Nurses are Consequence Managers

The author received training in applied behavior analysis at the Florida Institute of Technology under the late Dr. Jose Martinez-Diaz and performance management training with Dr. Aubrey C. Daniels. Dr. Daniels is recognized worldwide as the father of Performance Management. The author is board-eligible in applied behavior analysis.

Nurses are Consequence Managers. Unless there has been a significant change in every dictionary, medical diagnoses are the domain of physicians, dentists, audiologists, and other clinicians. I am an audiologist as well as a registered nurse. As an audiologist, I am “… an expert in diagnosing hearing loss and using technological solutions to help patients manage and live with their loss.” The operative word in medicine is diagnosis. Physicians use their decades of training and skills to determine patients' medical issues. These disorders often result from genetics, lifestyle, habits, or behavior. Consequences are “Something that logically or naturally follows from an action [behavior] or condition.” While there are many definitions for “consequences,” this one is simple and when compared with the purpose of “nursing diagnosis,” supports my following discussion. Nursing diagnosis, “Rather than focusing on biological processes, a nursing diagnosis identifies people’s responses to situations in their lives...”. NANDA refers to “…a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.” Much of the effort for NANDA has been delivered since its creation shows the risks patients face when under our care. Peeling away much of the rhetoric reveals significant harm that can be prevented. The Hospital Engagement Network (HEN) presented an important goal to prevent harm when it was introduced in 2011. Patient harm was identified as preventable injuries. The Partnership for Patients was a CMS initiative to keep patients from harm while hospitalized. These were falls, CAUTI, CLABSI, adverse drug events (medication errors), pressure ulcers, surgical site infections, venous thromboembolism, obstetrical adverse events, ventilator-associated events, and unplanned readmissions. As of 2021, 267 approved clinical use, testing, and refinement diagnoses exist.

Nurse Diagnosis – Tossing it out with the bathwater.

The domain of nursing is found in three primary areas: 1. Our assessment of patients at intake and ongoing during their hospital stay. 2. The prevention of harm while under our care. 3. Education of patients before discharge. None of these three areas of nursing expertise demands a diagnosis. Physicians have completed the diagnosis and differential diagnoses. They have written their care plans, and our nursing tasks include assessing and following the care plan. How are we consequence managers and not diagnosticians? To appreciate the difference requires a short course in applied behavior analysis. Cognitive behavior is the domain of psychologists. They live in a world of thoughts, feelings, and beliefs. We can transition to their world if we return to school for the next 8 to 10 years. Nurses manage behaviors or the things people do (applied behavior analysis).?

ABA – A Primmer

When asked what the ABCs are, every nurse will respond with Airway, Breathing, and Circulation. An equally important ABC is Antecedent, Behavior, and Consequences. I’ll refer to this to maintain some sanity as “ABC2”. Before breaking this down, there are also “Setting Events.” These set the tone for patient encounters. Keep in mind this information applies to nurses and patients. Get a speeding ticket (setting event) while driving to work. Park blocks away from the hospital because all the close parking is full (setting event). A colleague says, “Good morning,” when he sees you (Antecedent). Your verbal response eviscerates your colleague (Behavior), and you leave his bloodied corpse on the floor (consequence). Meanwhile, you feel better for getting your frustration off your chest (Consequence). Setting events may take years to manifest as a symptom (Antecedent) that prompts a person to see a doctor. Doctors do their assessment, various lab, and x-ray studies. A diagnosis is made (Consequence). The patient is admitted to your unit (Consequence), and that consequence becomes your antecedent to assess the patient (behavior), review the orders (behavior), and do another bazillion things (behaviors). In our next blog, we will get into the rolling ball of behavior and see how we constantly roll from antecedents to behaviors. Behaviors result in consequences. Consequences become antecedents, and so forth. ???????

You can see in the chart above that lifestyle, genetics, cultures, and habits are setting events for people to develop diseases (Consequences). Disease symptoms become antecedents, prompting people to see physicians. Physicians diagnose (consequence) and admit patients to hospitals (behavior). Physician’s orders become antecedents that result in patient admission behaviors (nurse). The nurse’s intake assessment (antecedent) evaluates the risks (behaviors) associated with the patient's disease and cognitive abilities. She assesses the potential environmental impact (consequences) and harms (consequences) that could occur to her patient. The condition has consequences, as does the care plan, the patient, and the environment. Patients also bring their behaviors and cognitive skills, such as they are. Nurses must then anticipate the risks associated with patient behaviors, the environment as a setting event, and known potential harm. There are no diagnoses to be found here. There is a significant amount of consequence management. Nurses must determine if the consequences are positive or negative, immediate or future, likely or unlikely, and whether each patient can perceive or not perceive the risks. Consequence Analysis will be reviewed in another blog.

As a registered nurse, I do not have to be a diagnostician. My role is to ensure my patient’s care plan is appropriate, the delivery of my services is professional, and I assess the internal and external risks and the consequences that could harm them. ?As a consequence manager, my first duty is to not harm. That includes looking into a crystal ball, recognizing potential liabilities, mitigating those harms, and educating my patients before discharging them.