by Murph E.
Before I start on this rant, I want to clarify that I’m not suggesting that nursing be “medicalised,” or that the role of nursing be expanded to include diagnosis and treatment of illness. In fact, I think it’s a good thing that there is a discipline for caring for patients, namely nursing, and a separate one for diagnosis/treatment, namely medicine. These are different and complimentary roles, and I wouldn’t want to be burdened with the responsibility of diagnosing and treating the illness as a nurse. After all, if the nurse is busy doing diagnosis and treatment, who will be doing the nursing?
That said, I’m confused about something that’s come up a number of times in different contexts in nursing school—it’s the fact that nurses have to pretend that they don’t know what’s going on if anyone asks, but they are responsible for acting as if they do. A nurse is not allowed to diagnose an ear infection, a broken leg or a heart attack for example. If a nurse did that, she would be overstepping what she is licensed to do.
I think an example will help to clarify: It is well within a nurse’s responsibilities in certain contexts to triage patients in order of medical priority. Imagine a case in which three patients arrive at the emergency room to be assessed and prioritised by the intake nurse. One patient has the signs and symptoms of an ear infection. The second patient has an obviously broken leg. (Imagine the patient is in extreme pain and the leg is bent at a 90º angle half-way down the shin.) The third patient has all the tell-tale signs of a heart attack, like chest pain, distress, tingling down the left arm, light-headedness, etc.
In such a case, the nurse would be responsible for making sure that the third patient (the one with the heart attack) was given priority and taken to see a doctor immediately. The nurse would then refer the patient with the broken leg to radiology or something, and then a doctor would have the bone set and put in a cast. The first patient, the one with the ear infection, would have to wait until the others were treated before getting what she needs—probably just a prescription for antibiotics. If the nurse gets the order of priority wrong, she will be held responsible for the consequences.
The confusing part about this whole process is that a nurse has to simultaneously think about balancing the medical priority of the three patients while being careful to remain intentionally agnostic about what it is exactly that is afflicting each of the patients.
The nurse can’t just say, “You have an ear infection,” or “You have a broken bone.” Those are diagnoses. Doctors make diagnoses. Nurses can’t make diagnoses. But the nurse has to prioritise and execute her practice as if she did know that the one patient was having a heart attack and the other was having an ear infection.
This is of course, something of a simplification. In certain contexts, nurses can make what are called “nursing diagnoses.” Unfortunately, this concept doesn’t clarify anything for me. I asked a professor of mine to give me an example of one. She said that a nurse could pronounce a nursing diagnosis of “failure to oxygenate” in the circumstance that the patient was having difficulty breathing, complained of shortness of breath and had an O2-sat of 60% or something. The problem with the concept of a “nursing diagnosis” (at least for me) is that I would be more likely to call “failure to oxygenate” a “sign” (an externally observable indicator of the state of a person’s health) rather than a “diagnosis.”
But the point remains that after assessing a patient, if the patient asks, “Am I having a heart attack?” a nurse would have to respond with something like, “Due to the legal constraints on my licensure as a nurse, I can neither confirm nor deny that you are having a heart attack,” but at the same time, she would need to act as if she knew that the patient was having a heart attack and prioritise her care accordingly, on pain of legal repercussions.
I think I’ve heard of this before.
To know and not to know, to be conscious of complete truthfulness while telling carefully constructed lies, to hold simultaneously two opinions which cancelled out, knowing them to be contradictory and believing in both of them, to use logic against logic, to repudiate morality while laying claim to it, … to forget, whatever it was necessary to forget, then to draw it back into memory again at the moment when it was needed, and then promptly to forget it again, and above all, to apply the same process to the process itself—that was the ultimate subtlety; consciously to induce unconsciousness, and then, once again, to become unconscious of the act of hypnosis you had just performed. Even to understand the word ‘doublethink’ involved the use of doublethink.
(Orwell, George (1949). Nineteen Eighty-Four. Martin Secker & Warburg Ltd, London, part 1, chapter 3, pp 32)
Ahh, that’s what it is! Doublethink! Now I remember. This is, as they say, realwise doubleplusungood.
It might be crimethink to say this as a health care professional (am I allowed to call myself that yet?), but I guess I just have an intuition that the world won’t end if nurses are allowed to actually diagnose certain things under certain circumstances. I’m not saying that because I would want to change the role of nurses or to take territory away from doctors, but rather because I want to allow nurses to be able to execute their own practice—that of caring for the patient—without having to go through all that doublethink.
So, how does my claim that nurses should be able to diagnose certain things square with my original disclaimer that I don’t want to change the role of nurses? Here’s how I make it fit in my head: There are some things (like an obviously broken leg) that a nurse would be more than qualified to identify and yes, even diagnose without any further training. (There are other things that a nurse is not capable of diagnosing, and I’m not suggesting that nurses be trained to be able to diagnose cancer or anything so extreme as that.)
When would a nurse go about making a diagnosis? Only when it is necessary for her to do in the context of her role in providing care for the patient as a nurse.
For example, after an assessment, a nurse often needs to perform certain interventions as a part of her role. These may include referring to other practitioners, engaging in conversation, providing education, reflecting strengths, or assigning priority, as in the triage example above. For these interventions, it is often tricky to come up with a rational way to justify one’s actions without reference to the patient’s illness. I would much rather be able to say “the reason for this intervention is the patient’s infection” than “the reason for this intervention is something that I’m not legally allowed to say much about.”
GREAT POST! and, *exceptionally* relevant topic. I’m not an nurse yet, and have LOTS too learn still about being a nurse. What (i think) I think about this, is that as nurses, we should be making coming up, and making diagnoses. we are educated to know the signs and symptoms of heart attack, ear infection, broken leg (errrrrrr, or else, we would not be nurses) AND we are educated (especially at an advanced level, like the DE program) to know what possible differential diagnoses may be. I believe that it is in our scope of practice to treat on the evidence we have… perhaps that is why the role of nurse practitioner has continued to grow.
It might be that it is not so much that we cannot diagnose, but, more that the problem lies within diagnoses itself… physicians work on a “rule out” basis (from what I have learnt). They go with multiple possibilities of diagnoses, and eliminate what it is definitely not . when we work with patients/clients (whatever you choose to call them) you have to make some sort of diagnoses, but, the problem is… (since you are a scientist, you’ll know this), even if it looks like an appendicitis, acts like appendicitis, feels like appendicitis… it might just be constipation. but, we won’t know that, until appendicitis is ruled out.
finally, it also depends on setting. here in urban canada, we (i believe) have a more limited scope of practice. when you get to more ‘resource limited’ settings, the need for good nursing diagnostic skills shoot up.
at any rate, i am generally not a good articulator on sunday mornings, but… again, great post. ALSO. remember that in the QY, the program pushes pushes pushes the psychosocial aspect of the mcgill model. as you keep moving in the program, the “rest” of nursing starts to come in :) especially in 3rd year. AND… (random question) who is your TA for 235?
I have been pondering the same things this week and searched the NANDA list. It seems we have to pay to find out what nursing diagnoses even are on their website, but I found an old list here: http://nclex.ucoz.net/_ld/0/30_NANDALISTOFDIAG.pdf
Nurses can dx sexual dysfunction but not ear infections?? interesting…
I think myself and all my classmates also had a lot of problems wrapping our heads around the nature of nursing diagnoses as well.
It seems to me that “nursing diagnosis” is a poor term used to describe the process nurses must use to respond to signs and symptoms that a patient/client/resident (whatever PC term your program or clinical setting would prefer you to use) is exhibiting during the duration of nursing care. It leads to this exact issue where we confuse the medical process of differential diagnosis with nursing practice.
Unfortunately, I don’t have a suitable replacement term in store. If I had one it would hopefully explain that the difference is that instead of evaluating all the signs/symptoms and formulating a hypothesis, we [nurses] are looking at the pathology (whether formally diagnosed or not) and breaking down the plan of nursing care into manageable and measurable bits to carry out and evaluate their outcomes.
The use of nursing diagnoses does not necessarily cheapen the nurse’s practice, nor does it ridicule a nurse’s ability to recognize patterns in signs/symptoms even though we are not able to diagnose them formally.
In my experience as a registered nurse, when new resident physicians are first stepping on to the floor, many are encouraged to not only work with the nurses but often to ask the nurses for advice to direct the plan of care precisely because we do know how to respond to the signs and symptoms that we see.
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In response to diagnosing sexual dysfunction: you must remember that the sexual dysfunction in that context is the symptom that is secondary to a psychological/pathological condition. So in effect: nurses can NDx sexual dysfunction but not Dx ear infections.
Also, NANDA’s rationale for not listing the diagnoses is on their website: “There is no real use for simply providing a list of terms – to do so defeats the purpose of a standardized language. Unless the definition, defining characteristics, related and/or risk factors are known, the label itself is meaningless. Therefore, we do not believe it is in the interest of patient safety to produce simple lists of terms that could be misunderstood or used inappropriately in a clinical context. (NANDA, http://www.nanda.org/NursingDiagnosisFAQ.aspx)”