We ask our members and followers to respond to a recent publication created by the International Standards Organization (ISO).
In this recent publication, ISO has stepped beyond its role as “to establish a nursing reference terminology model consistent with the goals and objectives of other specific health terminology models in order to provide a more unified reference health model” and chosen to comment on how nurses diagnose, how we make clinical decisions, and the results appear to reduce independent nursing knowledge and our autonomous nursing voice.
In Appendix A, the document states the following:
“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. Examples include: assessing risks for complications of treatment; monitoring treatment progress; assessing the person’s ability to carry out treatment plans” (ISO, 2023, p. 23; bold font, ours).
As concerning, the standard indicates that a clinical assessment (sign/symptom) is the equivalent of a diagnosis, and judgment is not identified as a requirement, and indeed there is no definition of judgment remaining in this updated standard. “Assessment includes one or a combination of a measurement, evaluation or judgment that relates to a variable pertaining to the status of a subject of care (3.2.2).
Note 3 to entry: Observation sub-category that are valid for representation of a type of assessment or activity, including a nursing diagnosis (3.2.7), include, but are not limited to measure (3.3.12), status (3.3.13), site (3.3.3), information from subject of care/carer (3.3.14) and from other care providers.” (ISO, 2023, p. 4; bold font, ours).
What You Can Do to Help
Every nurse should respond to this commentary, which undermines autonomous nursing clinical reasoning and clinical judgments. This type of statement is neither the role nor responsibility of this organization, nor does it provide an accurate description of clinical reasoning within nursing practice.
Further, this “updated standard” uses references that are frequently, and specifically when related to NANDA-I, NOC, NIC, ICNP, more than one decade old, negating a wealth of information and teaching that has occurred in the past decade.
There is not much room enabled for feedback, but we encourage individuals to comment on these topics.
(1) It is not the role of ISO to determine how nurses diagnose. Nursing judgments are autonomous and do not require collaboration with other disciplines, nor are they necessarily informed by the medical diagnoses or treatment plan. We must establish a difference between collaboration of disciplines on an equal footing and having to work with or under the direction or input of other disciplines. This also negates research that shows the nursing diagnoses are more effective predictors of some patient outcomes than are medical diagnoses.
(2) Lack of updated references indicates lack of review of new research and understanding regarding any of the major nursing terminologies.
(3) The confusion of signs/symptoms (observations or clinical findings) with diagnosis is erroneous and dangerous. Without clinical reasoning based on nursing knowledge, errors in diagnosis will occur, interventions will be omitted or resources will be used for no reason. This type of thinking would be akin to our colleagues in medicine considering a lab value as a diagnosis.
Once again, each of us has an opportunity to respond to this document, and we encourage you to do so! Please click here to give your feedback to ISO.
Reference: International Standards Organization (2023). ISO 18104:2023(E). Health informatics — Categorial structures for representation of nursing practice in terminological systems.