanted to reduce, he thought that I was anxious and was reducing my anxiety. So we can take ordinary situations and look at it from a nursing point of view and then evaluating the outcome. Well, the outcome is that today we talk about all sorts of interventions like

caving in and being silent and taking a bribe or giving a bribe or doing whatever else we're doing today in today's society that white people are doing today in today's society when confronted with a threat. So having mechanisms, diagnoses in response to a threat is a human activity. It's a diagnosis.

this little boy taught me in: 1968

Heather Herdman (: 20:23

Yeah. You know, yeah, it does. It's, thank you. It's helpful. You know, you have a background in public health and just as a quick commentary for those who may not know, public health is different than what many people think of as community health nursing in some countries. And that public health nursing focuses and correct me if I'm wrong here on broader population health issues and policy development. Whereas

Mary Ann Lavin (: 20:24

I don't know if that answered your question.

Heather Herdman (: 20:53

Community health nursing tends to focus more on direct care and promotion of health within specific communities or people. And as we're facing more and more global challenges from climate change, food insecurity, violent conflicts, mean, unfortunately we can go on and on. I'm wondering how you see nursing diagnosis that could be seen as influencing these key issues.

Mary Ann Lavin (: 21:20

Well, Larry Green from Johns Hopkins, Dr. Larry Green developed the idea of public health diagnoses, epidemiologic diagnoses after we had a conversation once upon a time. so I think nursing can draw from, I think it's bidirectional.

I think we need to draw from public health the data skills needed to examine etiologies of our nursing diagnoses in a manner analogous to the way in which public health examines etiologies in epidemiology. And I think epidemiology needs to...

and needs to develop a classification which is still lacking even though they use a diagnostic framework more frequently now and they use diagnostic terminology more frequently. I still don't think they have a classification of public health diagnosis. So I think that's the first step so that things like within the hunger domain could be more specifically identified.

and used more fluidly within the language of public health professionals. So it's all a matter of terminology, like the little 12-year-old. It's all terminology. The more we get accustomed to using diagnostic reasoning process and arriving at judgments within our profession.

And the more that that's spread within the profession, the more fluent we become within our own professional language. And the better able we are able to communicate it to others and to the world at large.

Heather Herdman (: 23:28

And I think that raises a really good point because often I think nurses and certainly nurses in practice, but I think also in education will equate diagnosis with documentation as opposed to with communication. And to me that there's a huge difference. I mean, we have to document, every physician has to document and hates it, but the diagnosis that

physicians use communicate a broad amount of information very quickly and it's a communication strategy and And I think for nursing it needs to be the same. Yes, we have to document it Nobody's gonna ever like that but it's more about how we communicate those broad ideas and concepts and terms quickly and effectively and and I was I was really struck by what you said about the hunger classification because

We've been working with a group that's led by Dr. Rafael Pessoa from Brazil who's looking at climate change and the information that they're identifying related to particulate matter and how it affects the cardiovascular system and the breathing issues and all these different.

responses, we're starting to see obstetrical complications related to even particulate matter from fires. It requires such a, I think, specificity of language that we maybe aren't there yet. We don't yet have. So it's interesting that you said that about hunger, because I can see where there's some overlap there with the climate change issues as well.

Mary Ann Lavin (: 25:14

Right.

Heather Herdman (: 25:15

You've always been, at least as long as I've known you, and I've known you a while, you've always been talking or have always talked about informatics and the electronic health record and the importance of getting data in the record. Probably long before many of us were.

even understanding why that was so relevant. And so I'm wondering how you see today the future of nursing terminology within electronic health records in terms of how we can use these terms to improve quality and advanced nursing research.

Mary Ann Lavin (: 25:58

Well, give me a nursing diagnosis off the top of your head.

Heather Herdman (: 26:03

ineffective breathing pattern.

Mary Ann Lavin (: 26:05

Okay, so I would start with going in and finding out how many times the term ineffective breathing pattern is used plus any number of keywords that convey the same motion without using the same words. because

Heather Herdman (: 26:23

Mm.

Mary Ann Lavin (: 26:29

Because if we're going to develop algorithms, let's say, for an effective breathing pattern, we have to be sophisticated enough to be able to use all the keywords that mean or relate to the same thing. One of the fascinating issues today in social media is if you use a word that that particular social media platform does not like,

it may kick you off or kick off that particular message. And all the user needs to do is to go back and use another keyword, another word in place of the word used initially. And presto, you're back on. That's because the people developing the algorithms within these platforms don't have enough life experience to know all the

all the keywords associated with what's triggering the algorithm. So it's very easy to get around. But in a more complex system, where you have a number of individuals accessing the computer, need to develop that flexibility. Okay, then once you have the

Heather Herdman (: 27:32

You

Mary Ann Lavin (: 27:55

the frequency of that diagnosis developed, then you have to go back in and see what are the interventions that nurses are using for that particular diagnosis. And then you can evaluate outcomes, not whether or not ineffective breathing is relieved, one, two, or three points.

but actual outcomes like in terms of O2 saturation or respiratory rate or any number of other physical as well as like your type of outcomes. then with regard to climate change, you might want to look at the etiology of ineffective breathing in this particular patient. Does the patient

Is the patient exposed to triggers like allergens or particulate matter or...

actual smoke that are interfering with the patient's breathing? Or is the patient giving evidence of a sign of an infection? what are the various ideologies associated with, you know, one million cases of ineffective breathing? And what are the, of these, what are the most frequent?

Mary Ann Lavin (: 29:37

and then write up the results. That itself is a research entity. You don't need to conduct a randomized control trial in order to conduct research. You can employ retrospective studies, analyses of actual data, and that is not the same type of research as a randomized control trial.

Heather Herdman (: 29:46

Thank

Mary Ann Lavin (: 30:07

but it is research.

Heather Herdman (: 30:09

Absolutely. And we're seeing a huge increase, I think, in interest within nursing, certainly within health care in general. I've seen a lot within nursing recently in terms of the possibilities that informatics bring to the table, what we can do with artificial intelligence and big data.

to improve nursing's visibility in terms of patient outcomes. So I think that's what you're speaking to there. I'd be interested in hearing what you're watching in the informatics world and where you think this field could move us within nursing in the next few years, especially in regards to kind of helping or supporting or improving clinical reasoning at the bedside.

Mary Ann Lavin (: 30:52

Well, I think AI has the potential for being a great resource in terms of improving clinical reasoning.

Heather Herdman (: 30:55

Thank

Mary Ann Lavin (: 31:03

I think that the best way to engage AI at the present time is conversationally, as far as students are concerned, is conversationally. But the students should, and faculty, need to be aware that AI is, when I'm speaking about nursing diagnoses, is usually wrong the first one or two times around. And you need to engage AI and say to AI,

regardless of whose AI it is. Actually that's not correct. That the more correct information on this particular subject is X, Y, and Z. And then AI will usually come back and say, oh, I'm sorry, I didn't look deep enough into the issue. You are correct. There is an organization called NANDA. They do look at nursing diagnoses.

And here's what Nanda says about X, Y, and Z. So once you get them on the same page that they are, you know, we're speaking Nanda now, you can now say, well, now develop a design for me in which you would determine what are the best treatments for diagnosis X. And see what it says. And if you don't like it, tell AI you don't like it.

And but eventually, you know, within a matter of minutes, you can come up with a fairly good design as long as you don't take everything AI says, you know, at face value. Yeah.

Heather Herdman (: 32:42

This gospel, yeah. I was just recently at the Ascendio conference in Rotterdam and it was just fascinating to me to see all of the different applications being used by people in the Netherlands and Italy and, you know, in America, Brazil, all over the place, looking at how to harness what's available within AI to...

improve a lot of things, whether it's just documentation in general, but specifically how to be able to pull data out of systems to get us to a better understanding of what's going on with patients and how we're affecting them. But sometimes I hear people say, well, once we have AI, once we have

You know, an AI in our computer systems, we're really not going to need these classifications anymore. We're not going to need ICD. We're not going to need blah, blah, blah. People are just going to be able to talk and the computer will figure it out. I see. So, so explain that a little bit, because I don't think people necessarily understand that.

Mary Ann Lavin (: 33:43

No, the computer uses those systems.

Mary Ann Lavin (: 33:52

Okay, AI is only as likely as any computer system. Garbage in, garbage out. If you don't put a classification in, then AI will have no knowledge that there is such a thing as a classification. Nor will AI on its own automatically come up with 350 pages of nursing diagnoses. It just won't. It doesn't replace.

It doesn't replace us. It reflects the best of our thinking. And its problem-solving abilities are really quite impressive. But in order to solve a problem, it needs information. And unless that information is entered into, unless that information is available.

on the web, then it has nothing to draw from.

Heather Herdman (: 34:55

Yeah. When you said garbage in, garbage out, I mean, that's been a statement that we've heard for, I think, as long as we've had computers. But it does make me think about the difference between terminology and classification.

and the use of terms that don't necessarily have standardized definitions and certainly that don't have assessment criteria that can be validated, so signs and symptoms. And so I'm wondering how you see or if you see a difference between those diagnostic terms that do require assessment criteria and those that don't in terms of advancing research on quality and patient outcomes.

Mary Ann Lavin (: 35:19

Right.

Mary Ann Lavin (: 35:43

Well, I think inclusivity is a good example. I don't know what Copilot is saying today about inclusivity. But most of the literature refers to it as welcoming or belonging or both.

Heather Herdman (: 35:49

in

Mary Ann Lavin (: 36:00

And yet.

The experience of people, which is not just classification, but the experience of people, reveals that to be considered inclusive,

is not just that you belong to a group on paper, but and not just that the people give you some sort of artificially superficial welcome to the group, but that they actually listen to you. They give you credit for what you say. They don't steal your ideas and then present them as their own. They don't ignore you when your hand is up. They don't.

you know, they recognize you as a valuable member of the group.

Heather Herdman (: 36:55

So these are the defining characteristics.

Mary Ann Lavin (: 36:57

Right. Okay. So,

Mary Ann Lavin (: 37:04

So what do we do with that though? We need to, for any kind of defining characteristic or a group of them, we need to reflect upon them. What does that mean for the diagnosis then of inclusivity? It should therefore be broadened and it should be broadened in such a way that it reflects the experiences of many people.

Okay, and.

Mary Ann Lavin (: 37:39

and that it is bidirectional. It's not just this group welcoming another, but it's the other who's now part of the group giving input and making suggestions, et cetera. And how do we measure that? Well, we don't have a metric for inclusivity yet, but maybe that might be the next step for

Heather Herdman (: 37:57

Thank

Mary Ann Lavin (: 38:09

So how do we measure it? Maybe we use this expanded definition and it's a checklist sort of thing. Maybe 10 out of 12 of the characteristics means that the group is inclusive. But we don't know. At that point, we need to conduct research. whatever metric we come up with,

needs to be applicable to any number of different groups.

or there need to be different metrics that are group specific, are group specific.

Heather Herdman (: 38:55

So there's.

Mary Ann Lavin (: 39:01

Inclusivity is not just a amorphous value, it's a behavior. And the problem in the literature is that they speak of it as just a value.

Heather Herdman (: 39:12

Thank

And so those characteristics that you're mentioning that eventually would be metrics that could be measurable are things that would allow then for us to validate when somebody did use that term that they are using the correct term.

Mary Ann Lavin (: 39:29

Right. Right. And then we also need to rule out what is not inclusivity.

And

Mary Ann Lavin (: 39:44

We have quite a few examples of that more recently.

within the United States.

Mary Ann Lavin (: 39:58

And that's an interesting phenomenon in itself in that, what is it, a photo represents a thousand words or?

Heather Herdman (: 40:11

Mm-hmm. Yep.

Mary Ann Lavin (: 40:16

A picture, a piece of art, communicates more dramatically what something is not than a thousand words could.

Heather Herdman (: 40:30

That's very true.

Mary Ann Lavin (: 40:32

And I don't know how we deal with that aspect of...

of terminology. But once we have a diagnosis, once we have the behaviors associated with it and a metric, then we have a diagnosis ready for insertion into a classification book if it can be validated. And it needs to be validated more than one culture.

Heather Herdman (: 41:02

Thank

Heather Herdman (: 41:07

Absolutely. And in more than one population, hopefully. Yeah. And I think that that's the huge difference between terms and a classification is you actually can validate. You can get to that. I'm curious, Marianne, because you're a nurse practitioner. And I often hear my NP friends or my advanced nursing

Mary Ann Lavin (: 41:10

Right.

Mary Ann Lavin (: 41:18

Right.

Heather Herdman (: 41:32

practice colleagues saying that nursing diagnosis are not relevant for their practice because their practice is about medical diagnoses. And personally, I find that fascinating because from my perspective, NPs are not there to replace physicians. They're bringing an advanced nursing background and phenomena of concern into every patient encounter. And it seems to me,

to be a wonderful opportunity to use a combination of medical and nursing diagnoses. And in fact, when you talk to patients about why they like their nurse practitioners so much, it's often those, as you were calling them, amorphous things. It's not that, she was able to give me the pill that I needed. It was, she always figures out things I didn't realize were wrong, or she gets me to tell her things that I always forget to say.

Mary Ann Lavin (: 42:13

You're right.

Heather Herdman (: 42:29

I think it's that ability of the nurse to form a relationship with a patient, but also to engage the patient in understanding what's going on, how they're responding to their disease, not just the management of the disease. So maybe reflect a little bit on the differences between nursing diagnosis, medical diagnosis, and how as an advanced practice nurse, we can use nursing diagnoses in clinical practice in a way that represents the knowledge of our discipline.

Mary Ann Lavin (: 43:02

Okay, so.

Mary Ann Lavin (: 43:14

So, okay, so this relates to hunger and it starts with a patient that I had in a housing authority apartment building for the elderly and disabled. And he was elderly and he had cancer of the spine and he was going to one of the academic health sciences centers in the city.

and they were prescribing narcotics, but they were also giving him radiation, which obliterated his spinal pain, but he didn't tell the prescribing physician that he no longer had pain, and the prescribing physician continued to give him narcotics. Now, he made less than the...

poverty standard income was less than the poverty standard for the United States. So at the end of the month under normal conditions he was he could either you know buy medicines or buy food but he couldn't buy both and usually it was food that he let go. So given that he no longer had pain and he was now getting narcotics and then specific narcotic

that he was getting at that time, two decades ago was $5 a pill. He would go back to his apartment building for the agent and disabled. And of course the agent had lots of aches and pains. And he would sell his script for $5 a pill. And then he would come, then he came down to me one day and wanted me to call the doctor and tell him he was out of medicine. And I said, but you just got the script two days ago.

And he said, but he's out. And I said, rumor has it that you're dealing to the elderly, to the people in the apartment building. And he said, you don't have to say what people are saying. And I said, well, I do have to tell the truth to the physician. And he said, well, I said,

Heather Herdman (: 45:25

Hahaha!

Heather Herdman (: 45:31

You

Mary Ann Lavin (: 45:35

you can stand here but I'm going to tell the truth and he said well you would have a better chance than I so go ahead. So I call up the physician and I say Mr. So-and-so is standing here and he says he needs another script for X and the physician said but I just gave him a script I said yes two days ago and he says well how many does he have left and I said it's empty and he says

Heather Herdman (: 45:43

You

Mary Ann Lavin (: 46:03

It's empty. Is he okay? And I said, he's fine. And he said, how can he be fine? And I said, because maybe he's not the recipient. And the physician goes,

Heather Herdman (: 46:06

you

Heather Herdman (: 46:17

Hahaha!

Mary Ann Lavin (: 46:19

And then he says, send Mr. So-and-so over. So that ended some of the excess selling on the side. A few months later, the pain was really back and Mr. X was dying. And Mr. X comes down one day. And then the...

Heather Herdman (: 46:30

Mm-hmm.

Mary Ann Lavin (: 46:44

And I'm assuming that the audience doesn't really need to hear what the diagnoses were, you know, that the man was selling narcotics, but the etiology was poverty. He needed money to buy food. Okay. So fast forward. And we did connect him with resources that would give him extra food. So then...

Heather Herdman (: 46:59

Mm-hmm.

Mary Ann Lavin (: 47:13

fast forward a few months and he's dying now and he really does need narcotics and he comes in one day and he's sitting at the desk and he's not saying anything and I didn't say anything I was waiting for him to say something and he didn't and then I finally said it's rough isn't it and he said yeah it's really rough. Okay so I guess

you know, it's rough, isn't it? It's sort of a nursing diagnosis. It's acknowledging that he's dying, that he has pain, that the emotions that surround a person at such time are probably difficult to cope with. And he said, yeah, it's really rough. And I said, are you talking to God? And there was silence.

And then he said, yeah, I talk to him every day. And then I was silent. And then, then,

Mary Ann Lavin (: 48:23

And then he said, and you know what? And I said what? And he said, he talks to me too.

Heather Herdman (: 48:31

huh.

Mary Ann Lavin (: 48:33

and he died a few days later. now I don't know what the exact terminology is, but nurse educators can get upset with me, but he was he was in need of support, you know, and and I think I think he got that support just by the very fact that I acknowledge that he was in connection with God. And he acknowledged to me the

Heather Herdman (: 48:39

you

Heather Herdman (: 48:46

Thank

Mary Ann Lavin (: 49:02

with in terms of the bidirectionality of nursing diagnoses, we learned from patients, patients learned from us that he was in close communion with God and he was okay to die and he died within a few days and that was good.

Heather Herdman (: 49:10

Mm-hmm.

Heather Herdman (: 49:19

Mm-hmm.

Mary Ann Lavin (: 49:28

There wasn't any point in getting mad at him about selling drugs to little ladies who had some extra pay. You know, there wasn't any need to get, you know, self-righteous or judgmental. You know, it could all be taken care of without that, as long as you diagnose the situation properly.

Heather Herdman (: 49:46

Mm-hmm.

Heather Herdman (: 49:50

Yeah. And, and I think that's, that's a great example because yes, he had cancer. Yes, he had, you know, spinal issues, et cetera, but he also had these human issues that were going on that somebody needs to deal with. And so as an NP, you can manage both. Yeah. Okay.

Mary Ann Lavin (: 50:05

Great.

Yeah, yeah. And I didn't mention his, except for cancer, the spine, I didn't mention a medical diagnosis. And I didn't prescribe anything for him. It was all nursing. And was it advanced practice nursing? I think so. I can't imagine myself dealing with it in the same way when I was an RN.

Heather Herdman (: 50:38

So I can talk to you all night, but let me just ask you one last question here, which is, know, if you had a chance to address a class of graduating nurses and talk to them about the importance of language, its impact on the future of their profession and why they should be thoughtful maybe about

using terms that have definition and have indicators that are measurable, what would you say to them?

Mary Ann Lavin (: 51:23

I would say that you're not professional unless you do.

Mary Ann Lavin (: 51:29

to me...

Mary Ann Lavin (: 51:37

To me, that's the definition of being a professional, is that when the Nurse Practice Act says that nurses assess, diagnose, treat, evaluate, et cetera, that term diagnose means that there are defining characteristics that are measurable.

have metrics associated with them and need to be addressed.

and have interventions that are diagnostic specific with outcomes in mind that you have when you make the diagnosis. These are the outcomes that you're headed for. And you will be measuring those outcomes in order to see if your treatments are effective for that diagnosis. That to me is the definition that's written into every, every

practice act in the United States practically and is the hallmark of a professional. So for some educators or some nurses to say that there's no place for diagnoses in the field, to me that's the epitome of being unprofessional, that they have never really grappled with what it means to be a professional.

Heather Herdman (: 53:13

Mary Ann, thank you so much for your thoughts. And of course, thank you so much for your vision in beginning the work to standardize the judgments that nurses make and to give voice to those things that are integral to our discipline, integral to our profession, to the way that we think. And I just, I want you to know that I think it's so important and there's so many people around the world who think that this is the way to

begin to give voice to.

the impact that nurses have on patient outcomes. And so thank you so much for your visionary ability there. And to our listeners, I wanna thank you for joining the conversation with Dr. Mary Ann Laven today. I hope you've enjoyed that conversation. And I would encourage you to join us at our international conference, which will be coming up in Lisbon this coming June. And I encourage you to go take a look at our website at www.lisbon.com.

for all the information. While you're there, don't forget to sign up for our newsletter. Follow us at LinkedIn or Instagram, on Facebook, and you will find links to get your own copy of the NANDA Eye Nursing Diagnosis, Definition and Classification text on our website. Mary Ann, I would like to thank you for your time here. Again, today, always a pleasure to speak with you, and I look forward to the next time we can meet face to face.

And I would encourage guests also to reach out to me, give us ideas about who else you'd like to hear on this podcast, give us a review on the platform you're using for the podcast. And we'd be really interested in topics you'd like to hear about. So drop me a line at ceo at nanda.org. And thank you for tuning into this episode of the NandaCast. We hope you will join us at our next episode.

Heather Herdman (: 55:13

And in the meantime, let's keep on defining nursing one concept at a time.

Mary Ann Lavin (: 55:19

Thank you very much. And if I could say just one more word, if you look at the menu above me that's in framed, was obtained, that menu was obtained in Madrid and it's the restaurant that Hemingway frequented when he was in Madrid. So it is from a dandaconference.

Heather Herdman (: 55:23

Of course.

Heather Herdman (: 55:36

Yeah.

Heather Herdman (: 55:40

I remember that conference. was a great conference. Okay. Thanks, everyone. Take care now.

Mary Ann Lavin (: 55:44

Right. OK, so thank you very much. Thank you, everybody. Goodbye.