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CURRENT CONTROVERSIES IN CRITICAL CARE |
Dr Howard Karl Butcher creates this opportunity for a critical dialogue on classification systems in his letter commenting on my Current Controversies in Critical Care column titled "Designing Formal Classification Systems to Better Articulate Knowledge, Skills, and Meanings in Nursing Practice" (September 2004;13:426–430). In this response to Dr Butcher’s thoughtful letter, I hope to clarify points of misunderstanding and extend the dialogue. The thesis of the column is that every classification system designed for indexing and retrieving records and communicating and documenting nursing work creates a particular view of practice. The particular view of practice that spawned the classification system has an inner logic. With continued use, that inner logic becomes reified and increasingly invisible as the classification system becomes a taken-for-granted understanding and approach to practice. The column warns that practitioners must be astute and critical of the unwitting styles of practice that are created as a result of the content, structure, function, and processes reinforced by the classification system. Nurses also need to be aware that the act of classifying factual information, though useful in communicating in large systems, is not the same thing as productive thinking, nor does it capture the full intent and content of the complex practice it represents. Naming something does not ensure understanding.
I fully acknowledge that NIC, NOC, NANDA,1 and "habits of thought and action" and "domains of nursing practice" are all classification systems, though the domains of nursing practice are more general and less formal as a system of classifying nursing work. No classification of the activities and concerns of nurses fully captures the intent and content of actual nursing practice. Classifications of practice are a pale image of a lively, complex, self-improving practice such as nursing.
Classifications, as labels, indexes, and all shorthand communication, point to more complex skills and practice. They can never capture the whole of the practice, nor make the practice completely explicit. Some aspects of the practice are more situated and underdetermined than others. The more complex and underdetermined aspects of practice create the greatest difficulties for classification systems. Another goal of the article is to compare the 2 different strategies for classifying nursing work, and to critique the powers of all classification systems.
In his letter, Dr Butcher wrote:
...Many nursing diagnoses, interventions, and outcomes address issues of meaning, emotionality, and intentionality, including Anxiety, Ineffective Coping, Disturbed Body Image, Fear, Anticipatory Grieving, Hopelessness, Risk for Loneliness, Chronic Pain, Powerlessness, Chronic Sorrow, Spiritual Distress, Chronic Low Self-Esteem; and interventions such as Active Listening, Calming Technique, Counseling, Dying Care, Emotional Support, Forgiveness Facilitation, Guilt Work Facilitation, Hope Instillation, Mood Management, Presence, Spiritual Support, and Values Clarification are just a few of the "labels" describing the work of nurses that address all of the invisible practices and actions identified by Benner. Each of the above diagnoses and interventions are just a few examples that are rich in describing the meanings, intentions, emotions, and perceptions embedded in the human-health experience.
While I agree that the above classes of patient problems and nursing interventions point to the relational work of nursing, I maintain that they do not sufficiently situate these relational aspects of nursing. This is a legitimate point of difference in judgment and opinion between Dr Butcher and myself. The leveling that I see as a problem in the "current" intervention classification system is that the labels, as labels, do not directly point to or correspond to major intents, skills, knowledge, and relational work of the professional practice of nursing. Indeed, the intents, the "in order to’s," and the "for sake of which" are missing from the intervention list. I agree with Dr Butcher that it takes the socially embedded knowledge of nursing practice itself to call forth the relational, knowledge-skill and judgment work associated with the current intervention labels. It is this "unlabeled background practices and meanings" of actual nursing practice that make the labels work at all. Without the ongoing meaningful practice, we would not know how to interpret the classified interventions.
Dr Butcher and I agree that these backgrounds of narratives, beliefs, content, "in-order-to’s," and situated understandings exist and are alive and well in the practice of nursing. My point is that clearer connections to the knowledge and relational work of nursing are needed in our classification strategies, and that these aspects of practice knowledge, meanings, and skills are rendered relatively invisible in the current classification systems. What begins as a problem with communicating with "outsiders" becomes dangerous to "insider practitioners" when the labels diminish the understanding and recognition of taken-for-granted background knowledge, meanings, and skills of the "insiders," ie, practicing nurses. For example, I consider the diagnostic label "ineffective coping" to be a dangerous label in the relational work of nursing because it makes the patient’s coping "deviant" or "other" than the nurse’s understanding of how the patient "should" be coping. The label short-circuits the question: "Coping with what?" Once the diversity of the concerns of the patient and family are understood, it is seldom the case that one can consider the coping "ineffective." Furthermore, understanding the patient’s concerns that give rise to his or her coping is the requisite of an effective relational space in which to understand and facilitate the patient’s coping. Identifying deficits and suggesting pathways to the "normal" (normalizing labeling) is at the heart of the medical diagnostic model that usually refers to "normal" physiological functioning rather than behavioral norms.
The term "diagnostics" brings with it inevitable theoretical loading related to identifying a norm and identifying a deficit in relation to the norm. This I refer to as the most skeletal account of Cartesian Medicine, that I referred to as "the medical model." The medical model is powerful and successful in many arenas. But a "diagnostic" system of normalizing and identifying deficits does not fit the logic of identification and strengthening the person’s own resourcefulness classified as "wellness or strengths diagnoses" in nursing practice and nursing diagnosis. I applaud the fact that the diagnostic classification in nursing recognizes this strong notion of good in nursing practice—the nursing mandate to work with the patient’s strength. But I wonder whether a "diagnostic" rubric adequately captures this knowledge-skill in nursing practice? When beauticians and car mechanics use "diagnostic language" and "skillful interventions" they too are drawing on a medical model of identifying deficits and repairing them from the outside in. This is the general logic of the medical model that has been diffused into many arenas of modern life, including education and nursing.
In his letter, Dr Butcher wrote:
It is false to assert that NANDA, NIC, and NOC do not address the 7 invisible practices of nurses listed in Table 2 [In Benner’s September 2004 column]. . . . One benefit of the classification system is that it identifies what "skilled know-how" is required for each intervention. . . .
I contend that "skilled know-how" includes situated judgment, reasoning across time about the particular and taking appropriate actions in response to the patient’s condition and responses to therapies.2 It is precisely this situated judgment and knowledge-laden skilled know-how and action that become trivialized when they are reduced to a list of simpler tasks. Not that the listing can’t be helpful, rather the point is that the list fails to sufficiently describe the context and skillfulness of nurses’ situated actions. This is a built-in limit to all formal classifications, mine included. The point is to recognize the limits of classification systems to capture situated practical knowledge that requires judgment. Nurses must avoid asking any classification system to do what formal classifications are poorly equipped to do. Similarly, labeling an emotion is not the same as understanding the meaning of the emotion in the situation. This is why a nursing diagnosis such as "ineffective coping" is dangerous in practice because the label and its explication assume a normalized stance to what is "effective coping" and fails to ask the essential question of "Coping with what, and to what end?" The "invisibility" refers to the way this label hides an understanding of coping with what and to what end, in the person’s situation. Coping is transactional and must be related to the person’s concerns.3
Every classification system will necessarily render some things visible and some things invisible. We need to critically think about how and what we are making visible. What are the assumptions about the labels we use? I do not look to any classification system to adequately capture a complex, undetermined practice such as nursing or medicine (including my own classification of situated knowledge). This critique points to the hubris of imagining that any classification system fully or adequately captures and articulates all the "legitimate" knowledge of any profession. All classifications have elements of dangerous reifications that overlook essential aspects of nursing practice. We must continually critique and point out what is left out by a flat representational list of categories. It is dangerous in the classroom and in practice to assume that memorization of the aspects of the classification system, whether it be the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV4 or the latest version of the NANDA, NIC, and NOC, is the same as understanding the clinical experience of the patient or the relational qualities needed in facilitating the patient’s coping resources and recovery. We must continue to question the ability of classification systems to capture patient concerns and nurses’ skilled know-how, notions of good and judgment in situated practice. Examining what a particular classification renders less visible, even as we use it to retrieve our records, and to claim nursing contributions that fall outside of the range of classification systems remain crucial to a self-improving practice. Precision, objectivity, and clarity contribute to standardization. I am not against standardizing what can be standardized safely. However, critical thought and a self-improving practice require that we identify what cannot be standardized or reduced to simple classification.
I agree that scholarly dialogue between different schools of thought and different research methods can enrich the thinking of all involved, and it is to that end that this article was written. I do not imagine an "oppositional" choice between methods, or classifications. Here, Dr Butcher and I are in agreement, and I welcome the dialogue. I look forward to a continuing dialogue between formal classification systems, strategies of standardization, and ongoing critical examination and articulation of our situated practical knowledge in practice. All insightful observations and dialogue are welcome. Perhaps classification becomes most dangerous when it is sacrosanct and above critical re-examination, and when we forget that classifying and naming is not the same thing as productive thinking and understanding.
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