Walking the walk

We have come a long way in the development of professional nursing since the introduction of the nursing process in the late 1960s. Looking back we can see that over the following decades it was adopted internationally as an essential guide to nursing practice.

But as nursing knowledge grew, the nursing process attracted criticism, notably that the four steps of the process itself; assessment, planning, implementation and evaluation, were used by all healthcare professions and not just nursing.

Ironically, given that the nursing process was grounded in a problem-solving cycle, it originally did not include a problem identification step. Without a problem identification step it had no rudder and could easily begin to flounder.

Minimal research examining the nursing process has been published, nonetheless it continues to be widely used. Sometimes a fifth step of problem identification or diagnosis is included, but often it is not.

Is the easiest walk really the best walk ? 

The nursing process may seem an easy approach to thinking about nursing practice but it has little power to drive nursing practice or to future-proof the profession's ability to fulfil its social mandate. Its critics propose that because of its persistent use it should be revised to meet the standards required of a profession that is central to healthcare. Nursing must be able to articulate clearly its distinctive contribution to healthcare, especially as a member of a multidisciplinary healthcare team.

A change of pace

In fact, what can be considered the revision of the nursing process began some years ago. In the 1970s nurses in the United States recognised its limitations. They were also bold enough to recognise that the term 'diagnosis' was not the prerogative of any one profession.

They claimed for the nursing profession the distinctive characteristics of diagnoses, that is, precision in identifying and differentiating patient problems within the scope of nursing practice. Likewise, they demonstrated the need for in-depth nursing assessment, clinical reasoning and decision-making, required to make a diagnosis. This was necessary especially to differentiate between diagnoses with similar defining characteristics.

Knowing that these factors were vital for patient safety and fostering health, they set about raising the practice bar for all professional nurses. Thus were born standardised language systems for nursing diagnosis. Today, the most widely used system, NANDA-International, is currently in its 10^th edition (Herdman & Kamitsuru, 2014). It has been translated into 18 languages and is used worldwide.

Use of NANDA-I is linked closely to standardised nursing outcomes (Moorhead et al., 2012) and standardized nursing interventions (Bulechek et al., 2013). Together, these language systems articulate clearly, for all to see, professional nursing practice responsibilities. NANDA-I is electronic record-friendly and is linked internationally to umbrella healthcare electronic record systems.

Power walking

What NANDA-I and the outcomes and interventions languages do is give us words to put on what we know and do. As nurses we are often concerned about empowerment. Standardised nursing languages empower us by giving us the power to control our practice and drive it forward. As Clark and Lang (1992) famously put it, "If we cannot name it, we cannot control it, finance it, teach it, research it, or put it into public policy" (p. 109).

There are a good number of diagnoses to choose from, currently 235, classified according to Gordon's widely known Functional Health Patterns. They can be problem-focused (a clinical judgement concerning an undesirable human response to a health condition/life process), risk-focused (a clinical judgement concerning vulnerability for developing an undesirable human response), or health promotion-focused (a clinical judgement concerning motivation or desire to increase well-being and actualise human potential) (Gallagher-Lepak, 2014, p. 22).

They encompass the nursing care and needs of people experiencing a wide range of threats to their health. Likewise, they can be used by nurses working in a wide range of practice areas. The following Table shows examples of diagnoses ((Herdman & Kamitsuru, 2014) that can be used in different practice areas and situations:

Power walking in the wind

Winds of change are always blowing us from different directions. But no matter what their direction and strength, NANDA-I, and its associated languages, keeps us on our professional course and enables us to provide our distinctive professional service in society. It does this by assisting us to identify each person's individual responses to illness and intentions to enhance their health, from a nursing perspective.

Thus, our practice is firmly directed towards helping people cope with, adjust to, and aim towards overcoming the limitations posed by their condition. It is research based and its objectively defined outcomes allow us to measure the effects of nursing care along the continuum of people's recovery.

Further, NANDA-I provides us with a structure for practicing collaboratively with other health care professions. With its associated languages it allows us to articulate clearly our distinctive contribution to interdisciplinary collaboration.

Collaborative practice

Take for example nursing's collaboration with medicine. Most people being cared for within a healthcare system have at least one medical diagnosis. Along with each medical diagnosis most people also have two, three or more nursing diagnoses that they participate with the nurse in choosing, as they are able to do so. Parallel with medicine and medical/surgical outcomes, nurses and the person identify measurable nursing outcomes which they wish to achieve, and which complement medical/surgical outcomes. Parallel and/or subsequent to medical/surgical interventions nurses and the person choose nursing interventions that they think will best help achieve nursing outcomes. The following illustration is an example of such collaborative practice: This example is hospital-based but the same principles are followed in all practice situations. You will notice that specific collaborative problems are identified. A collaborative problem is a potential physiologic complication that nurses monitor to detect onset or change in status and manage using medically-prescribed and nursing-prescribed interventions to prevent or minimise the complication (Carpenito, 2012).

As with medical care, nursing diagnosis-driven care may be short term or long term and is reviewed and revised as frequently as needed. It may begin in a person's home in the community and transfer with the person to a hospital if a period of intense, specialised care is needed. Or, it may begin in a hospital and transfer with the person on recovery to their home in the community. In this case the nursing diagnosis-driven care will be powerfully geared to fostering and supporting the person's ability to care for themselves and work on enhancing their health, either alone or with the help of family and/or community. 

Fostering truly person-centred care

Over hill and dale of a person's healthcare journey, people carry with them both their medical diagnosis-driven care and nursing diagnosis-driven care. Its details may be documented in written or electronic form. Their nursing diagnoses are always there to be opened, considered again and continued with as necessary.

In an important sense people can come to live with their nursing diagnoses, outcomes and interventions, in a wonderfully healing way. Recall from above that people participate in selecting their diagnoses, outcomes and interventions, to the extent that they desire and are able to do so. Naturally this encourages them over time to think about and deepen their knowledge of their responses and vulnerabilities related to illness and ways they can increase and maintain their health and well-being.

For example, the many people with on-going health concerns, such as a particular disability, diabetes mellitus, a tendency to depression or being overweight, can become familiar with and take on their own "nursing" care. In effect, their nursing diagnoses and related outcomes and interventions can become a structure for their on-going health education and self-care. 

Future-proofing professional nursing

Everything considered, it is entirely fitting that we up our pace from walking to truly professional power-walking in our practice. Using NANDA-I nursing diagnoses to drive our practice will benefit the people we have a professional mandate serve and future-proof our profession's distinctive and vital role in healthcare.

References

Bulechek, G.M., Butcher, H.K., Dochterman, J.M. & Wagner, C. (Eds.). (2013). Nursing Interventions Classification (NIC) (6^th ed.). St Louis/London: Mosby/Elsevier.

Carpenito L. J. (2012). Nursing Diagnosis Application to Clinical Practice  (5^th ed.). Philadelphia: Lippincott Williams & Wilkins.

Clark, J. & Lang, N. (1992). Nursing's next advance: an internal classification for nursing practice. International Nursing Review, 34, 4, 109-112, 128.

Gallagher-Lepak, S. (2014). Nursing diagnosis basics. In Herdman, T. H. & Kamitsuru, S. (Eds.), Nursing Diagnoses Definitions and Classifications 2015-2017 (52-90). Oxford: Wiley Blackwell, 21-30.

Herdman, T. H. & Kamitsuru, S. (Eds.). (2014). Nursing Diagnoses Definitions and Classifications 2015-2017. Oxford: Wiley Blackwell.

Moorhead, S., Johnson, M., Maas, M.L. & Swanson, E. (2012) Nursing Outcomes Classification (NOC) (5^th ed.). St. Louis/London: Mosby/Elsevier.

Therese Meehan

Raphael Mc Mullin