Nurse methodology applied to clinical practice: Reality or fiction?

Dear Editor,

In the area of academia and health, we read the clinical case of Zariquiey-Esteva et al.¹ about the medical diagnosis of a patient with botulism and we congratulate the authors on their efforts in describing it using nursing methodology, which adds a further plus to its complexity. Furthermore it is relevant to cover this case given the seriousness of this disease and the shortage of information on it available to healthcare staff and the public. We also analysed a previous clinical case published in EnfermeríaIntensiva²; however we received no response, and the nursing methodology has still not been resolved.³

Since the beginning of the profession, patient care has been task-based. When the literature started to refer to the nursing process in terms of care of the individual, family or community, a large number of professionals thought that this systematic, organised, demonstrable and assessable method was purely theoretical and limited to the academic area. Irrelevant, inconvenient, extensive and frustrating aspects featured in the literature. In its favour, this process is no different to that used by other professionals in the area of health and other areas of knowledge, since it is the logical way of approaching problem-solving using nursing methodology. To complete this process, as nurses we have developed a language to clearly distinguish care work from other work. However, we believe there are few professionals who have understood what this involves and how useful it is. The root causes might be that, first, it is the health system's imperative to focus on meeting standards and not health outcomes⁴; and second, that diagnostic reasoning is taken as read and a great many professionals have received no training in it.

That said, and aware that the plan benefits the patient–family binomial, we would like to make a series of methodological considerations that otherwise might lead to confusion when it is applied in clinical practice. The patient assessment focuses on the neurological, respiratory and digestive systems; and there is no express mention of the family, and therefore it appears to be more of a standardised plan than an individualised one. We were struck by the fact that the authors put potential problems and/or collaboration problems as nursing diagnoses (ND). ND are clinical judgments on the human response to real or potential life processes of health, that nurses identify, validate and manage, and are responsible for their final outcome.⁵ On examination, only one of the 9 ND from the clinical case would be correct (risk of caregiver weariness, applied to the family). The remaining ND are potential collaboration and/or complications, since they are associated with therapies and medical diagnoses. This implies that it is the doctor who has the ultimate control, authority and responsibility for final outcomes. Nursing action is not autonomous and requires validation by another professional, in this case, the doctor.

A lack of knowledge, errors and inaccuracies in ND can extend to the care process, and can result in the opposite of the intended effect for the person receiving care and for the nurse, and ultimately impact the progress of the discipline of nursing.