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Does a Traditional Nursing Care Plan Prepare Students to THINK Like a Nurse?

By July 21, 2016February 1st, 20194 Comments

Well known and respected nurse educator Linda Caputi remarked at a recent conference that there is little evidence to support much of what is done in nursing education.

Though the traditional nursing care plan has been a staple in nursing education for decades, is there conclusive evidence that the use of this approach effectively teaches novice students to think more like a nurse?

I believe that it is an academic exercise that obsesses over the correct wording of a 3 part NANDA-I diagnostic statement, but does not practically capture the essence of how a nurse thinks in practice.

There is a better way!

Emphasizing clinical reasoning and integrating this nurse thinking skill will strengthen student learning as well as bring needed transformation to nursing education (Benner, Sutphen, Leonard, & Day, 2010).

Trouble in Paradise

When I started nursing school in 1981, NANDA nursing diagnostic statements were created as a language of the nursing profession. I remember how awkward it was to apply nursing diagnosis as a nursing priority and then write a “correct” three-part statement for my traditional written care plan.

After graduation, I quickly realized that nurses do not think in three-part NANDA statements and began to develop other ways of thinking like a nurse that included the ability to THINK in ACTION and capture the essence of the problem which are principles of clinical reasoning.

Imagine my horror when I re-entered nursing education twenty-five years later as a new nurse educator and found that NANDA-I was still emphasized and was the ONLY way that students were allowed to identify the nursing priority!

I was torn.

How could I support my students who were repeating the same struggles I had as a student twenty-five years earlier?

It was painful and hard to watch this clinical drama unfold every week as clinical students took their NANDA summary card of all 205 nursing diagnostic statements and reviewed it over and over to find a statement that would “fit” their patient for their written care plan.

But in order to be willing to rethink the traditional written care plan, I would like to share some observations that first need to be considered:

1. Nurse Thinking More Complex than Nursing Process

Nursing process is one of the very first things taught in nursing education so students can begin to develop needed nurse thinking to safely care for patients. Nursing process as it is currently taught in nursing education and by fundamental textbooks (Berman & Snyder, 2012) consists of the following five steps:

  1. Assessing
  2. Diagnosing
  3. Planning
  4. Implementing
  5. Evaluating

The use of the word “diagnosis” or “diagnosing” in step two of how nursing process is typically taught infers that only a NANDA-I nursing diagnostic statement can be used to identify the nursing priority. This is simply not born out in real-world clinical practice.

As a practicing nurse and nurse educator, I believe that NANDA-I remains relevant but should be seen as a beginning or fundamental level of nurse thinking.

Fundamental content always remains relevant to the practicing nurse with advanced skills built upon this foundation in the second level of nursing education.

In the same way, once NANDA-I and nursing process are taught in fundamentals, PRIORITY setting (with or without NANDA-I) and thinking like a nurse using all aspects of clinical reasoning must be incorporated in the second level of nursing education to successfully transition students to real-world professional practice.

See past blog Transform Nursing Education with a Can of NANDA-Lite!

Multiple Ways of Thinking Needed

Multiple ways of nurse thinking need to be incorporated into nursing education (Benner, Sutphen, Leonard, & Day, 2010).

As a nurse in practice, I see at least three distinct aspects of nurse thinking in addition to nursing process that students must be taught:

  • Critical thinking. The ability to USE and APPLY knowledge.
  • Pattern recognition or the ability to identify relationships of clinical data to one another
  • Clinical reasoning. The ability of the nurse to think in action, reason as a situation changes, identify what clinical data is relevant, and grasp the essence of what is needed to advance the plan of care (Benner, Sutphen, Leonard, & Day, 2010). 

2. Three part NANDA-I Nursing Diagnostic Statements is NOT How a Nurse Thinks in Practice

Once the systematic and continuous collection of clinical assessment data is done by the nurse in step 1 of nursing proces, this data must be analyzed and clustered to determine what is most relevant and formulate the best and correct nursing diagnosis.

Step 2 of nursing process requires the student to formulate the correct nursing diagnosis using one of the 205 NANDA statements and then complete with a three-part nursing diagnostic statement that includes the following key components:

  • NANDA statement
  • Related to…
  • Manifested by…

There is only one problem with this traditional approach: this is NOT how a nurse in clinical practice thinks and establishes nursing care priorities, especially when there is a change of status.

As you reflect on your experience as a nurse who practiced at the bedside, did you think and set care priorities using only NANDA-I statements and then formulate a three-part statement?

Other clinical concerns related to the exclusive use of NANDA-I in care plans is that there are numerous NANDA-I statements that do not capture the ESSENCE of the current patient priority.


The inability of NANDA-I to capture the essence of a change in status, translates to failure to rescue when a change in patient status occurs (del Bueno, 2005).

del Bueno (2005) 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 due to inappropriate use of NANDA 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 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). For more, see past blog Why NANDA is a NONO.

3. Clinical Reasoning is the Essence of Nurse Thinking

In order to transform nursing education one of the paradigm shifts advocated by Patricia Benner and the Carnegie Foundation was the need to EMPHASIZE clinical reasoning (Benner, Sutphen, Leonard, & Day, 2010).

In order for something to be emphasized, it is obvious that something else needs to be deemphasized. From my lens of clinical practice, NANDA-I and the use of a traditional written care plan need to be this needed casualty in order for transformation to be realized in nursing education. See past blog Two Words that must be Known to Clinically Reason.

The following four components comprise the essence of clinical reasoning (Benner, Sutphen, Leonard, & Day, 2010):

  • Priority setting
  • Rationale for everything
  • Grasp the essence of the situation
  • Identify and trend relevant clinical data

In next weeks blog I will share in greater detail why clinical reasoning is foundational to nursing practice and how to practically integrate this into the clinical setting. For more see past blog Real Reason for the Current NCLEX® Decline.

Embrace Change (and new nurse educators!)

Just as nurses in the clinical settings must embrace numerous changes inherent in practice, nurse educators must also be willing to EMBRACE and then IMPLEMENT needed change (especially if it is educational best practice derived from Educating Nurses: A Call for Radical Transformation!).

New nurse educators who are current in clinical practice are the greatest asset to any nursing program. Their input and perspectives to strengthen the content and curriculum of the program must be considered.

Unfortunately new nurse educators, like new nurses in practice are often targets of incivility. This  needs to change. Because nursing is a practice-based profession, not merely an academic degree, this practice-based perspective needs to be returned and emphasized in all that is done in nursing education.

Those educators who are recent or current in practice can be the bridge and catalyst to realize this needed transformational change.

This will not only strengthen the nursing program, but will also improve student learning, improve NCLEX® pass rates, and most importantly, improve the outcomes of the patient’s these nurses will care for once in practice!

What do you think?
What have you found effective to teach nurse thinking besides a traditional written care plan?
Comment below and let the conversation begin!

Want More?

e-book-cover2015Today’s blog was derived in part from chapter 8  “Clinical Reasoning is Nurse Thinking”  from my new student text THINK Like a Nurse: Practical Preparation for Professional Practice.

See for yourself why programs around the country have adopted this text in their programs! Contact me if you would like a faculty eBook preview copy.

Save $20 or 50% on paper text through Sunday, July 24th!

For those who want a tangible book they can hold and mark up, then now is the time to get the paper text at 50% off! Simply enter the coupon code “summer20” when you check out. Click this LINK to get you to the store!

What’s Coming!

  • OB educators…next week I will have 2 topics for you to bring active learning that emphasizes clinical reasoning… Placental abruption and Preeclampsia.
  • I have revised and “freshened up” all posted topics on my site with faculty reviewers, additional citations and improved flow. If you subscribe to my updates you will be in the loop! More to come shortly!


  • Benner, P., Sutphen, M., Leonard, V., & Day, L. (2009). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
  • Berman, A. & Snyder, S. (2012). Fundamentals of nursing. (9th ed.). Upper Saddle River, NJ: Prentice Hall.
  • del Bueno, D. (2005). A crisis in critical thinking. Nursing Education Perspectives, 26(5), 278–282.

Author Keith Rischer

More posts by Keith Rischer

Join the discussion 4 Comments

  • vicki meyers MSN RN says:

    I too have seen the outdated effects of NANDA in my 20 years of teaching. Can you please explain a bit further your statement about the use of it at the fundamental level. This is where I struggle with current faculty who strongly believe teaching NANDA structure and linear care planning in the assessment course is relevant yet once we move to the very next level with direct care of clients in settings we move to concept mapping. We are a concept based curriculum. The students are now even more confused. My approach and belief is that NANDA is important to teach as part of our history and evolution of our practice, but 100% agree we do not talk or practice this way.

    • Keith Rischer says:

      Thanks for your response Vicki and will do my best to answer your question. In order to teach students how to think like a nurse, you need to lay a simple foundation and then BUILD upon it. NANDA can be that starting place and has many statements that remain relevant to nursing practice such as “acute/chronic pain, activity intolerance, fluid volume excess/deficit.” Start with these and then build upon this foundation with an emphasis of clinical reasoning and the use of the word nursing PRIORITY instead of nursing DIAGNOSIS for step 2 of nursing process. Allow students to state the nursing care priority (with or without NANDA) after the first semester or year.

  • Jodi Nelson says:

    I was educated 17 years ago in a diploma nursing program. I think I still think in terms of NANDA – the patient’s oxygen saturation is low. I notice their pale, clammy skin and use of accessory muscles. I’m considering ineffective gas exchange? Ineffective airway clearance? Is increasing the oxygen delivered or changing to a different appliance so a higher concentration can be delivered going to make a difference? Do they need a respiratory treatment to open their airway? While I’m not formally organizing the statement in my head, I learned the basics so it happens automatically and I can respond appropriately.

    In response to a source you quoted in this post – For example, when a patient had a condition change consistent with a stroke, the nurse used the NANDA 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). – it appears the nurses lacked the proper knowledge about what causes a stroke and MI and knowledge about each nursing diagnosis, and in the end failed to respond to the needs of the patient. I feel it comes back to the education.

    I see NANDA as a learning tool, a formal way of organizing thinking about the problem, assessment, and cause during the learning process in nursing school.

    That said, I do have struggles with NANDA. I am frustrated that it seems so prescriptive – it must be written this way and that way can seem very textbook and not patient friendly. So the student focuses more about getting the words right. I want students to distinguish between an ineffective airway and the ability to exchange oxygen with carbon dioxide effectively so they can treat the problem and prevent respiratory arrest. They get hung up on finding something from the list, as you pointed out. I also feel NANDA doesn’t always have the diagnosis for the problem – infection, bleeding, for example. I will deviate from the diagnosis and tell the student that it isn’t a risk for as stated in the book but rather an actual infection so what is your nursing care going to be like when they have an actual infection instead of a patient with a risk for infection.

    I’m curious about what other educators are doing – if they teach with NANDA or not. Those that are not, how is it different?

    • Keith Rischer says:

      You make an excellent point. There are NANDA statements that remain relevant to the bedside and should be used when they do “fit” such as “ineffective or impaired gas exchange.” Unfortunately there are many statements that do not readily “fit” to the bedside and educators need to be flexible with allowing students to state the care priority in their own words as you allude to. We are actually on the same page and appreciate your insights and perspective!

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