Though nursing process is traditionally the primary way that students are taught to establish care priorities and  think like a nurse in academia, the way that nursing process is traditionally taught from most nursing textbooks can actually be a barrier to develop practical clinical reasoning and nurse thinking in students.

There is one word in the current definition of nursing process that needs to be deleted and one that needs to be added by nurse educators to develop nurse thinking in students.

Remove the word DIAGNOSIS from step two and replace it with “PRIORITY”.

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Nursing Process

The following five steps of nursing process are well known to both nurse educators and students:

• Step 1: Assessment
• Step 2: Nursing Diagnosis
• Step 3: Outcomes/Planning
• Step 4: Implementation
• Step 5: Evaluation

Though I have no problem with the 5 steps of nursing process and its relevance to nursing, I believe that step two needs to be reworded to help bring needed transformation to nursing education.

Step 2: Nursing Diagnosis

You cannot have a nursing diagnosis without NANDA-I language. Though NANDA-I is a taxonomy that has some relevance to clinical nursing practice and priority setting, there are other ways that a nurse in practice establishes care priorities besides NANDA-I.

If NANDA-I is emphasized as the ONLY or primary way that students are allowed to establish a care priority throughout the nursing program, this can be a barrier that will limit their ability to think like a nurse.

One of the limitations of NANDA-I is that many of the nursing diagnostic statements are best suited for stable patients with expected outcomes or is unable to accurately capture the patient care priority. Use NANDA-I only if it truly “fits”.

But when the status of the patient changes and is in need of rescue, there are often no salient NANDA-I nursing diagnostic statements that come close to identifying the  capture the essence of the current problem.

Nurses in clinical practice do not think in a three-part NANDA-I nursing diagnostic statement with “related to” and “as evidenced by” that lay the foundation of traditional care planning and use of nursing process in nursing school.

I believe that NANDA-I has relevance to clinical practice, but clinical reasoning needs to be emphasized and integrated within the nursing process, especially step 2 (nursing diagnosis/priority) to develop students’ ability to think like a nurse in practice.

To practically implement this in academia, allow advanced students to simply state the nursing care priority in their own words, and use NANDA-I language only if it truly “fits”.

NANDA-I vs. Clinical Reasoning

As a circulating/Rapid Response nurse in acute care, I recently came across a patient who had collapsed in his room. After determining that he was unresponsive and had no palpable pulse and no respiratory effort, how did I (or any staff nurse) think like a nurse to establish the care priority.

Did I use NANDA-I with a three part nursing diagnostic statement or clinical reasoning?

NANDA-I

In this scenario, a three part NANDA-I nursing diagnostic statement that would be expected of a nursing student on a written care plan could be:

1. “Ineffective tissue perfusion-cardiac-neuro and renal”.
2. RELATED TO: Ventricular fibrillation, but  oops…I cannot use the medical diagnosis but must state instead that this is a condition in which there is uncoordinated contraction of the cardiac muscle of the ventricles in the heart, making them quiver rather than contract properly.
3. MANIFESTED BY: Absence of pulse, absence of BP, absence of RR and ashen pale skin color

Clinical Reasoning

Or would you clinically reason by capturing the essence of the scenario and current priority:

• NO PULSE, NO RESP… the nursing priority: call a code and begin CPR to begin lifesaving interventions!

Though this is a dramatic example, it highlights the importance of clinical reasoning to practice and the need to be flexible and not so rigid with the insistence of NANDA-I taxonomy to situate nursing care priorities.

Though “ineffective tissue perfusion” technically fits, does it truly capture the true “essence” of this scenario?

NANDA-I and “Failure to Rescue”

Though NANDA-I nursing diagnostic statements have been an established taxonomy to identify nursing priorities for over 40 years, del Bueno (2005) identified a relationship between the use of NANDA-I nursing diagnostic statements and the nurse’s inability to readily recognize a change of status (see past blog-I See Dead Patients).

Del Bueno (2005) found that 65% of new nurses were unable to exercise correct clinical judgment at a basic level to “rescue” (identify the problem and then intervene) their patient in a simulated scenario due in part to the inappropriate use of NANDA-I nursing diagnostic statements to make them “fit” when there was a change in status (del Bueno, 2005).

For example, when a patient had a condition change consistent with a stroke, the nurse used the NANDA-I statement “alteration in sensory perception” or “alteration in nutrition.” In another patient having symptoms consistent with a myocardial infarction, the nurse used “activity intolerance related to pain.”

Del Bueno (2005) summarizes her research findings with the following statement, “Many inexperienced RN’s also attempt to use a nursing diagnosis for the problem focus. Whatever the original intent for its use the results are at best cumbersome and at worst risible” (p. 280).

Complexity of Nurse Thinking

Thinking like a nurse is extremely complex and something that experienced nurses tend to take for granted.

As I reflect upon my own clinical experience and practice, thinking like a nurse requires at least four separate aspects that must be DEEPLY understood by students and then applied to practice.

Four Components of Nurse Thinking

1. Nursing Process
2. Critical Thinking
3. Identify Relevance/Relationships of Clinical Data (pattern recognition-see past blog on pattern recognition)
   
4. Clinical Reasoning (see past blog on clinical reasoning)
   

In nursing education, the two aspects that have been traditionally emphasized are nursing process and critical thinking. Just as important are identifying the relevance/relationship of clinical data and the clinical connections (pattern recognition) and clinical reasoning. These aspects must also be emphasized to thoroughly prepare students for professional practice.

In Closing

I believe that NANDA-I and traditional written care plans have a place in nursing education, but should be seen as a “fundamental” approach to thinking like a nurse that needs to be further developed with a practical emphasis of clinical reasoning.

Just as basic nursing skills are first introduced in fundamentals and complex skills added later once these basic skills have been mastered and practiced, clinical reasoning is a higher level, complex nurse thinking skill that must be emphasized in the advanced level of nursing education.

It is imperative that nurse educators emphasize and integrate clinical reasoning to realize and make possible the radical transformation that is still needed in nursing education.

When students understand, apply, and then use clinical reasoning in practice, this will better prepare students not only for the NCLEX®, but more importantly real-world clinical practice!

What do you think?
How does your program integrate clinical reasoning to transition students to real-world clinical practice?
Comment below and let the conversation begin!

References

• Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
• del Bueno, D. (2005). A crisis in critical thinking. Nursing Education Perspectives, 26(5), 278–282.