The profound wisdom of the nursing diagnosis

When I was in nursing school there was always a lot of eye-rolling when it came time to discuss nursing diagnoses.  This was mostly because nursing diagnoses were followed by book-length nursing care plans that we had to produce for various imaginary patients. There was also a faction, including myself, who thought a medical diagnosis was just fine, thank you, no need to reinvent the proverbial wheel.

For example, for a patient with congestive heart failure (medical diagnosis) patients have trouble breathing, less ability to take care of themselves, loss of independence, and confusion about what congestive heart failure is.   Nursing diagnoses might be things like altered respiratory status, decreased ability in activities of daily living, altered self-image, knowledge deficit related to diagnosis, etc.  Kind of seems like silly semantics, doesn’t it?   To my knowledge, nursing diagnoses are no longer really used in practice, much less those endless care plans.

I’m here to suggest, however, with the perspective of age and experience, that there is profound wisdom in the nursing diagnosis format that can be used not only for illness but for the problems of everyday life.

Let’s take job dissatisfaction.  That will be our medical diagnosis.  Treatment: Find a new job.

Now, a nursing diagnosis is structured as “the problem” (diagnostic label), “related to” (the etiological factor or what is causing it), and “as evidenced by” (assessment data or clinical markers).  A nursing diagnosis addresses the actual experience of the individual.  “Job dissatisfaction” is not a nursing diagnosis, because job dissatisfaction affects each individual differently and is caused by different factors in each person.  We want to address the human response to job dissatisfaction.

Say your experience is boredom.  Boredom is a common response to working at something that doesn’t interest us. So if boredom is the problem, what is it related to?  Maybe your work is too repetitive, or you feel like you never get anywhere. And if you’re bored, how can you tell whether it is because your work is too repetitive as opposed to unsatisfactory in some other way?  Because, as you are now noticing, you make shopping lists and compose sonnets in your head while the rest of you follows well-worn paths.  Your nursing diagnosis is this: Boredom, related to the repetitive nature of your work, as evidenced by your ability to do your work while thinking about something else.

But that is not your only diagnosis.  You also feel like a bad parent because you snap at your kids every night after work.  This is also a human response to the disease of job dissatisfaction.  So the nursing diagnosis is ineffective parenting, perhaps.  What is it related to?  Are your kids particularly irritating?  No, because you love spending time with them on the weekends and on vacation.  If you tell a friend, “The kids are driving me crazy,” and she asked you why, do you always say, “I’m so tired after work”?

Nursing diagnosis: Ineffective parenting, related to fatigue, as evidenced by your ability to enjoy your children when on vacation.

Now you have a new diagnosis: fatigue.  But wait.  Maybe fatigue is the evidence of something else. If you don’t know what the problem is, try structuring the diagnosis backwards.

Evidence: I’m tired all the time.
Related to: work
The problem: I don’t know, work makes me tired.

Having done the work above, you do know what the problem is.  Your work is boring and repetitive, and it drains you instead of energizing you.

But now you have a new problem: You’re drained and tired and don’t have the energy to carry out the doctor’s prescription of “get a new job.”  You have an inability to follow treatment, related to fatigue as evidenced by the fact that you’re still in the same job one year later.

This approach to problem-solving can, in effect, help you to nurse yourself.  Now you are not paralyzed with thoughts like, “I hate work, I’m stuck forever, There’s no way I can quit, I have no idea what I really want to do, I’m just whining and I should suck it up, it’s hopeless,” circulating uselessly in your brain.  Now you find ways to make the work less boring or to distract yourself.  You know why you’re impatient with your kids and get your mom to come over and help between 5 p.m. and 8 p.m.  Having help makes you less tired, and you’re able to find an online course on a subject that has always interested you.  You still have job dissatisfaction, but you feel a whole lot better.

That’s nursing.

Shirie Leng, a former nurse, is an anesthesiologist who blogs at medicine for real.

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