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3 Reasons Why NANDA is a NONO to Develop Nurse Thinking (7th in a series)

By April 16, 2014February 2nd, 20196 Comments

 I believe like that RADICAL transformation is needed and can be realized in nursing education today. I have crafted a document: “A Declaration to Transform Nursing Education” that situates 7 needed practical paradigm shifts to help make needed transformation in nursing education a reality.

The 5th paradigm shift of this document: I will  allow nursing priorities  to be situated in new ways in addition to NANDA nursing diagnostic statements.

Topic of todays blog: The image for this weeks blog represents the tragic consequence of a patient going down for the last time whose plight goes unrecognized by the lifeguard. The same fate is also possible for the patient whose nurse “fails to rescue” because of an over-reliance on NANDA to establish a care priority (2).

I have 3 reasons as an experienced clinical nurse of 30 years as well as nurse educator why NANDA must be de-emphasized in nursing education and replaced with an emphasis of clinical reasoning:

  1. Does not represent the essence of how a nurse in practice thinks
  2. Contributes to “failure to rescue” by the nurse when the status of a patient changes
  3. No NANDA statement to identify a change of status or care priority
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#1: Does not represent the essence of how a nurse thinks in practice

I was working recently in the cardiac monitoring center where all the remote telemetry patients are continuously monitored. A critical alarm went off on the screen monitoring a med/surg patient. Over the next several seconds, the heart rate decreased from 50…40…30…20 beats per minute and continued to slide! It was clearly NOT artifact, and I called the operator to initiate a code and ran promptly to the room before the code was paged overhead.

When I got to the room of the patient who was in dire need of “rescue” do you think I took one look at this woman and immediately formulated this 3 part NANDA nursing diagnostic statement:

Ineffective tissue perfusion-cardiac-neuro and renal  RELATED TO sinus bradycardia/sinus arrest, but oops!…I cannot use the medical diagnosis but must state instead that this is a condition in which there is a decrease in the heart rate that is caused by numerous factors including hypoxia & sinus node dysfunction MANIFESTED BY absence of pulse, absence of BP, and ashen pale skin color”
This beautifully worded 3 part NANDA nursing diagnostic statement may get an “A” on a care plan, but it FAILS to prepare nursing students to THINK LIKE A NURSE IN PRACTICE!
If this is the complexity of the thinking that is required to establish a care priority in crisis, by the time I would have formulated this thought, this woman would be dead!
Instead, I used clinical reasoning which is “nurse thinking” that emphasizes the need to “grasp the essence” of the clinical scenario (1). I quickly recognized the “essence” of the situation and simply stated to myself “NO PULSE…NO RESP…BEGIN CPR!” and life saving interventions of beginning CPR, obtaining the crash cart and calling a code quickly followed (this patient did survive!)
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#2: Contributes to “failure to rescue” by the nurse when the status of a patient changes

NANDA nursing diagnostic statements can be a barrier to identifying the current care priority when the status of a patient changes. Dorothy Del Bueno found that 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.

The reason? Inappropriate use of NANDA nursing diagnostic statements to make them “fit” when there was a change in status (2).

For example, in Del Bueno’s research, she conducted a simulation that had a patient present with symptoms consistent with a myocardial infarction. Instead of using clinical reasoning to grasp the “essence” of the scenario, the nurse used the NANDA statement, “activity intolerance related to pain” instead.
This is like making a square page fit into a round hole. NANDA was never meant to be a tool to set care priorities, but a taxonomy of “diagnostic statements” to distinguish nursing from physician “diagnosis” back in 1982. Therefore in nursing education, we are forcing NANDA to do something it was never intended to do.
In closing her research article, Del Bueno summarizes her 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 laughable” (2).
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#3: No NANDA statement to identify a change of status or care priorities
Many common clinical scenarios have NO NANDA diagnostic statement that even comes close to identifying the problem. For example, if you were caring for a post-op pt patient on a Dilaudid PCA who has now become more lethargic and is unresponsive but still has a respiratory rate of 16/minute, of the 205 NANDA nursing diagnostic statements there is not even ONE that comes close to identifying this nursing priority! If NANDA is the primary method that is taught to establich care priorities, now what is this nurse to do?
But instead, if clinical reasoning has been taught so that the nurse can grasp the “essence” of the situation, this nurse will simply state,”opiate over sedation” which captures the essence of the problem and needed “rescue” begins.
Once correctly identified, nursing interventions readily follow which includes Narcan IV push and monitor airway, breathing, and O2 sat as well as TRENDING the assessments of neuro and resp status.
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In Closing…
NANDA is a needed FUNDAMENTAL level of thinking that is best used and situated with stable patients with expected outcomes.
But just as fundamental skills are first established and then more complex skills are built upon that foundation in nursing education, clinical reasoning is advanced “nurse thinking” that must be situated in the second level or advanced component of the program, and is built upon the appropriate use of NANDA.
“Acute/chronic pain, fluid volume excess/deficit, and impaired skin integrity” are examples of NANDA statements that capture common nursing priorities and are relevant to practice. But most NANDA statements are not highly relevant to real world practice and have limited value from my perspective.
In the widely used EPIC electronic medical record that our hospital uses, the nursing care plan does NOT even use NANDA in anyway to establich care priorities based on the medical problem.
I am not advocating for a complete reversal of the use of NANDA in nursing education. As nurse educators we must have a “crucial conversation” with our students and be open and honestly communicate the limitations of NANDA that I have outlined, and more importantly identify the strengths of clinical reasoning to nursing practice and situate this in our programs to better prepare our students for professional practice!
To DEEPEN your knowledge of clinical reasoning and its relevance to nursing education please see my past blogs The Real Reason for the Current NCLEX® Decline5 Rights of Clinical Reasoning, and Where’s the Thinking?
Comment Question:
Is NANDA still relevant to practice today? How have you taught nurses to think in other ways in addition to NANDA in your program? 
Respond in the comment section below and let the conversation begin!
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To go deeper on this topic:
1. Bringing Down Sacred Cows-(NANDA)-YouTube by KeithRN
3. 5 Rights of Clinical Reasoning-YouTube by KeithRN
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References

1. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass
2. Del Bueno, D. (2005). “A Crisis in Critical Thinking,” Nursing Education Perspectives26(5), 278-282.

Join the discussion 6 Comments

  • In response to current blog, I could not agree more. When I was in nursing school it was difficult for me to think in terms of nursing diagnosis. I could assess and collect clinical data but to put a correct label on this seemed weird to me. I can tell you in my current practice as a nurse I do not use nursing diagnosis to help me guide my care. I mentor students from time to time and they spend so much time trying for figure out a nursing diagnosis. They will sometimes ask me for help and I tell them sorry I don’t think like that. In my opinion the NANDA nursing diagnosis process in a unnatural process in guiding patient care and it cripples students in their thinking process.

    • Keith Rischer says:

      Thanks for the response Georgia. From your perspective you also see that it does not capture the essence of how a nurse thinks and prioritizes in practice. It is encouraging to know that others also see the shortcomings of NANDA and how it is currently used to establish care priorities for practice.

  • Keith… I graduated with my BSN in 1971. I know we had a ridiculously primitive approach to clinical reasoning back in those old days. Silly us… we actually learned to think using classical logic and the nursing process, along with Maslow’s hierarchy to set priorities

    So it was a “happy day” when the lady-light-bringers of NANDA finally stood up to “Define the Knowledge of Nursing” for the rest of us who were obviously ignorant and intellectually impoverished, who clearly couldn’t be trusted to care for patients without their taxonomy.

    Sarcasm aside… I have had to defend my lack of enthusiasm for NANDA ever since they came into existence and began speaking for the profession. Naturally, those in nursing education have been the ones most in thrall to NANDA and our students have suffered accordingly.

    I try to tell my students… if nursing was horsemanship, NANDA would be dressage. Real nursing is rodeo.

    But the problem of using NANDA pedagogically is that it requires the wrong type of reasoning for the becoming-nurse. NANDA’s can be shuffled and organized in every way imaginable. There is nothing “reasonable” (i.e., one concept built upon another) about them. Each stands on its own. Therefore the type of knowledge we’re demanding students use (before they know ANYthing) is “gnosis”. Gnosis is all about recognizing. (You’re lost. You see a landmark. Suddenly the map just snaps together in your head and you “just know” where you are. That’s gnosis.) That’s also what NANDA is. (Diagnosis from Gr. gnosis)

    What we should be doing is using “Episteme” to teach nursing students. This word from Greek is most often applied to scientific knowledge. Concept-application, leading toward another related concept then an associated corollary and so on and so on. I unwrap some of this on my (very early/primitive/nascent/always changing) website. Feel free to cruise around. I’ve assembled it for my students… because they come to me every semester so nutted up. I had to do something for my own sanity.

    Thanks Keith. Good luck with the crusade.

    • Keith Rischer says:

      It is encouraging Jeanette to know that I am not alone. Your thoughtful and insightful analysis is needed to have an honest dialogue regarding the inability of NANDA to teach care priorities to our students and to more effectively prepare our students for professional practice!

  • Jenn Gable says:

    I have just started teaching a Level 1 NUR 101 lab and I see the students struggle with the care plans and deciding on the “right” nursing diagnosis. And I struggle to teach this as I don’t think this way, it’s very challenging to teach a care plan when my brain just doesn’t work from a care plan. After I taught the care plan disastrously (my opinion because all the care plans turned in were horrible!), I decided I was going to change the way I teach these fabulous things. I started to ask the students to put things into their words. So if the patient outcome is Effective gas exchange, I asked, “what does that mean to you?” and most were like, “i don’t know, it’s what the book said” so we dove into deciphering what the book states and applying it to a clinical situation. For example, if one method to measure gas exchange is through ABGs how would you know your patient is achieving that goal? What would you monitor? How would you help your patient reach that goal? How can nurses help gases exchange? Pulmonary toileting? etc. I felt like this helped them look at the picture better than just plugging what the book said into a box on a piece of paper.
    I think care plans for a level I class are good for laying a foundation, if you press the students to think. There are some professors who tell the students, “you don’t know enough so just put down whatever is in the book” how does this help?! It’s frustrating and I just started doing this full time teaching thing.
    What nursing diagnosis would I write for me?! (c:

    • Keith Rischer says:

      Thanks Jenn for sharing. Your experience with students is not unique and I appreciate taking the time to share so other educators know they are not alone! It is obvious that in order to prepare our students for practice, the educational reserach in Educating Nurses got it right. We need to teach OTHER ways of nurse thinking that includes an emphasis on clinical reasoning which is what you were doing by encouraging students to put nursing priorities in their own words. Well done!

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