A Discourse Analysis of Nursing Diagnosis

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QUALITATIVE HEALTHRESEARCH/September2002Powers/NURSINGDIAGNOSIS

A Discourse Analysis of Nursing Diagnosis

Penny Powers

The author presents a discourse analysis in three sections: a genealogy, a structural dis-courseanalysis, anda power analytic.Sheconcludes that thediscourseof nursing diagnosissustains conditionsof social domination, limits autonomy and responsibility, and oppressesindividuals and groups. The discourse of nursing diagnosis restricts what counts as evi-dence and limits acceptable input of voices, thus excluding, for example, the voices of the

patient and his or her family. The discourse of nursing diagnosis appeals to the dominance of empirical analytic science and equates this dominance with professional social status. Theauthor discusses potential discourses of resistance that provide speaking positions fromwhich to articulate specific practices that resist oppressive effects of nursing diagnosis.

The controversial idea of nurses assigning a “nursing diagnosis” to a patientthat is different from a medical diagnosis first appeared in the American nurs-

ing literature in the 1950s and became increasingly prevalent up to the early 1990s.The discourse of nursing diagnosis has received little critique and no systematicanalysis. I chose discourse analysis following Powers (1996, 2001) for this examina-tion because of the emphasis on powerrelations. I will present this discourse analy-sis in three sections: a genealogy, a structural discourse analysis, and a poweranalytic.

GENEALOGY

A genealogyexamines the major influences on the development of a discourse. Thetext for this genealogy consisted of all articles and books published in English onnursing diagnosis up to the first national conference in 1973. The model discourseson which the discourse of nursing diagnosis was based are identified as medicine,empirical analytic science, and professionalism.

The implicationsof the choiceof the word diagnosis forthe discourse of nursingdiagnosis are pervasive. Diagnoses are not immutable entities in an absolutelyknowable reality, but dynamic social and historical constructions (Bynum &Nutton, 1981). The models implied by the choice of this word inform the structureand functioning of the discourse of nursing diagnosis.

Consider the social context of the discipline of nursing in the 1950s, when theconcept of nursing diagnosis was being addressed in the United States. The social

context illuminates the range of options available as models for the discipline of nursing. At this time, there were few nurses with advanced degrees, and thesedegrees were predominantly in other disciplines, such as education or sociology.Medicine was the preeminent model of a profession in U.S. culture. The empirical

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analytic tradition was the only model of scientific inquiry generally available,marginalized discourses such as critical social theory and phenomenologynotwithstanding.

In post-World War II America, nurses returning from military service hadincreased skills in treating medical diagnoses in cooperation with physicians.Returning to peacetime practice, nurses faced renewed domination by physiciansand social pressureto return to traditionally defined female roles with reduced sta-tus to make room in the workforce for returning male soldiers. Consequently,nurses felt increased pressure to redefine their unique status and value. This goalhad been articulated in various forms since 1900 (Turkoski, 1992), but after WorldWar II, the drive intensified, and many nurses went back to school. The discoursesof medicine and science constituted the desirable discourses available to any disci-pline inthe1950sthat couldbe used to describevalue,power, andstatusin themod-ernpostwar socialworld. Using these discourses as modelsand professional statusas a goal, nursing diagnosis was constructed.

McManus (1951) and Virginia Fry (1953) advocated the discipline-specific termnursing diagnosis in nursing literature andsuggestedadoptionof care plans to guide

nursing practice, based on a model of human needs from psychology. In 1956,Hornung argued that occupational health nurses are often called on to make medi-cal diagnoses when there is no physician in attendance. These she called “nursingdiagnoses” (p. 29).

There were very few articles published in the 1960s on nursing diagnosis, anddiffering definitions were used (see summary in Edel, 1982). During the 1960s, theterms problem and need were more prevalent than diagnosis, but all three termsreferred to an independent function of nursing, the use of which, it was felt, wouldcause “vaguedescriptionsof the patient’s condition[to] disappearfrom ourvocab-ulary” (Hornung, 1956, p. 30).

Furthermore, duringthe late 1950sandearly1960s,the term science wasappliedto nursing, andthis hasalso hadan important influenceon thediscourse of nursingdiagnosis. An early instance of theterm nursing science in nursing literature is found

in the early work of Rogers (1963), Abdellah (1969), and Jacox (1974).The major discourse in the daily practice language of nursing has been, and

remains, medical (Street, 1992). The concept of nursing diagnosis had the appeal of combiningthe socially desirableand powerfuldiscourses of medicine,science, andprofessionalism, which were major models of social authority, power, and value inthe 1950s and 1960s, and remain so today.

Historically, nursing has vacillatedbetween highlighting differences and high-lighting similarities between itself and medicine, according to the ideological pur-pose servedby each positionin a specific historical context. The concept of nursingdiagnosis had the advantage of being able to emphasize both the similarities andthe differences at the same time. “Medical and nursing diagnoses differ in as muchas medicine and nursing differ and are similar in as much as medicine and nursingare similar” (Edel, 1982, p. 7).

Theconceptof nursing diagnosiswassubsequently incorporatedinto a compo-nent of thenursing process,which wasincorrectly perceivedat thetime to be a vari-ant of the empirical analytic method (Douglas & Murphy, 1990; Hiraki, 1992).Nursing used the discourse of nursing process to standardize the concept of nurs-ing care, hoping that it would help to earn professional status (Gebbie & Lavin,1975, p. 23; Hiraki, 1992, p. 130). McFarland and McFarlane (1993) argued that

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nursing diagnosis was the critical link in the nursing process because “the symp-tomsof conditionsdiagnosed canbealleviatedor modified bynursingactions”(p. 11).

The increasing influence of hospital computers was thought to demand a stan-dardized language from nurses (Saba, 1989). Levine(1989) recalledthat the processof creating this standardized nursing language was meant to be accomplishedthrough clinicians’ sharing real-life clinical experiences (p. 5). Nursing diagnosiswas seen as the approach that could provide the “frame of reference from whichnurses could determine (a) what to do and (b) what to expect” in a clinical practicesituation (Edel, 1982, p. 9).

Nursing diagnoses were also intended to define nursing’s unique boundarieswith respect to medical diagnoses (Douglas & Murphy, 1990; Pridham & Schutz,1985).Harrington (1988), forexample, arguedthat nursing diagnosiswasthedefin-ing characteristic of nursing practice. This argument was based on the definition inthe American Nurses Association’s (ANA) 1980 social policy statement: Nursing isthediagnosis andtreatment ofhumanresponses. Basedonthis judgment,the NorthAmerican Nursing Diagnosis Association (NANDA) meant the standardization of nursing language to be the first step toward having insurance companies pay

nurses directly for their care (Carpenito, 1989; Edel, 1982; Gebbie & Lavin, 1975;Gordon, 1982; Webb, 1992).From a genealogical perspective, the discourse of nursing diagnosis arose in a

social context using both surfaces of emergence and conditions of possibility thatwere acknowledged and appropriated, and made visible by the emerging dis-course. One surface of emergence for the discourse was the change in emphasisfrom illness care to health care. In this revised notion, health is viewed as a life goalinstead of a physical state consisting simply of the absence of disease. This orienta-tion became one sort of language that the discourse of nursing diagnosis could useto have some kind of social meaning, power, and value.

Another surface of emergence used by the discourse of nursing diagnosis ishospital accreditation documentation. In the 1950s, hospital accreditation proce-dures began to necessitate written documentation for assessment of quality care. A

discourse of nursing diagnosis could demonstrate nursing’s contribution to thequality of care. Forexample, automatedrecord keeping wascited in thefirst confer-ence as one of the changes in health care that necessitated a specific nursing lan-guage (Gebbie & Lavin, 1975, p. 1).

Oneconditionof possibility used by thediscourse of nursing diagnosiswastheadvanced education of increasing numbers of nurses in the postwar science andtechnology boom. This educational system producednurseswhocould teach nurs-ing, create journals in which to publish, and speak academic language. The dis-course of nursing diagnosis is in large part an academic project.Thefirst conferenceon nursing diagnosis was held at the St. Louis University School of Nursing andAllied Health Professions in 1973.

The surfaces of emergence and the conditions of possibility create an environ-ment conducive to the creation of a discourse specific to the circumstances, usingmodel discourses availableat thetime. Another importantstep in this process is thediscursive creation of a physical space withinwhich to assert theright to pronouncetruth. The discourse of nursing diagnosis constructed the description of a physi-cally based, socially described space of action on human bodies. The discourse of nursing diagnosis represents the attempt of the discipline of nursing to constructand take control, physically and conceptually, of what can be called the clinical

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encounter, to carve out a professional turf distinct from other disciplines. Withinthis turf, or territory, or domain, the discourse claims the right to describe what is,and should be, happening.

To summarize the genealogy, it is clear that the discourse of nursing diagnosisclaimstheright to pronounce truth in a domainof human experience. By using con-ditions of possibility and surfaces of emergence, identifying influential and sociallydesirable discourses as models, and naming a physical space, nursing diagnosisconstructed specificdiscursivepractices. Thesepractices create a perceivedneedforpronouncing truth in a move of power to further long-standing professional goals.The justification of this move using the power of redefinition was phrased in termsof the scientifically verifiable language of patient benefit and fiscal and socialresponsibility.

STRUCTURAL ANALYSIS

Structuralanalysis addresses the discursiveprocesses, in other words, the structure

and functioning, of the discourse of nursing diagnosis. The text for the structuralanalysis consisted of all of the published literature concerning the NANDAconfer-ences and concurrent articles and books published in the U.S. This analysis claimsthat the functioning of nursing diagnosis continues to be influenced by the threemodels identified in the genealogy: medicine, empirical analytic science, and pro-fessionalism. The structural analysis proceeds on three axes: knowledge, authority,and value or justification.

The Axis of Knowledge

The discourse defines as its objects of concern what are termed in the later confer-ences the human responses (orresponse patterns) to illness. The subjects of the dis-course, the variables for manipulation constructed by the discourse from theobjects, are the nursing diagnoses.

Rasch (1987) argued that the ANA’s 1980 Social Policy Statement declares thehuman responses and the nursing diagnoses to be the same objective entities. Con-fusion regarding what nurses diagnose was evident at the seventh conference, forexample, when Newman (1987) argued that nurses diagnose patterns of humanresponses and not singular human responses. Subsequently, the name of the orga-nizing framework for Taxonomy I was changed from “unitary man” to “humanresponse pattern” (Carroll-Johnson, 1989).

According to the discourse of nursing diagnosis, human responses (the objectsof thediscourse) areassumed to be universal, objectiveentities that exist in individ-ual human beings in a preinterpreted objective reality. Being objective entities, theobjects of thediscourse are amenable to description through scientific research. The

diagnoses, the subjects of the discourse, are acknowledged to be scientific con-structs used to represent the objective entities linguistically.Thenursing diagnoses, thesubjects of thediscourse,areviewed as thenames of

the objects in the same way that psychiatric diagnoses are often thought to be thenames of conditions assumed to exist in humans and described by empiricalresearch. From a postmodern perspective, both the diagnoses and the human




responses (the objects and the subjects) are reified entities, statistically associatedwith each other in terms of such factors as causes, etiologies, or determining charac-teristics, to name a few, and described using the methods of science.

Many diagnoses take the form of an “alteration” or a “deficit” of something,such as alteration in family processes or fluid volume deficit. The words situation,condition, human response, and response patterns are often used interchangeably forthe objects of the discourse in the nursing diagnosis literature and in the conferenceproceedings. They have all been called the focus of nursing or nursing’s uniquedomain.

The rules of the discourse specify how a diagnosis is recognized as empiricallyvalid within the clinical encounter. At the first conference, it was stated, “A majortask ofallnurses is to locatethosediagnoses that were neglected, to test anddevelopthem, and to present them to the professionso that theymight be included infuturelistings” (Gebbie & Lavin, 1975, pp. 57-58). Through 1982, however, the diagnoseswere still obtained through the members of NANDA and the work of a group of nursing theoristswithin NANDA. Fawcett (1986) alsoencouraged eachnurseinter-ested in nursing diagnosis to select a theoretical strategy and continue the work of

developing andvalidatingnewnursing diagnoses.Derdiarian (1988) proposed thatpracticing nurses should be taught to formulate, test, and evaluate new nursingdiagnoses (p. 139). However, Carpenito (1993) disagreed, saying that practicingnurses should be spending more research time on the diagnoses that already exist,not on identifying newones. Submission guidelines were revised and published inthe proceedings of the ninth conference. Considering the amount of work involvedin the submission procedure, it seems highly unlikely that practicing nurses couldundertake this task.

Discourses identify defining characteristics, quantify definitions, arrange subjects in a taxonomy (called grids of specification),attribute causal mechanisms, andgive rules for the application of the subjects to individual bodies (Powers, 2001).NANDA’s Taxonomy I is a grid of specification because the taxonomy defines thediagnoses, relates them to each other, and places them into a classification scheme.

A grid of specification is not a neutral tool; it structures the interventions that arisefrom it. After a diagnosis is recognized as worthy of consideration, it is subjected tothe rules of evidence specified by the discourse to determine approval and integra-tion into the grid of specification, in this case, the Taxonomy. Forexample, the diag-nosis of Altered Protection has the number 1.6.2. Beginning with McCloskey,Bulecheck, et al. (1990) and McCloskey & Bulecheck (1993), work continues toexpandthe grid of specification beyondthe diagnosesto nursing interventions andpatient outcomes.

Discourses contain rules for the appearance and the dismissal of subjects. Twoexamples of diagnosesthat have been suggestedas candidates forremoval from thegrid of specification are knowledge deficit (Dennison & Keeling, 1989; Jenny, 1987;Pokorny, 1985) and noncompliance (Keeling, Utz, Shusler, & Boyle, 1993). The per-severance of diagnoses despite evidence that they do not meet NANDA’s explicitcriteria for acceptability suggested that the discourse itself had attained a certaindegree of authority within the discipline, which conferred a degree of immunity tocritique.

The grid of specification structures the process of applying the practices of thediscourse. Thediagnoses are applied to theindividual bodiesof nursesandpatientsin the clinical encounter structured in part by identifiable authorities of




delimitation. The authorities of delimitation arethe external disciplines, which con-trol the existence and limits of the space for the actionof the discourse. In the case of nursing diagnosis, these authorities are physicians, hospital administrators, andinsurance companies, because they determine when a person becomes eligible fornursing intervention. The authorities of delimitation are unacknowledged in thediscourse of nursing diagnosis.

Used in the clinical encounter, nursing diagnosis serves to constitute the indi-viduals involved—the nurse and the patient—for themselves and others in pre-scribed ways, according to the existing power relations (Allen, 1986). Specifically,the diagnoses are used on the bodies of the nurse and the patient to specify theassessment strategies, interventions, and outcomes. These specifications assume ahierarchicalpowerrelation of thenurseas a socialagentandthe patient as therecip-ient of nursing care. This assumption of hierarchy is not referred to specifically inthe discourse, because science is assumed to be value-free (Hekman, 1986) and itsapplication by social agents is not appropriately questioned by ethical discourse.The result is a technical, mechanical discourse of prediction and control of socialeffects consistent with current power relations, assumed to be for the good of

patients.It is instructive to note where in the discourse individual differences, devia-tions, and complaints by patients are allowed to emerge. From a scientific perspec-tive, the diagnoses should be the names of real things in the real world. The resultsof these investigations should provide universal knowledge that can be used bysocial agents to help people become more normal (whether they want to or not) asnormality is described in nursing research.

Individual patient differences were supposed to be acknowledged in the “dueto” or “related to” part of the diagnostic statement (Carpenito, 1993; McFarland &McFarlane, 1993). The first half of the diagnostic statement was assumed to be uni-versally applicable to all human beings because it was constructed using science.The second half of the diagnostic statement contained the specific individual etiol-ogy. However, the possible etiologies were already spelled out in the handbooks

and textbooks (Carpenito, 1995; McFarland & McFarlane, 1993).Thediagnoses areassignedby assessment using universalsignsandsymptoms

drawnfromnursing research. Then thecausal etiologies areassignedfromthelistof possible “individual” etiologies. The full nursing diagnosis statement can thus beviewedas an attempt to combine a universalscientific entityandan individual clin-ical situationin a unique classification (Taylor, 1979). One problem with the clinicalapplication of generalized knowledge is that probability statements resulting fromresearch can describe only the tendencies of groups, not those of individuals.

Confusion regarding these dimensions of the concept of diagnosis was wide-spread. For example, consider Fitzpatrick’s (1990) description of the axes consid-eredforTaxonomyII, whichincludedageand chronicity. Shearguedthat usingaxeswould integrate the “clinical with the scientific for discipline development” (p. 106).Henderson(1978) defined nursing practice as consisting of “both nursing interven-tion basedonnursing diagnosisandnursing care originating inpatient problemsorhealth problems” (p. 79), which assumed that nursing diagnoses and patient prob-lems are separate things. Presumably, this combination was made to capture moreof the individual patient’s unique circumstances within a generalized system of unique nursing knowledge.




Maas, Hardy, and Craft (1990) called this idea of accuracy, or validity, the rela-tionship between the nurse’s inferred problem and the patient’s “true problem”(p. 25). The true problem was an entity assumed to exist in an objective manner sep-arate from our understanding of it. In other words, the“object” of the discourse, thehuman response, wasa true problem,and thenurse’s inferredproblemwasthe sub-

ject of the discourse: the diagnosis. If the science was performed correctly, therewould be perfect correspondence between the patient’s true problem and thenurse’s choice of diagnosis.

Interventions become a normalizing influence on both nurses and patients,constructing the nurse’s behavior within the clinical encounter toward what has

been scientificallydeterminedby the discourse. Indeed, idiosyncraticdiagnoses arediscouraged. The clinician must decide which of the standardized diagnoses andinterventions should be used to obtain standard outcomes.

Conflicting goals seem to govern the appearance, disappearance, replacement,and coexistence of the diagnoses. Some authors complained that there was nocoherent conceptual model of nursing to guide the discourse (Logan & Jenny, 1990;Meleis, 1991). Others argued that the diagnoses should be generated from work in

practice settings and not from conceptual frameworks. Serious questions wereraised regarding the adaptationof theoretically generateddiagnosesto clinical situ-ations (Rasch, 1987).

Furthermore, there were conflicting approaches evident in the construction of the taxonomy from the perspectiveof taxonomicscience. Porter (1986) pointed out,for example, that the diagnoses were sorted into four levels of abstraction, butaccording to taxonomicscience,the entitiesclassified ina taxonomy must allexistatthe same level of abstraction for the organizing principles to sort them by similari-ties and differences (p. 137).

The Axis of Authority

The right to pronounce truth in the realm of the clinical encounter was claimed byNANDA on the basis of its imitation of the discourses of medicine and sciencewithin a linguistically constructed professional domain that was claimed to beuniquely nursing. Other possible claims to the power of pronouncing truth in theclinical encounter have failed (Levine, 1989). NANDA was and is the authority forthe discourse. NANDA was incorporated in 1985, and a refereed journal dedicatedto researchconcerning nursing diagnoseswasinaugurated in 1990. Thestructure of the association provides justification, legitimacy, authority, and social presence forthediscourse ina mannerconsistent with otherdisciplines based ona model of pro-fessionalpower andprivilege. However, oneunintended consequence of thisstatusis a commitment to maintaining the current power relations.

The first conference acknowledged that the participants were an elite groupand wondered about the acceptance of nursing diagnosis by the “average” nurse

(Gebbie & Lavin, 1975, p. 35). Membership in NANDA is open to all nurses from allsettings, but participation requires major effort on the part of a full-time practicingnurse. Indirectly, this selects for nurses who have the time and money to travel andwork on their own without being paid for it. Speaking positions, therefore, are lim-ited by the criteria of membership and participation in NANDA.




Positions from which to speak this discourse were thus limited by the hege-monic dominance of NANDA. At the seventh conference business meeting, amotion was passed that stated, “Moved that NANDA go on record as supportingthe concept that only registered, professional nurses be responsible and account-able for identifying the nursing diagnoses for their patient population” (McLane,1987, p. 529). One implication of this motion was that nurses who are not registeredor are not professional have no right to wield this language.

Some authors have argued that acknowledged imperfections in construction,application, and dissemination of nursing diagnosis should be handled with moreclinical research (Carpenito, 1993; Fawcett, 1986; Kritek, 1985). Other authors haveviewed the imperfections as indicative of deeper problems that cannot beaddressed by more research (Shamansky & Yanni, 1983).

The discourse was and is preserved and transmitted in a manner that consoli-dates the dominance of NANDA as the pronouncer of truth. This is done byNANDA publications, conference proceedings, newsletters, a speakers’ bureau,workshops developedby NANDA,and dissemination to faculty whoteachthedis-course to students. An incorporated association with bylaws, a journal, and a

national forum lend legitimacy to the discourse entirely apart from the content of the discourse.

The Axis of Value or Justification

The technologies of power used in the discourse of nursing diagnosis have beenovertly justified within the discourse by reference to nurse empowerment andimproved patient outcomes (Carpenito, 1993). On a deeper level, the justificationfor theapplication of disciplinary technologiesrests on the assumptionthatpower/knowledgeconfers the statusof social agency onits practitioners.Disciplinarytech-nologies assume that nurses are justified in deriving goals and interventions with-out full participation of patients (Allen, 1987b, p. 46). In other words, patients arespecifically constituted by the discourse to be self-revealing targets of normaliza-tion strategies applied by social agents.

The language of empirical analytic science assumes that description and actionin new regions of experience are justified because knowledge generation providespower over ignorance. Using the language of professionalism, we are justified inapplying the knowledge we construct to our own bodies and the bodies of ourpatients by educatingsocial agents in science andprofessionalbehaviorcreateddis-cursively by ourdiscourse. The justification providedby nursing is thesocially val-ued one of patient safety. As an example of justified punishment of a practitioner,consider that Carpenito (1993) believes that missing a diagnosis should be consid-ered nursing malpractice in the same way as it is in medicine.

When a discourse gathers membership, influence, power, and momentum,seeking hegemony, creatingdefinitions, highlighting differencesbetween itself and

other competing discourses, it seeks to discredit and suppress other discourses inthe interests of solidifying the ideology that constitutes meaning. A dominant dis-course, convinced of the “rightness” of the ideology, seeks to exclude other view-points in an effort to accrue power/knowledge by citing benefit to some socialgroup. Whether the intent is to highlight the similarities or the differences between




nursing and medicine, the medical language remains the basis of comparison. Likemedicine, we diagnose, we treat, and we measure outcomes. Unlike medicine, wediagnose andtreat human responsepatterns based on our ownbody of knowledge.Throughout this process, medicine is the privileged other, the invisiblebinary part-nerof nursing in the relationthat defines nursing as a discipline. The followingrea-sons support the claim that the dominant regularity in the discourse of nursingdiagnosis is medicine.

1. The choice ofthe worddiagnosis at the firstconference maintains boththe similaritiesanddifferencesbetweennursingandmedicineat thesametime, withoutchallengingthestatus quo ofpower andinfluence. Thewords treatment and intervention arethere-fore widelyrepresented.Turkoski (1988)notes thatthe discourseof nursingdiagnosisfrequently uses medical diagnoses as descriptors (p. 143), medical labels, language,andmodels withinthe concept anddesign of thediscourse (p. 144). Theconspicuousabsence of the word disease, however, is noteworthy. The grid of specification—thetaxonomy—of nursing diagnosis was meant to mesh with existing classificationschemes such,asthe ICD, theCPT-4 inmedicine, theDSM-III in theAmericanPsychi-atric Association (APA), the SNOP in pathology, and the SNOMED (SystemizedNomenclature of Medicine) in medicine (Gebbie, 1989).

2. The discourse is based on a model of symptomatology and etiology. At the first con-ference, the diagnoses were referred to as having definitions that would be definedoperationally interms of“signs andsymptoms”(M. Gordon,1976).Other termswerealsoadded:etiologicalfactors(Carpenito,1995),influencingfactors (Fitzpatrick,1987,p. 63),and risk factors (McFarland & McFarlane, 1993). At the fifthnational conference, Toth(1984) praised nursing diagnosis for the opportunity to compare patients diagnosedas “acute diabetic patients who are noncompliant with therapy because of a knowl-edge deficit” from one hospital to another (p. 100).

3. Thediscourse emphasizes pathology. Fawcett(1990)arguedspecificallyagainstwhatshe called the factthat NANDA’s system is basedon an externally-driven biomedicalperspective with an emphasis on pathology. The emphasis on pathology is broughtinto sharp contrast by the inclusion of diagnoses that are health-related. Such a diag-nosis is that of effective breast-feeding (McFarland & McFarlane, 1993). Popkess-Vawter (1991) recommends adding more wellness-related diagnoses, such as func-tional grieving, adequate individual coping, improved coping, activity tolerance,

and effective airway clearance (p. 22; see Stolte, 1996).4. The discourse emphasizes a disease model (Meleis, 1991). The ICD was one of theclassification schemes studied at thefirst conference. It wassuggestedat that confer-ence that themedical classificationof diseases (SNOMED)was theonly onethat hadroom initsnumerical classification system fornursingdiagnosesto be added (Gebbie& Lavin, 1975, p. 20). NANDA was denied inclusion in the International Classifica-tionof Diseases (Webb,1992),andClark & Lang(1992),therefore,recommend a sepa-rate international classification for nursing practice.

5. The discourse of nursing diagnosis has a strong physiological bias (Webb, 1992). Atthefirst conference,workinggroupswere designated andassignedto a physiologicalsystem, even though the conference organizers recorded opposition to such a moveas committing the system “irretrievably” to a pathological and disease-based model(Gebbie & Lavin, 1975, p. 5). The resulting diagnoses, predictably, reflect the organi-zation of theworkinggroups.Approximately halfof thediagnosesin TaxonomyI arephysiologically-based (Fitzpatrick et al., 1989), but for critical care nurses, “The so-called medical model of treatinganaphylacticshock better describeswhatwe do forapatient than do 20 different nursing diagnoses” (Curry, 1991, p. 124).

6. The diagnoses are supposed to be applied in nursing practice, in clinical situations,even though many nursing diagnoses do not seem to fit patient situations (Frank,1990). The diagnosis is established through the clinical judgment of the nurse, basedon scientifically derived categories and recognition of symptoms and risk factors.




Most nursing researchers are committed to the dominant empirical analyticparadigmas a model for the professionand not onlyas a tool to answerappropriatequestions (Dickson, 1993). The debate between knowing and doing reflects thesocial value placed on knowledge over practice. Evidence that the discourse of nursing diagnosis is based on the assumptions of the empirical analytic founda-tional position is placed into the following categories:

1. Reductionism. The discourse of nursing diagnosis is based on a reductionist assump-tion (Tierney, 1987) that the conceptualization of human beings can be “reduced” tosets of diagnoses for ease of identification, treatment, and measurement of uniquelynursing outcomes (M.Gordon,1982). Doing so avoidssocial context andvalue judg-ments. Meleis (1991) calls the diagnoses“esoteric in languageand nonrepresentativeof the complexity of human beings” (p. 161). “There is a growing number of nurseswhoviewthe labeling inherentin thediagnosticprocessastoorestrictive fordescrib-ing human beings” (Mitchell & Santopinto, 1988, p. 25).

2. Determinism. A strictly deterministic, linear view of causality is assumed by the dis-course (Turkoski, 1988). Multiple causal factors are assumed to be discoverable andspecifiable in advance (Bircher, 1986; Fitzpatrick, 1987; Forsyth, 1984; M. Gordon,1982). Nursing care is defined as effective when measurable, expected outcomes

result from the planned action (McFarland & McFarlane, 1993) within the clinicalencounter. The emphasis on prediction reflects the linear view of causality (Kritek,1985).

3. Essentialism (Allman, 1992; Dickson, 1993). Essentialism refers to the discreditedphilosophical assumption that words are names of unique things in a real worldandthat proper use of a word requires the existence of an invariant core set of propertiesthat justify application of the word. The essentialist perspective has serious implica-tions in nursing, not the least of whichexists withinthediscourseof nursing diagno-sis (see Allen, 1986; Thompson, 1992). At the sixth conference, Kritek (1986) empha-sized that taxonomic ordering should reveal the essential properties of phenomena(p. 23). Porter (1986) asserts that a taxonomy is necessarily an essentializing dis-course. Nonessentialist taxonomies would function by stipulative definitions, themeasuresof which arepragmaticandfunctionalratherthanessentialist(Allen,1992).

4. The reification of entities. Reificationis thetransformation of socialrelations from rela-tions between persons to relations between things (Hiraki, 1992, p. 131). The objects

of the discourse, the human responses or response patterns are not viewed as socialconstructions by the discourse. Hiraki quotes Watson (1990) as saying the develop-ment of nursing knowledge that encourages the view of humans and health caringprocesses as problems to diagnose gives power to the problems and processes byaccording them law-like status, separated from the experiences of human beings(p. 19). Reification assumes value-neutrality and tools structure their own use indiscoverable ways. Hagey and McDonough (1984) state, “Either supporters of nurs-ingdiagnosissee thecategoriesas harmlesswithoutsocialcontextor they take asself-evident and acceptable the political outcomes such categories produce” (p. 153).

5. The discourse of nursing diagnosis is based on instrumental knowledge. This is a “formulaapproachto people, objectifying,codifying,andreifying human experienceswith‘of-ficial knowledge’ that takes on a life of its own; a life that is separate anddecontextualized rather than connected” (Watson, 1990, quoted in Hiraki, 1992,p. 19). Forexample, at theseventh conference, Levine(1987) raised what shecalled a“serious philosophical issue” with respect to the idea that the essence of nursing istreating human responses (p. 51).She arguedthatthis viewassumesthathumansare

simply responding dependent systems, or “targets” for interventions without anyconsideration of a concept of human agency (p. 52).

6. The discourse holds natural science as the ideal (Dickson, 1993; Donaldson & Crowley,1978; Jacobs & Huether, 1978; Kim, 1983; Silva & Rothbart, 1984; Street, 1992). Theideal of natural science is reflected in thechoice of thewords andprocedures of taxo-nomic science. For example, Kritek (1985) suggested that it might take nursing 300years to complete the taxonomicsystem, consideringthe taxonomicdevelopment of




the periodic table of elements. The ideal of natural science is also clearly representedin the comparisons made between nursing and other disciplines. Carpenito (1993)compares the diagnosis of decisional conflict to the diagnosis of pancreatitis, arguingthat they are both objective entities scientifically describable and amenable to stan-dardized treatments that professionals should be accountable for treating.

7. It is a standardized model constructed from foundational science. As such, the model wasassumed to be able to substitute for knowledge and experience in a novice situationandthereforebe a teaching guide. Thingsthatare hard tomeasure were left out, caus-ing concepts like caring and sensitivity to be devalued or not evaluated at all(D. Gordon, 1984). Care basedon predeterminedstandards contributes to thefailureof treating persons as individuals (Bond, 1988; Niziolek & Shaw, 1991). In fact, com-puterized nursing diagnostic software has been suggested (Bulechek & McCloskey,1990; Hirsch & Chang, 1990).

Nursing, in imitation of the medical model, participates in, reinforces, andreflects the discourse of professionalism in U.S. culture. Medicine is generally con-sidered the prototype model of a profession. The status and power of medicine isincreased by an alliance with science, because this allows the discourse to deny theideological nature of its own knowledge (Street, 1992). Nursing diagnosis partici-

pates in the discourse of professionalism because science and profession are believed to be coextensive discourses (Dickson, 1993).

POWER ANALYTIC

In this section, I present an analysis of the web of power relations in which the dis-course of nursing diagnosis is situated. The domination of patients by nurses isextendedbythediscourse ofnursing diagnosis. Theclinicalencounter viewedfromthe discourse of nursing diagnosis is based on a model of social hierarchy. Socialagentshave theduty ofmonitoring andupholding thestatusquo ofpowerrelations(Foucault, 1988) or risk being seen as unfaithful to their educationandtheir science.The model of social agency assumed by the discourse of nursing diagnosis consti-

tutes nurses as the authorities to deliver what the discipline decides is needed, notwhat the patient wants (Porter, 1992).

Domination of patientsis perpetuatedby thecontrol-basedlanguageof science,which producesdiscursive acts of violence against patients (Wright & Levac, 1992).Using nursing diagnosis becomes diagnosing defects in personhood. Such defectsoccur with respect to some predefined norm that thepatient is notlivingup to,suchas a defect in coping, self-esteem, adaptation, and knowledge, which nurses assessand treat based on a superior position as a social agent due to education, profes-sional status, and power (Diers, 1986). Individuals are thus constituted as predict-able systems to be manipulated by the nurse. Thus, words adapted from medicine(such as diagnosis) have unintended consequences that increase our dominationover patients.Hiraki (1992) arguedthat when the empirical analytic traditionover-steps its bounds and becomes a metaphor for the entirety of nursing care, as it does

within the discourse of nursing diagnosis, it reframes (recreates, reconstructs) thereality of the clinical encounter in particular, and possibly unintended, ways.

The mystification of common, everyday concepts, such as grief, that alreadyexistsin thesocial domainof patientsandnurses results inperpetuation ofthedom-ination of nurse over patient. Nurses are, in effect, being asked to deny all their pre-vious notions of the social meaning of these terms in favor of the normalized truth




from the discourse of nursing diagnosis. Nurses are then instructed to apply thisdiscourse to patients without regard to the patient’s understanding of these sameterms. Treatment then follows a standardized care plan to remedy this defect, defi-cit, or abnormality. When the outcome criteria are met, the diagnosis is “resolved”and the patient’s power is reduced, whereas the nurse’s power is increased. Thispower strategy producesuncriticalpatients who are emotionally and economicallydependent (Mitchell, 1991; Street, 1992). The emphasis on control-based strategiesprovides the basis for the diagnosis of noncompliance. Calling noncompliance adiagnosis is, in effect, naming a patient decision a defect.

Furthermore, domination of non-Whites by Whites is perpetuated by the dis-course of nursing diagnosis. Geissler (1992) states, “The inadequacy of the currentofficial nursing diagnoses . . . reflects the inability to respond to cultural needs of patients” (p. 303). Coler, Lima da Nobrega, de Almeida Peres, and Nunes de Farias(1991) also identified problems with translating nursing diagnosesforusein Brazil,due to cultural differences from the research base of North American culture. “TheNANDA diagnostic classificatory [sic] system needs to be reevaluated, reconsid-ered, and refocused into transculturally relevant, meaningful, and useful trans-

cultural perspectives” (Leininger, 1990, p. 24).Domination based on racial markers is also perpetuated by the language of thediscourse of nursing diagnosis (Wake, Fehring, & Fadden, 1991). Nursing studentsare taught that stereotypical views of non-Whites for the purposes of individualiz-ing“our” treatmentof “them” constitutes culturally sensitivenursing care(Allman,1992). Furthermore, Harrington (1988) proposed that educators should limit teach-ingdiagnosesto theNANDAlist only, saying“random creative efforts in theareaof nursing diagnosis threaten the society of nursing and the development of a taxon-omy” (p. 94). Theuse ofnursing diagnosesphrasedintermsof“potential for(some-thing)” is a good example of an entry point forethnocentrism. Thestereotype of theviolent Black male can result in a diagnosis of potential aggression more often forBlack than for White male patients. Patients of color have had whole constellationsof behaviors identified, diagnosed, and equated with their non-Whiteness

(Fernando, 1988, p. 63; Santiago-Irizarry, 2001).Furthermore, the language of the discourse of nursing diagnosis perpetuates

the oppression of women. For example, it has been shown that women are moreoften diagnosed as manipulative or depressed than men are (Allen, Allman, &Powers, 1991).This research then producesa “risk factor” in women fordepressionand shows up in diagnostic schemes for psychology and nursing. In a similar man-ner as racially identified characteristics, the risk factor is assumed to exist in thenon-maleness of the patient. Diagnoses categorize constellations of feminine expe-rience intonormalizing notions that are value-laden. Womendiagnosedwith“inef-fective coping, individual” or “impaired role performance” by a nurse would seektreatment, not seek to critique the research that generated the diagnosis.

Class domination is perpetuated by the discourse of nursing diagnosis.Classism is defined as (a) stereotyping on the basis of economic class with resultingdiscrimination and (b) valuing class-based models, goals, and strategies from thedominant culture over those groups peripheralized in the society (O’Neill, 1992,p. 140). Oneunintended consequenceof educationalelitism in nursing is that it cre-ates tensions in people from other than White, middle-class, and owning-class

backgrounds(Carnegie,1991). The processof educationwithinthe value-ladensys-tem of nursing diagnosis results in adherence to a professional ideology that places




the culture of the professional nurse in the social positionof service to lowerclasses(Rodgers, 1991).

The use of nursing diagnosis is also classist in that it reinforces the assumedvalue of the capitalistic base of American economy. Nowhere is it mentioned in theliterature on nursing diagnosis that the etiology of any of these diagnoses might bean oppressive economic system. The goal of nursing diagnosis and treatment is forthe patient to adapt to current role expectations, not to change them. For example,consider the nursing diagnosis of powerlessness and its application to people whoarehomeless andjobless.Is thesituation ofpowerlessnessanalteration ofsome nor-mal state of affairs to which everyone has a right? Consequently, is the interventionto get them a job or a home? To support a revolution that puts the means of produc-tion in the hands of the working class? Acknowledgment of oppressive relations inAmerican economy is absent. Instead, the definition of powerlessness is “the per-ception that one’s actionwill notsignificantly affect an outcome: a perceivedlack of control overa certain situationor immediatehappening” (McFarland& McFarlane,1993, p. 505). The interventions include providing opportunities for the patient toexpress feelings about self and illness; engaging the patient in decision making

whenever possible (e.g., the selection of roommate or wearing apparel); encourag-inga sense ofpartnership with thehealth care team;reinforcing thepatient’s right toask questions; teaching self-monitoring; providing relevant learning materials;exploringreality perceptions and clarifying, if necessary, by providing informationor correcting misinformation; and helping patient communicate effectively withother health team members (McFarland & McFarlane, 1993, p. 508).

Clearly, these strategies are control-based, giving only trivial and illusorychoices andfeedbackto patients.Whenthepowerlessnessof thepatient is relatedtoeconomic circumstances, these interventions further trivialize the concerns of homeless and jobless people, ignoring the economic inequalities and perpetuatingthe oppression of homeless and jobless people.

The domination of nursing by medicine is reinforced by the discourse of nurs-ing diagnosis because the discourse is based on the medical model of professional

scientific hierarchy, which is treatedas “natural”and “normal.”Nurses appropriate“both theforms of knowledge[ofmedicine]andthe paradigm in which this knowl-edge is created” (Street, 1992, p. 8). Thus, the discourse of nursing diagnosis rein-forces the handmaiden status of nurses (Todd, 1991) by adherence to the model of the dominant group. By denying the complex and intimate nature of the structuraland social power/knowledge relations between medicine and nursing, the dis-course of nursing diagnosis perpetuates the domination of nursing by medicine.

Thediscourse ofnursing diagnosisalso perpetuates thedominationof academ-ics over practicing nurses. Historically, achieving professional status for nursinghas been viewed as a more appropriate goal than that of control over the allocationof nursing knowledgeandskills(O’Neill, 1992).Thediscourse of nursing diagnosisremoves the control of practice from the individual nurses and places it in the aca-demic sphere. At the fifth conference, for example, practicing nurses were asked torespond to the conceptual framework for the classification of nursing diagnosisdeveloped by the nurse theorists. The responses ranged from acknowledgment of potential to rejection (Kim & Moritz, 1982, pp. 264-272). The most common com-ments from the practicing nurses cited the time involved in documenting the nurs-ing diagnoses using the conceptual framework and the poorly-defined nature of “unitary man.”




Goals common to all nurses have therefore been separated into professionalgoals andworking conditions. Workingconditions arethereby conceivedof as hav-inglittle relationshipto the taxonomyof nursing diagnoses.An ideologysupported

by the elite of nursing has the potential to split the profession into confrontationalgroups(Gamer, 1979).“So long as nursing practice is explainedas originating from,and elaborating on, formalized theory and technological advances, bedside nurseshave not had, orperhaps did not want, any particular share in it” (Maeve, 1993, p. 6).Thomas and Newsome (1992) add, “Nursing diagnosis has been a part of somenursing curricula since the ’70s, but a gap still exists between theory and practice”(p. 183).

Onedifficultythat practicing nurseshave with nursing diagnosisis that thedis-course values the general overthe specific, thestandardoverthe individual. Dickoff andJames(1986)addressed theeighth nationalconferencewithrespect to academicand practicing nurses. They asked specifically, “Who has controlling say in thenursing diagnosis movement—practitioners or academicians?” (p. 101). They rec-ommend returning control to the practitioners because “it is not clear that theusers—in the very role as users—are regarded also as developers and creators of

concepts” (p. 101).The appropriate professional goal for nursing within the health care environ-ment, according to the discourse of nursing diagnosis, is power and status equal tothat ofmedicine.Usingthe language ofthediscourse ofnursing diagnosis, Harring-ton (1988) asserts, “The ultimate goal of nursing diagnosis is to achieve adaptation[of nursing to its environment]” (p. 94). The environment of nursing is not consid-ered, therefore, to be changeable. According to Thompson (1992), nursing in the1970s and 1980s constructed representations of health, nursing, people, and envi-ronment that were achievedby privileged Whitenursesto secure theirownlocationin a health care system dominated by business and medicine without addressingpower issues. Value-free imitation of discursive practices of groups that dominatethe health care system were believed to promote autonomy, independence, and theright to self-governance.

This care-versus-cure debatewas part of a largermovement that included nurs-ing diagnosis. The emphasis on care sought to totally dissociate nursing from itsrelationship to medicine, and nursing reference to the concept of disease became aserious mistake. What was calledthe “regressive medical paradigm” (Kritek, 1985)made treatment of disease an action that nurses disdained, but imitated. “Nor isthere evidence that they [nursing diagnoses] have contributed to clarifying thenursing mission or to improving communication among nursesandwith the rest of the health care team” (Meleis, 1991).

Resistance Practices

Resistanceto theoppression perpetuatedby thediscourseof nursing diagnosismay

arise in singular instances of nursing practice involving nurses and patients or inlargergroup contexts. The resistance of a nurse in a hospital situation will be differ-ent from that of a student, patient, or academic. The discourses of resistanceacknowledged here represent potential constructed subjectivities that might beused as speaking positions to resist the oppressive power effects of the discourse of nursing diagnosis.




Because the practice of nursing is an oral culture, there is biculturalism in thediscipline. Nursing diagnosis is a part of the written culture of nursing viewed bysome practicing nurses as being forced on them by academics (Mitchell, 1991). Theresistance activities that arise from practicing nurses take the passive form of “notdoing the paperwork,” or at least doing it in a perfunctory manner, because it is noteasy to tell if the nurse is organizing patient care using nursing diagnosis. The aca-demic culture of nursing interprets such passive resistance as nurses not takingaccountability for their actions and decisions (Carpenito, 1993).

Academics and administrators sometimes hold the assumption that writtenculture is superior to oral. They seethe limitationsof theoral culture for thesystem-atic analysis of nursing practice at an abstract level (Street, 1992). “Formal explicitstatements fixmeaning anddo notallow fornuances of interpretationthe waytacitunderstanding does” (D. Gordon, 1984, p. 246). The resistance of practicing nursesis passive and unorganized (Street, 1992, p. 269) as it is in any oppressed group andespecially among women. Consciousness raising groups have helped nurses valuetheir own oral culture, critique power relations and develop strategies to compileand learn from the stories of others (Street, 1992). The discourse of expertise in spe-

cific, contextualized clinical situations provides a speaking position and the wordsfor nurses to use to express resistance to the nursing diagnosis movement.Feminist discourse is a strong candidate for provision of alternative speaking

positionsand wordsthat canbe used to form discursive practicesof resistancetothedomination effects of nursing diagnosis. Nursing devalues feminist discourse ingeneral (Dickson, 1993), and nursing diagnosis in particular avoids feminist dis-course. In following the medical model of profession, White, middle-class nursingleaders have traditionally severed their ties with women’s groups and allied them-selves with male professional groups instead (O’Neill, 1992).

Ethical discussions are devalued in a discourse that assumes a foundationalperspective because the body of knowledge is assumed to be value-free in both itsconstruction and application. On the other hand, Maeve (1993), citing Bishop andScudder (1991), states that the dominant sense of nursing in general is moral and

personal, as opposed to professional and technical (p. 10). The marginalized dis-course of ethics and practical morality in nursing literature argues that using thisapproachcould givenursing authority(Dickson,1993). Thesediscourses could pro-vide ways of talking and acting that could be used by individual practitioners, aca-demics, andadministrators to resist theoppressivepower relations of nursing diag-nosis. Mitchell (1991) claimed that human suffering is created by the diagnosticprocess (p. 99).She arguedthat being forcedto usenursing diagnosisputs nursesinethical conflicts (p. 102), causing unacknowledged stress, suffering, and tension intheir practice.

The discourse of patient advocacy is related to the practical, moral perspective.It canalso give rise to ideologicalsubjectivitiesthat provide a language of resistanceto theoppressivepower relations ofnursing diagnosis. Porter (1992)argued that theattempt by nursing to achieve social agency by the attainment of a body of nursingknowledge, such as nursing diagnosis, contradicts the role of advocacy for nurses.He argued specifically that this oppressive situation further devalues the voice of patients and their families because they are considered the targets of the interven-tion, not sources of knowledge. “One cannot rehabilitate lives in a social structurethat is directed to their dehumanization” (Lichtman, 1982, p. 284).




The discourse of unionism as a source of talk about power is devalued by thediscourse of nursing diagnosis because it is not viewed as part of the professionalideology. Anti-unionism reflects classism in nursing and separates nurses from apossible source of resistance strategies (Allen, 1987a). There is no union language inthe discourse of nursing diagnosis and no discussion that the work of the majorityof nurses is shift work.

Roberts (1983), Hedin(1986), Skillings(1992), andRicci (1993)arguethat nursesare an oppressed group and describe examples of behavior that demonstrate this,such as horizontal violence and cultures of silence. Therefore, the skills used bynurses to resist what they consider oppressive do not reflect open critique of domi-nation. Nursesfeeloppressedbyforcesoutside ofnursing, such as medicine,and byacademic and management nurses within the discipline. Nursing diagnosis is con-sidered another oppressive condition within the practice of nursing. The uncon-scious strategies of resistance among oppressed groups are silence, passive-aggressive behavior, foot dragging, and complaining.

Using the discourse of empowerment as a source of alternative speaking posi-tions would provide nursing with strategies, processes, andwords to resist individ-

ual practices of domination from nursing diagnosis as they arise. The discourse of empowered social activism that could arise from this potential source of resistanceis easily co-optedby nursing diagnosis,however. Considerthe following diagnosis:Alteredhealth maintenance relatedto inabilityto secure adequate permanenthous-ing for self and family (McFarland & McFarlane, 1993, p. 23). One of the symptomsof this condition is “verbalization of inaccurate information.” The political, eco-nomic, and power aspects of this patient situation are ignored. Expressing inaccu-rate information is a “symptom” of altered health maintenance. Any possible dis-course concerning social action aimed at provision of adequate housing is divertedinto assessment of the patient’s ability to tell the truth.

Talkof empowermentcanthusbecoopted easilyto referinsteadto a “task”for asocial agent. In this “empowerment as a treatment” model, patients are considered“empowered” when they are compliant with treatments and make choices that the

nurse considers well-informed. In the case of the entire discipline of nursing,empowerment is seen by the proponents of nursing diagnosis as existing whennurses use the discourse in practice (Carpenito, 1993). Truly empowered nurses,however, might make different choices.

Thevoice of thepatient iscompletely absentfromthediscourse ofnursing diag-nosis. Patients are constituted according to the discourse as the targets of the inter-ventions, not as participants in the discourse. Individual differences betweenpatients are treated by the discourse as research variablesamenable to standardiza-tion. Patients are not invited to conferences or invited to submit diagnoses for con-sideration. Panels of patients are not given diagnoses to review. Patients are notacknowledged to have any appropriate place in the discourse.

CONCLUSIONS

Theconcluding claimsof this discourseanalysisarethe following. First, there is evi-dence that the discourse of nursing diagnosis depends on,reproduces, and extendsconditions of social domination by using notions of science, normality, and the roleof social agency, which constitute individuals for themselves and others in an




oppressive manner according to hierarchical categories determined by empiricalmarkers such as race, gender, and class. The discourse thus limits autonomy andresponsibility in a systematic manner, but not by purposeful design.

Second, there is evidence that the discourse of nursing diagnosis restricts whatcountsas evidenceandlimitsacceptable input of voicesinto the structure andfunc-tioning of the clinical encounter to those social agents with scientific nursing exper-tise, thus excluding, for example, the voice of the patient and the patient’s family.

Third, the discourse of nursing diagnosis suppresses discussion relating to theoperation of power and resistance to power by appeal to the dominance of empiri-calanalyticscience andequates this dominancewith professionalsocial status. Thisresults in the perpetuation of oppressed-group behavior among practicing nurses

by creating tensions within the practice of nursing between competing discoursesas potential subjective speaking positions.

The models available at the time of the developmentof nursing diagnosis werelimited to male- and power-based constructions that conflict with other traditionsin nursing thought. Basedon an assumption of value-free power/knowledge, nurs-ingdiagnosishaswidespread influenceandserious consequences inthe U.S.Poten-

tial discourses of resistance that provide speaking positions from which to articu-late specific practices that resist oppressive effects of nursing diagnosis have beendiscussed.

The intentions of the original proponents of nursing diagnosis were timelyandwell thought out, but the models available at that time were limited. The unin-tended consequences are now being recognized. The influence that the discourseseeks in itsdescriptionoftheclinicalencounter for thepurposeof determining truthwithin that sphere does not impinge on the turf of medicine, because if it did, nurs-ing would now be facing powerful opposition or co-optation. The sphere of influ-ence we are carving out comes instead from patients and their families, and we areusing the language of science, professionalism, and medicine to justify ignoringthese voices.

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Penny Powers, Ph.D.,R.N., is the Department Head, Graduate Nursing, at South Dakota State Uni-versity, College of Nursing.


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A Discourse Analysis of Nursing Diagnosis