NURSING IS UNDER ATTACK: A CALL FOR THE USE OF EVIDENCE TO COMBAT THE ERASURE OF OUR PROFESSIONIn current literature, we hear calls for more and more interprofessional or interdisciplinary care; this seems to provide the opportunity for the richest and most inclusive care model possible for our patients. A true interdisciplinary team is one in which each discipline brings its knowledge base and areas of practice together with the patient/family to provide the best possible treatment plan. Effective teams share responsibilities and promote role interdependence while respecting each individual discipline’s perspective, knowledge and autonomy. This suggests that each discipline brings its own disciplinary knowledge and approach to the interdisciplinary table.
Recall that in the definition of a profession, common characteristics include: high level of individual responsibility and accountability, specialized body of knowledge, relatively high degree of autonomy and independence in practice, and a strong professional identity and commitment to the development of the profession1. Nurses work closely with all health care providers, but there seems to be a movement taking us backwards toward working under or only in collaboration with other disciplines, as opposed to being seen as autonomous professionals.
In its recent document, the International Standards Organization2 makes the following statements: “Nurses may undertake diagnostic assessments related, for example, to growth and development, behaviour, parenting capacity, family functioning etc., often in collaboration with mental health or social care professionals. In assessing the subject of care's responses to health problems and as part of their collaborative role with doctors, nurses often address aspects of illness or injury management in their assessments. This is informed by the medical diagnosis and chosen treatment option determined by the doctor, where possible in consultation with the subject of care or significant other”.
It is concerning to me that a standards organization for healthcare terminology feels the need or in fact, the right to define our autonomy and role. And to incorrectly state that nursing diagnosis, terms which represent nursing judgments of patients` human responses which are separate from medical diagnosis are defined as being informed by the medical diagnosis and chosen treatment option determined by the doctor. These statements do not align with our discipline’s autonomous role in diagnosing human responses. And yet, this document is now circulated internationally. And it does not stop there. SNOMED CT also is pushing the “interdisciplinary and collaborative nature” of nursing, denying our ability to be able to access terms that we, as a discipline, feel are important.
On its site, SNOMED International3 indicates its mission is “The safe, accurate and effective exchange of health information is an essential foundation to improve healthcare around the world. We strive to determine the best global standards for health terminology and to engage with the global healthcare community to improve SNOMED CT and patient safety.” Yet, we are told that many of our nursing diagnosis terms that, in the case of NANDA-I are evidence based, peer reviewed terms, are not all “acceptable” to SNOMED CT and do not meet its “interdisciplinary, collaborative model”. I wonder if our colleagues in medicine or physical therapy are told the same?
How is it that non-nursing organizations are now able to dictate what is and what is not a necessary term for nursing practice? These subtle, yet potentially disastrous steps being taken by those outside our profession will undermine our ability to document using evidence-based terminologies that represent our own disciplinary knowledge. If our terms are not available to us, we become invisible. Our ability to measure the impact of nursing on patient care, as is being done now through excellent research, will be diminished4-7.
This is also why our terms, our diagnoses, outcomes, and interventions must be evidence-based, linked to assessment data collected by nurses, with clearly defined diagnostic criteria which enable validation of our diagnoses, and with measurable outcomes. To enable us to identify those interventions that are most effective for different populations, and in different settings or at different times in the diagnostic trajectory. To use anything less leaves us open to the criticism that the terms used by nurses are meaningless and unmeasurable, and that they can be automatically established by an electronic health record system, rather than determined using nurses’ clinical reasoning that is for some reason easily attributable to other disciplines, but somehow remains invisible in ours.
We cannot ignore this issue. Interdisciplinary care if truly interdisciplinary is the ultimate in quality for the patient. If, however, it leads to subjugation of nursing under other disciplines, we cannot allow or enable this. We must use our research, our nursing science, to fight against those who would silence our impact on patient care. We must act now, globally, to address this issue!
The language we use to document our knowledge matters. What will we choose? I, for one, believe we must insist on evidence-based terms that can be validated in the clinical setting, using informatics tools (or even a manual review of assessment data), and through research using clinical validation methods. Further, I believe if we do not do this soon, we will look back in the near future to realize that our disciplinary knowledge and our profession are completely invisible within the electronic health record, and therefore our impact on patient care has been erased.
REFERENCES
- 1. Catalano JT. Nursing now: Today's issues, tomorrows trends. Philadelphia, PA(US): FA Davis; 2019.
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2. International Standards Organization (ISO). International Standard ISO 18104: Health informatics - Categorial structures for representation of nursing diagnoses and nursing actions in terminological systems [Internet]. 2023 [cited 2024 December 13]. Available from: https://www.iso.org/standard/81132.html
» https://www.iso.org/standard/81132.html -
3. SNOMED International. About us [Internet]. 2023 [cited 2024 December 13]. Available from: https://www.snomed.org/about-us
» https://www.snomed.org/about-us -
4. D'Agostino, F; Vellone, E; Cocchieri, A; Welton, J; Maurici, M; Polistena, B; et al. Nursing diagnoses as predictors of hospital length of stay: A prospective observational study. J Nur Scholarsh [Internet]. 2019 [cited 2024 December 13];51(1):96-105. Available from: https://doi.org/10.1111/jnu.12444
» https://doi.org/10.1111/jnu.12444 -
5. D'Agostino, F ; Sanson, G ; Cocchieri, A ; Vellone, E ; Welton, J ; Mauric, M ; et al. Prevalence of nursing diagnoses as a measure of nursing complexity in a hospital setting. J Adv Nurs [Internet]. 2017 [cited 2024 December 13];73(9):2129-42. Available from: https://doi.org/10.1111/jan.13285
» https://doi.org/10.1111/jan.13285 -
6. Sanson, G ; Welton, J; Vellone, E ; Cocchieri, A ; Maurici, M ; Zega, M; et al. Enhancing the performance of predictive models for Hospital mortality by adding nursing data. Int J Med Inform [Internet]. 2019 [cited 2024 December 13];125:79-85. Available from: https://doi.org/10.1016/j.ijmedinf.2019.02.009
» https://doi.org/10.1016/j.ijmedinf.2019.02.009 -
7. Sanson, G; Vellone, E; Kangasniemi, M; Alvaro, R; D'Agostino, F. Impact of nursing diagnoses on patient and organisational outcomes: A systematic literature review. J Clin Nurs [Internet]. 2017 [cited 2024 December 13];26(23-24):3764-83. Available from: https://doi.org/10.1111/jocn.13717
» https://doi.org/10.1111/jocn.13717
