Garbace. Artificial semantic applied to common sense

Like Renzo I do not see a dichotomy between my role as a Nurse Practitioner in the UK (seeing, diagnosing, treating referring or discharging patients) as being distinct from my role as a nurse - it is an inherent part of my nursing role and there are elements of this process that nurses have historically and more contemporarily been found to have provided on a more effective basis than medical colleagues - communication skills, approachability and safe discharge advice being a few. Having said that I have worked with some very good doctors (who perhaps should have been nurses : ) - and some awful nurses. Whenever I see the word autonomous as applied to nursing my temperature rises - who would want, who would expect and who thinks that they have reached such a pinnacle of expertise that they would want to practice autonomously? - I would swap this word for any of these (take your pick):

arrogant

over-confident

dangerous

I would place a great emphasis on team working where all disciplines have something to learn from each other - so I work with colleagues from:

the ambulance service

physiotherapy

medicine

nursing

other allied health professionals

and thankfully the majority acknowledge that although sometimes having unique skill sets we can share these with each other to our mutual benefit and most importantly for the benefit of the patient

Thanks Renzo and James. I hope to explain my question. I believe that nursing, which is a unique expression of the nurse, according Carpenito, but also the ANA, ENA, can stand out in two stages. “nursing diagnosis” through where the nurse by signs, symptoms, history, etc., recognizes the human response to health problem, sets out the outcomes for the patient, uses nursing interventions, evaluates the results and “potential complications” that is collaborative problems. It is clear that the nurse collaborates with other health professionals and I'm sorry if my words have been interpreted as a quest for professional autonomy. Renzo probably does not consider the Carpenito’ model a nursing theory. But the nursing diagnoses do not represent a fundamental moment of critical thinking in the nursing process? And the complications are not treated as collaborative problems? The bifocal model is dichotomous or it can be a way to explain two distinct focus of a thought unit? Thanks for your answers.

Nicola, the critical thinking is required for the inquiring process (hypotheses, empirical indicators, relationships, etc) aiming to a clinical judgment, not for selecting a judgment between others (pattern recognition process). Diagnostic reasoning is truly different from a taxonomy of clinical judgements in form of stable, well identifiable patterns. When I was a beginner (I am still like that), in my ingenuity I used to think that a reference system of diagnoses could be a substitute of the old system of Maslow's needs. Well, for nursing they are basically the same model, just a different semantic for labelling. There is no ontology, no capacity to answer the basic question "Why?". In the 80' (30 years ago) we use to teach that in the nursing domain there are at least two areas: one where the nurse is accountable for making decisions and one where the nurse is accontable for correctly implementing others' decisions. At least, we did not add confusion using the term "problem" (situation for which there is not an interpretation available) that Carpenito considers synonimous of difficulty, or risk, or alteration, etc. Despite my old friendship with Carpenito, I really think that is an old way of thinking about nursing, more related to social power (to be recognized, to be independent) than to be effective and having added value in a multiprofessional team, like Jason has brillantly stated. Even in medicine, no one would refer to diagnoses as a selection of pattern in a classification system simply because there is no theory, no critical thought about the reason of a sign (theories of the processes), the connection between signs (theories of the system), and so on. A judgment is in itself an interpretation and the reason of a theory is to provide the power for interpreting. See, a diagnosis in itself is a theory application, not just a pattern recognition. Therefore, what usefulness has a diagnosis without a prognosis?. But a prognosis is feasible only if you have theory about the natura of the process identifiable by its empirical signs.

However, this is a long lasting discussion, I just hope that in the nursing schools start to get rid of this easy, but false knowledge. Diagnosis, if not based on scientific theory it is expression of personal opinion, common sense. If so, diagnosis may satisfies the need for self esteem of a frustrated nurse but at great price of impoverish his culture and reduce his critical awareness.

Renzo Thanks for your kind words. I'm glad you've explained your thinking, which I find very interesting. (I have read in the past your reflections on nursing, which I found stimulating for my growth as a nurse, and I plan to do it more often). I think the reflections on the theme of critical thinking and nursing thinking should be further developed in Italy. I know your weight in this regard and shall not fail to grasp the stimuli that you will want to give us. Thank you for your comment.

Hello, can I joint? In my opinion the bifocal model can be applied in emergency. As we know, nursing process on emergency setting need to be done very quickly. In my ISDA e - book, most cases in emergency can be found in page 10 and 11. For your information, ISDA is abbreviation from Intan's Screening Diagnoses Assessment. This is a tool to help to screen possible nursing diagnoses and collaborative problem. ISDA can help in the process of diagnostic reasoning. ISDA is already available in e-book for easy access.Please feel free to check it the example at http://www.nursediscovery.com/publication-2/. Regards Intansari.

Sorry I just checked, it should be on page 7 and 8 on ISDA e book. Please feel free to check.

Many thanks Intasari for your reference. I will read your e-book with very interest. Best regards.

You are welcome. I forgot to attach one exampe of page in ISDA

Here it is

Regards

Intan

Good morning to all, especially to my friend Nicola.

Allow me to carry my opinion in this interesting discussion. Sorry if my English is not as fluent as your…

After a long professional experience in emergency and critical care, I have recently gone to education of nursing students.

My feeling is that the uncritical and irrational application of the bifocal model, as required by some nursing teachers, is the most important - and often insurmountable - obstacle to the possibility for students to learn and practice the clinical reasoning.

The student is led to avoid any form of systematic diagnostic assessment! His only aim is to place the patient in the standardized and pre-packaged diagnostic pattern that most resembles his "problem ". Thus, all patients with acute exacerbation of COPD or with an AMI have the same "problems"! But it could be worse, because these "problems" are relevant only as they identify standard interventions, automatically divided (into a Manichaean way) between "autonomous professional" or "collaborative problems". The result is the loss of any ability in

clinical assessment and diagnostic reasoning. Could someone explained to me the usefulness of this process or its impact on nursing, and not only in critical care?

I am sincerely convinced that the bifocal model represents one of the best condition to prevent an intra- and interprofessional team work.

I deeply agree with Renzo: diagnostic reasoning is truly different from a stable taxonomy of well identifiable patterns. By educating our students according to this model, we will make them not ever be able to answer to many "why" of care and cure, nor to know how to ask the right questions.

Hello Gianfranco, thanks for your comment. Nice to meet you. I try to explain my idea about the bifocal model, nursing diagnoses and collaborative problems. I use this model to explain to students that nurses use the diagnostic process daily, in all cases, even when attending their collaborative interventions appear only on prescription. But I like to teach them to use a nursing language (standardized). Using a standardized language, does not mean delivering standardized care. Even the use of the linkage between NIC, NOC and NANDA, does not mean depersonalize assistance. On the contrary, I like to be focused attention on the "uniqueness"and "priorities" of the problems that the patient may present. The language is standard. Nursing care is personalized. Not coincidentally, I talk to the students about critical thinking, diagnostic process, problem solving along with NANDA, NIC and NOC. The taxonomy reflects requirements for classification, the standard language for responding to the development needs of a nursing language shared. The bifocal model is useful to understand that the nurse is not only a good performer, but it is the professional who diagnoses and treats human responses to health problems. It does this by working with a doctor and acting independently on the priority needs of the patient. Simultaneously ! using clinical judgment, knowledge and tecnical or non technical skills.Even in the emergency department where it seems that the health problems are exclusively in terms collaborative. and yet how important are the intellectual skills and the use of critical thinking.

In my opinion, so far nursing diagnoses could not cover all of phenomena in clinical setting. Collaborative problem helps to cover those phenomena that nurse sometimes cannot name it. In my experience, student mostly determined diagnoses both nursing diagnoses and collaborative problems without checking whether the data is sufficient or not to establish diagnoses. Sometimes even the data is available but nurses or students are not sure where that data is belong to which diagnoses. It becomes more complex when we realize that one data or symptoms can be belong not only to nursing diagnoses but also belong to collaborative problems. Actually through the process of scrutinizing nursing diagnoses and collaborative problems, I could find that data or symptoms can be divided into three categories. Firstly is data that belong to nursing diagnoses and collaborative problems, secondly data that belong only to nursing diagnoses and thirdly is data that belong only to collaborative problems. Understanding this idea is very important. For example when we find data that we know this data is belong to both nursing diagnoses and collaborative problems, then we realize that the other health professional such as physician also need to know this data as well. In this circumstance, nurses need to let physician know about this data. On the other hand, there are also some data that only belong to nursing diagnosis. This data is really belong to nurses and sometimes other health professional may not have any business with this data.

In my opinion, nurses and other health professional will work in the data that belong to both nursing diagnoses and collaborative problems. This is a grey area, I reckon. I found in some clinical nursing site, for example in psychiatric nursing, the collaborative problems are not as much as in maternity nursing or in medical surgical nursing. As you can see in that picture I have attached that related to blood pressure, we see that there are many word with a blue color. It means that there are many collaborative problems probably experienced by client if we find an abnormal blood pressure value.

I try to explain my position.

I am not denying the importance of a standard language to categorize the activity of the nurses in terms of “problems”, interventions and outcomes.

However, the main problem is related to the fact that (I agree with Intansari) NANDA diagnoses do not cover all aspects of nursing clinical activity and “collaborative problems” are chosen every time a medical intervention is needed as a part of problem solving process (but, even when a procedure is performed on prescription, the nurse is responsible for a substantial part of the process!). In this way the attention for the intervention anticipates (or replaces) the diagnostic reasoning, avoiding a complete data collection before establish the diagnosis.

The clinical reasoning must precede the diagnosis, and the clinical assessment must precede (and assist) clinical reasoning. In my opinion, at clinical stage it makes no sense to label the identified problem as "nursing diagnosis" or "collaborative problem". If the data recorded on the patient and the next (contemporary) diagnostic reasoning identified the situation as associated with a "problem" to be solved, it is necessary to define objectives, interventions and indicators of outcome relevant to its solution. The standardization of the "name of the problem" is not useful, or better, it is misleading at this stage.

Moreover, the fact that interventions are "autonomous" or "collaborative" is not predictable a priori, but is a consequence of the skills of the individual practitioner and should depend by protocols and procedures used in the clinical setting in which the activity takes place and, not least, the Country in which it operates. For example, administering any drug or oxygen can be an intervention "autonomous" in some settings (eg EMS) or "collaborative" in others. But also the prescription of interventions as simple as an enema, which NIC includes as autonomous nursing intervention, in Italy is possible only after a prescription!

On the contrary, once the clinical path is completed it is very important to classify data about the activities carried out by the nurses (diagnosis, interventions EVEN ON PRESCRIPTION, outcomes REALLY obtained). In THIS phase is essential to use a shared taxonomy that allows comparison processes and definition of benchmarchs.

Hi Gianfranco, thank you very much for your comment! I like to know your point of view that originates from the work on the field and comes to teaching. I'll consider your ideas as well as those of Renzo, James, and Intasari. When you say it: "theory without practice is empty. Practice without theory is blind."

Dear all colleagues, this is very good discussion. I have the next question then, is there any research published show that NANDA is not cover all phenomena in clinical site? Then by using bifocal model, is it able to cover the gap that NANDA has?

I have just done research in psychiatric setting by comparing what the nursing diagnosis mostly found in the clinical setting and what data or symptoms they (nurses) frequently found. It surprises that there is a gap between what the nurse think the most frequent nursing diagnoses and what the possible nursing diagnoses (based on the symptoms).

Nursing diagnoses which established by nurses can be referred to 15 diagnostic foci (Axis I in NANDA taxonomy) whereas the possible nursing diagnoses identify from signs and symptoms found by nurses can be referred to 33 diagnosis foci. Means that there is a gap between the nursing diagnoses established by the nurse and the possible nursing identified through a thorough analysis of patient symptorrms.

The result of this study shows that there are many nursing diagnoses that nurses can not recognize! It is supported by other result that only 18 of 102 diagnoses written by participant were found to be accurate in statement aspect, in accordance to NANDA International diagnoses.

What I have said that NANDA may not cover all the phenomena in clinical site (in here: psychiatric setting) cannot be confirmed in this study. What I found is that the nurses probably in the situation in which they did not follow the process of diagnostic reasoning appropriately.

I need a prove that NANDA can cover all of phenomena in the clinical setting or not, but without doing the process of diagnostic reasoning properly, this question will never be answered. This study shows that nurses possibly not familiar with NANDA taxonomy, they found the symptoms but they cannot predict what Ddx (Diagnosis differential) for those symptoms! Or they may not recognize the symptoms showed by client as an important data!

From several diagnostic reasoning workshops I run in 2011, and 2013, I found that most of participant tend to 'jump in conclusion' in the process to confirm nursing diagnoses, they mostly do not realize that there are more possible nursing diagnoses and collaborative diagnoses (Ddx) even for one symptoms the client have.

This workshop anyway still in the phase in which we want nurses to do diagnostic reasoning process properly by making sure that all possible diagnosis (nursing and collaborative) will be considered. We believe after we do the process in diagnostic reasoning properly, then we can prove whether NANDA and bifocal model can cover all of phenomena in clinical setting. It is still a long way to go.

Dear Intansari, I don't know if the NANDA-I nursing diagnoses cover all phenomena in clinical site. In the past, when I was Head Nurse in Neonatal Intensive Care Unit, I used for four weeks during my ward's workshop on diagnostic reasoning an experimental nursing record with 39 nursing diagnoses. These diagnoses covered many neonatal and parental conditions at any dependency level of the patients. It was a great experience on diagnostic reasoning and nursing diagnoses utilization in this clinical site. Now in Emergency Department I use few nursing diagnoses with my students for introduce them at diagnostic reasoning and at critical thinking. Yes, you have reasoning when you say "It is still a long way to go". But I hope that nurses around the world want to accept this challenge!

Dear Nicola, I agree with you. Let's work together for this challenge!

Dear Nicola, just my curiosity, which diagnostic reasoning model did you use for the workshop? Thanks a lot for your information. Regards. Intan

Very interesting, Intasansari!

Did you publicate the result of your study in psychiatric setting? And you, Nicola, about Neonatal ICU?

Hi Gianfranco... I and my team has submitted the result of that research too Mental Health Conference in Perth, October 2013, but we are still waiting for the result. I will also present the result of my other research related to two different methods of diagnostic reasoning process (4 and 6 step method of diagnostic reasoning) at the International conference in Singapore 8-9 July 2013. I am still working on manuscript to publish in a journal. Still very tight with my PhD schedule anyway.

Hello everyone, I published our experience in the NICU of Perugia Hospital about the newborn with surgical problems on Connect (Neonatal Surgical Intensive Care: "Bifocal Clinical Nursing Model" approach. Connect, 2011, 8 (3), 91 - 94.). The approach used was the Carpenito's Bifocal Model and Gordon's Functional Health Patterns.

Hi Gianfranco, I have upload the result of my previous study in psychiatric setting (in 2011). Feel free to have a look. Regards. Intan

Thank you Nicola and Intansari!

I'll read your paper as soon as possible!

 It is a model that allows the nursing professional to carry out an autonomy in the care and in turn collaborate with the multidisciplinary team. This model is useful for nursing professionals, since it is a referential basis for the application of nursing care based on a care systematization, which will allow a reduction of error at the moment of providing care. In the emergency service the nursing professional must provide care in a way that ensures life, as it faces situations in which time is gold.