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Published in final edited form as: Nurs Outlook. 2021 Jan 14;69(3):362–369. doi: 10.1016/j.outlook.2020.12.005

The Critical Need for Nursing Education to Address the Diagnostic Process

K Gleason 1, G Harkless 2, J Stanley 3, APJ Olson 4, ML Graber 5
PMCID: PMC8178169  NIHMSID: NIHMS1656932  PMID: 33455815

Abstract

Diagnostic errors are among the most common medical errors and the deadliest. The National Academy of Medicine recently concluded that diagnostic errors represent an urgent national concern. Their first recommendation to address this issue called for promoting the key role of the nurse in the diagnostic process. Registered nurses across clinical settings significantly contribute to the medical diagnostic process, though their role in diagnosis has historically gone unacknowledged. In this paper, we review the history and current state of diagnostic education in pre-licensure registered nurse preparation, introduce interprofessional individual- and team-based competencies to improve diagnostic safety, and discuss the next steps for nursing education. Nurses educated and empowered to fully participate in the diagnostic process are essential for achieving better, safer patient outcomes.

Keywords: Diagnostic error, nursing, education

Introduction

Diagnostic errors are among the most common medical errors and the most deadly (Saber Tehrani et al., 2018; Singh et al., 2014). The National Academy of Medicine’s (NAM) report, Improving Diagnosis Healthcare, highlighted the catastrophic impact of diagnostic errors and designated eight specific goals to address the problem (NAM, 2015). The report’s first two goals are relevant to nursing education:

Goal 1: Facilitate more effective teamwork in the diagnostic process among healthcare professionals, patients, and their families.

Goal 2: Enhance healthcare professional education and training in the diagnostic process.

In the recommendations on how to achieve these goals, the report calls for increased nursing engagement in the diagnostic process.

Although registered nurses have always been crucial members of the diagnostic team, providing essential observations and interpretations of these findings, the work of diagnostic thinking and reasoning in nursing practice has often not been recognized. Registered nurses may have concerns about acknowledging their role and responsibility in the diagnostic process because of perceived scope of practice constraints and the misperception that nursing observations and interpretations are separate and distinct from the diagnostic process. Considering the need to aggressively confront the problem of diagnostic errors, we believe that nurses are essential members of the diagnostic team and should enter practice with the expectation to participate actively and meaningfully in the diagnostic process, and that nursing education should prepare them to assume this responsibility and accountability.

In clinical and community settings, nursing practice is time-intensive with patients and families. Nurses coordinate care, monitor the patient’s course or response to treatments, detect subtle changes, initiate new diagnostic evaluations, and make informed diagnostic judgements that are communicated to the care team. Nurses are frequently the first to recognize that a patient is deteriorating and are first-line responders, whether they are in an acute care, long-term care or community setting and are accountable for acting on these observed changes (Cahill et al., 2019).

Nurses play a critical role in enhancing communication between physicians and patients and are often key in enabling the patients to become more proactive in their care (Gleason et al., 2017). They are in an ideal position to partner with patients to ensure accurate, subjective and objective data gathering and to monitor the accuracy of a diagnosis and to prevent diagnostic errors. If what they are observing in the patient does not align with an assigned diagnosis, or if observed changes appear to indicate a new or different diagnosis, this creates an opportunity and an obligation to intervene and mitigate diagnostic errors before there is harm (Gleason et al., 2020). For example, when a nurse identifies that a patient has deteriorating vital signs and initiates the sepsis protocol, this clinical judgement is a crucial step toward diagnosing a patient with sepsis (Kleinpell, 2017). Diagnoses such as sepsis cannot effectively be made without a nurse “thinking like a nurse.” “Thinking like a nurse” requires a “flexible and nuanced ability to recognize salient aspects of an undefined clinical situation, interpret their meanings, and respond appropriately” (Tanner, 2006). Darling versus Charleston Community Hospital (1965) set a legal precedent of holding nurses accountable for this professional responsibility of “thinking like a nurse” and monitoring and intervening when needed in the diagnostic process (Wiet, 2005).

To participate confidently and fully on the diagnostic team, nursing education must explicitly link clinical reasoning and clinical judgment to the diagnostic process. This is essential to not only prepare nurses to participate in the communication of diagnosis and prognostic information but to also take on new, expanded responsibilities in the work of diagnosis. An integrative review study identified knowledge deficits as a barrier to nurses participating in diagnosis and prognosis-related communication as full members of the clinical team and recommended interprofessional training focused on diagnosis discussions as essential to promoting diagnostic collaboration (Newman, 2016). With further education and support, nurses have been found to be safe and effective diagnosticians in the area of eye-led lesions, chronic obstructive pulmonary disease, health failure, and delirium (Mohite et al., 2016; Strong et al.; Eberly, 2018; Wand et al., 2014). Strengthening instruction on the diagnostic process in the didactic and clinical nursing curriculum will better prepare nurses to participate on the diagnostic team and ultimately achieve better diagnostic outcomes for patients.

In this paper, we review current registered nursing educational expectations and competencies, what individual and team-based competencies we believe are necessary to engage in diagnosis, and our recommendations for implementation across the curriculum.

Current Nursing Educational Expectations and Competencies

Historically, nurses have used the term diagnosis in two ways. Medical diagnosis refers to a provider’s assignment of a syndrome or disease label to a set of signs, symptoms, and other findings. In contrast, nursing diagnosis is “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. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability” (Herdman & Kamitsuru, 2017). However, nurses often work in highly medicalized environments and are expected to identify and intervene in a wide range of medical diagnoses, including life-threatening conditions like stroke, pulmonary embolism, and sepsis.

Although their knowledge base—largely a result of different training—may be different, the clinical reasoning process is essentially the same for physicians, nurses, and other clinicians involved in diagnosis (Tanner, 2006). It has recently been argued that education and training to improve the diagnostic process could reduce diagnostic errors in practice (NAM, 2015; Graber et al., 2018; Olson et al., 2019); this includes the requirement to improve training in clinical reasoning in all healthcare professions. Nursing textbooks focused on diagnostic reasoning and clinical judgement were published as early as 1991 (Carnevali & Thomas, 1993; Carpenito, 1989). However, the scientific foundations of human reasoning, judgment and cognitive error have continued to evolve, and these more recent findings need to be broadly incorporated in the education of healthcare professionals. In particular, nursing curricula need to address the challenge of diagnostic errors and how to avoid them. Addressing this challenge requires that nurses be familiar with the diagnostic process and assume responsibility as crucial members of the diagnostic team to help prevent diagnostic errors or help recognize them and speak up in time to avoid harm. This aligns well with nurses’ commitment to quality improvement, patient safety, and evidence-based practice (Considine & Currey, 2015; NAM, 2011).

The American Association of Colleges of Nursing’s (AACN) current Essentials of Baccalaureate Education for Professional Nursing Practice states that baccalaureate nurse graduates, among other expectations, promote safe, quality patient care and use clinical/critical reasoning to address simple to complex situations (AACN, 2008). The Essentials also include references to nurses’ role in the work of diagnosis, including the need for nurses to be active participants on the interprofessional team and for nurses to be prepared to evaluate patients’ health status over time. Furthermore, the Essentials of Baccalaureate Education for Professional Nursing Practice and the Essentials for Master’s Education for Professional Nursing Practice state that nurses must develop skills to articulate methods, tools, performance measures, and standards related to quality (AACN, 2008; AACN, 2011)—goals that are aligned with the important role nurses have in reducing diagnostic errors. In addition, most nursing textbooks include sections on the foundational concepts of critical thinking and decision-making in nursing practice; these texts draw on the same cognitive science upon which medical diagnostic reasoning and clinical judgment are built (Cappelletti et al., 2014).

One perceived barrier to including content on the theory and process of diagnostic reasoning in the nursing curriculum is the false assumption that nurses cannot participate in the diagnostic process because of current scope of practice regulations (Cahill et al., 2019). This frequently held assumption is more of a barrier than the regulations themselves. While the act of medical diagnosis is restricted by scope of practice laws in some states, it is well within nurses’ scope of practice to identify and label a patient’s clinical situation and responses using the most accurate terminology. Every nurse is clearly responsible and accountable under current scope of practice laws to fully participate on the diagnostic team (Cahill et al., 2019).

Competencies Needed to Improve Diagnostic Safety

The NAM report Improving Diagnosis in Healthcare calls for healthcare education to address diagnosis both explicitly and more effectively (NAM, 2015). Similarly, the NAM report, The Future of Nursing: Leading Change, Advancing Health, called for a transformation in nursing practice in the United States (NAM, 2011). Two of their four key recommendations are directly aligned with increasing nurses’ participation in diagnosis: (1) Nurses should practice to the full extent of their education and training, and (2) Nurses should be full partners with physicians and other healthcare professionals in redesigning health care. The report emphasizes the need for enhanced training in clinical reasoning with a call to tie coursework to the realities of patient care. Clearly, what we are presently doing is not sufficient or effective enough.

Building on these broad mandates, the Society to Improve Diagnosis in Medicine, enabled by funding from the Macy Foundation, used a consensus-building process to identify 12 key competencies that should be acquired by all healthcare professionals to improve the quality and safety of diagnosis (Graber et al., 2018; Olson et al., 2019). These competencies identify individual competencies, team-based competencies, and system-related competencies, each of which is relevant to nursing education.

Individual competencies

The competencies that focus on an individual provider emphasize the ability to elicit a complete and relevant healthcare history, perform a focused physical examination, and combine this information effectively with a relevant knowledgebase to formulate the diagnostic possibilities. In addition, individual competencies include knowing how to refine the possibilities using testing and consultation, observations over time, and critical thinking and reflection to help minimize the chances for error.

All the above competencies are foundational in nursing education and practice. Nurses should be prepared to know the major diagnoses of their patients, to detect, report, and document changes in patients’ conditions, to help patients communicate with the clinical team to provide the best diagnostic data, to educate patients on their diagnoses and the diagnostic process, and to be familiar with diagnostic errors and prevention strategies. These are each well-aligned with current nursing education; it is a matter of linking the education nurses currently receive to the diagnostic process and medical diagnosis and complementing current curricula with content and experiences relevant to the new competency elements that are currently lacking. Knowledge and skill in reflective and critical thinking are building blocks of most nursing education curricula; however, mitigating the effects of cognitive bias and effective use of second opinions and decision support tools are generally not prioritized or adequately practiced in current nursing education, just as they are lacking in physician education. In both cases these additional skills could play an important role in reducing the likelihood of diagnostic errors in practice.

Team-based competencies

To fully participate in diagnoses, nurses must be effective team members. The organizational members of the Interprofessional Education Collaborative (IPEC) have firmly stated that “to deliver high-quality, safe and efficient care, and meet the public’s increasingly complex healthcare needs, the educational experience must shift from one in which health profession students are educated in silos to one that fosters collaboration, communication and a team approach to providing care” (IPEC, 2016). The IPEC competencies (IPEC, 2016) delineate core competencies for interprofessional collaborative practice that builds on each profession’s expected disciplinary competencies to prepare graduates to function as effective team members. The Commission on Collegiate Nursing Education (CCNE) and the National League for Nursing’s Commission for Nursing Education Accreditation (NLN CNEA) require interprofessional education experiences in the curriculum (CCNE, 2018; NLN CNEA, 2016). The Accreditation Commission for Nursing Education (ACEN, 2017) in its standards requires interprofessional collaboration in its curriculum and instructional processes but does not state that students must have interprofessional educational experiences. These requirements can be leveraged to include opportunities for nursing and medical students to work through complex diagnostic cases. Interprofessional education provides the opportunity to demonstrate to nursing students how the diagnostic process works, and for both medical students and nursing students to recognize the role of the nurse and the role of the physician in diagnosis as well as their shared roles. The ability to communicate effectively using common terminology, develop a shared mental model, and ensure a common understanding of the role of team members are also critical.

The benefits of improving teamwork have been demonstrated in many different areas of health care; however, the recommendation to improve teamwork in diagnosis is novel (Graber et al., 2017; Olson et al., 2020). Educational exercises to promote diagnostic teamwork have been described (Blondon et al., 2017), and examples of teamwork improving diagnosis are available (Rodriguez et al., 2017; Schwartz et al., 2019; Thomas et al., 2016). For example, Rodriguez et al. (2017) found that following the implementation of an interprofessional management approach improved the assessment of dizzy patients, increased disease-specific diagnoses and, most importantly, improved patient outcomes.

Teamwork can directly improve diagnosis by facilitating communication, sense-making, and problem-solving. A team can also be effective in catching and ameliorating breakdowns in the diagnostic process, especially in the clinical-reasoning steps. Considering the many cognitive biases that underlie many diagnostic errors, it may be easier to detect the faulty clinical reasoning of another healthcare provider than to catch one’s own errors; put differently, fresh eyes are good for catching mistakes (Dror, 2011; Klein, 2006).

System-related competencies.

System-focused competencies speak to the many ways in which the environment, clinical context, and the tools at hand influence diagnostic safety and are recognized as crucial elements of the diagnostic process (Merkebu et al., 2020). Nursing education has widely adopted the Quality and Safety Education for Nurses (QSEN) competencies, and nurses are viewed as frontline messengers of safety and as role models for providing patient-centered care across the care continuum in all types of systems. These skills are highly relevant to achieving diagnostic excellence and should continue to be emphasized in nursing education and reinforced in practice post-graduation. Feeling safe to disclose system-related breakdowns and errors to the healthcare team and patients is an essential skill set for all healthcare professionals. Teaching system-related competencies presents another opportunity for interprofessional education to improve diagnostic outcomes.

Recommendations and Considerations for Change

Nursing Curriculum

The curriculum for all pre-licensure nurses—including master’s entry, bachelor’s and associate degree programs, and diploma programs—urgently needs updating to address the role of nurses in the diagnostic process. We have summarized the key elements of the individual, team-based, and system-related competencies that students in healthcare professions should acquire. Learning objectives for each of the key competencies have been published (Olson et al., 2019). We call upon the educators in the healthcare professions to develop and strengthen the content, delivery approaches, and assessment instruments needed to implement this competency-directed curriculum as quickly as possible. Nurses’ understanding of and preparation for their role in ensuring diagnostic safety is crucial for the improvement of diagnoses and mitigating diagnostic errors.

Updating an already complex, full curriculum is a challenge; however, much of the current content is well-aligned with the competencies needed to prepare nurses to effectively contribute on the diagnostic team. Teaching this content in different contexts and preparing nurses to feel comfortable in assuming accountability for this role will challenge educational program instructors to rethink curricula and pedagogies. In nursing education and across all healthcare professions, graduates need to acquire new individual, team-based, and system-related competencies relevant to the diagnostic process.

The AACN is currently re-envisioning all three of its Essentials documents that delineate the expected outcomes for baccalaureate, master’s and doctor of nursing practice (DNP) programs (AACN, 2020). In this revision process, the Society to Improve Diagnosis in Medicine’s (SIDM) interprofessional competencies are being introduced for both entry-level and advanced-level professional nursing education (AACN, 2020). By integrating these competencies across the nursing curriculum, explicitly linking the content to the nurse’s role in making diagnoses and empowering them to fully participate in the diagnostic process, future nurses should be better prepared to assume accountability for and effectively contribute to improving diagnostic safety.

Interprofessional education is already strongly recommended in both nursing and medical schools (IPEC, 2016). Interprofessional training—centered on communication and collaboration that are essential to achieving diagnostic excellence—often involves case studies and simulation exercises. Ensuring that the case studies and simulation exercises conducted during interprofessional experiences include scenarios specific to commonly missed diagnoses can help nursing, medical students, and other allied healthcare professional students link their training to the diagnostic process.

Clinical Practice

It is well-documented that nurses have long been held accountable for their role in the diagnostic process (Gleason et al., 2017), even if they have not been supported in this role. The responsibilities of nursing to monitor physiologic status and communicate findings are crucial to the diagnostic process and are the foundation of professional nursing practice. In Darling v. Charleston Community Memorial Hospital (1965), one of the most important legal cases in defining nursing responsibilities, a man required a cast for a fractured leg. During his almost two-week hospitalization, nurses assessed and documented potential complications in his affected leg (severe pain, foot blisters, edematous, cyanotic, and foul odor). However, they did not go beyond documenting these warning signs and following orders. Ultimately, he was transferred, his leg was amputated, and a lawsuit ensued. The court held that the nurses were expected to recognize the critical complication, exercise independent judgment, and report substandard medical treatment to higher authority, setting an important precedent in 1965. A recent analysis of malpractice cases involving diagnostic errors highlights that nurses are still held to this high level of accountability (Gleason et al., 2020).

Nurses entering practice confident and aware of their essential role in diagnosis would, hopefully, lead to change. We describe a scenario in Table 1 that compares a nurse prepared for the role in the diagnostic process with one who is not. With the additional preparation, there would be more interactions and discussions among providers, with a greater recognition of how working together achieves diagnostic excellence. A greater situational awareness among nurses regarding the diagnostic process would develop, including instances of uncertainty in diagnosis and differential diagnoses. Patient education about diagnoses and the diagnostic process would be enhanced. These changes would ultimately improve the diagnostic process and both prevent and identify diagnostic errors.

Table 1. Hypothetical Scenario: The Difference between a Nurse Prepared for Role in Diagnosis and a Nurse who is not Prepared for the Role in Diagnosis.

Hypothetical Scenario: Orthopedic Post-operative patient reports to nurse: “I am feeling really anxious. I have this sense that something really bad is about to happen. This is unusual for me. I’m also feeling really lightheaded.”

Nurse not Prepared for Role in Diagnosis Nurse Prepared for Role in Diagnosis
Nurse reassures patient that she is in good hands with the nurse and the team. Nurse gives patient wet washcloth for lightheadedness. About an hour later, the patient care technician takes the patient’s vital signs every 4 hours on the ordered schedule. Nurse views vital signs and pages in-house provider: “Patient in room 220, heart rate 110, SpO2 86, will put on supplemental oxygen.” Nurse places patient on oxygen and continues regular care. Pulmonary embolism goes uncaught through nurse’s entire shift, with ultimate dire consequences for the patient. Nurse is concerned that a patient seems to be reporting an “impending sense of doom,” which she has been taught is a telltale sign of an impending serious health event. Nurse obtains vital signs immediately and sees that the patient’s oxygen level is decreasing, and heart rate and respiratory rate are increasing. Nurse calls and notifies provider that she is very concerned about this patient, who is postoperative day 2. She states the vital signs, that she has placed her on supplemental oxygen per ordered protocol, that the patient reported unusual anxiety and a feeling that something bad is about to happen, and that the patient refused her anticoagulant doses from the night nurse. Nurse states that she suspects a pulmonary embolism and requests the provider come to bedside immediately. Pulmonary embolism is identified and treated in a timely manner.
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One readiness to practice assessment tool—del Bueno’s Performance-Based Development System, used by a number of large healthcare systems—requires that the nurse respond to a scenario of a patient with an emerging acute condition, delineate the salient clinical observations, name the clinical changes, and state what he/she believes to be the cause of the change. The exam is testing the nurse’s ability to recognize and name the medical diagnoses. This important work, often occurring in rapidly evolving clinical situations, is essential to arriving at a correct medical diagnosis by the clinical team (Cahill et al., 2019).

Regulations and Licensing Requirements

Scope of practice laws are not the barrier they are perceived to be, as discussed earlier. Though some states explicitly prohibit nurses from making medical diagnoses (Cahill et al., 2019), we suggest that nurses must be prepared and hold themselves accountable for playing an active role in the diagnostic process, not that they assume accountability for making medical diagnoses. However, this false perception that scope of practice laws prohibit nurses from participating in the diagnostic process is a hurdle we must acknowledge and overcome. The lack of consistency across states’ scope of practice laws in the language used to describe the role of nurses in medical diagnosis certainly adds to the confusion (Cahill et al., 2019). State boards of nursing should adopt common regulatory language that makes it clear that contributing to the medical diagnostic process is within the nurse’s scope of practice.

The National Council Licensure Examination (NCLEX) for registered nurses is changing and will align well with the interprofessional diagnostic competencies across the three domains. The new exam, known as The Next Generation NCLEX, will build on the National Council of State Boards of Nursing (NCSBN) Clinical Judgment Measurement Model (CJMM; Sherrill, 2020). The new test (NCLEX-RN) will assess different facets of the Clinical Judgment Measurement Model, including the recognition of cues, analysis of cues, hypothesis prioritization, solution generation, action planning, and outcomes evaluation. The current and future NCLEX-RN test emphasizes that management of care encompasses collaborating with interprofessional team members, verifying that the client receives appropriate education, assessing the need for referrals, and participating in quality improvement projects and processes (NCSBN, 2019).

Conclusion

Diagnostic errors are the most common and deadly of medical errors (NAM, 2015). To better serve our patients, the diagnostic process must improve. Nurses are in an ideal position to play a central role in achieving diagnostic excellence. Their role in assessing, evaluating, and communicating cannot be underestimated for its importance in the diagnostic process. Yet, many nurses enter practice with an antiquated belief that diagnosis is not in their domain, and they are not adequately prepared to participate in the process. It is crucial for nursing education to address this misperception, and that nurses enter practice confident and ready to be a full participant on the diagnostic team.

Highlights.

  • The National Academy of Medicine recently highlighted the urgent issue of medical diagnostic errors, and their first recommendation to address this issue explicitly called for promoting the key role of the nurse in the diagnostic process.

  • Strengthening instruction on the diagnostic process in the didactic and clinical nursing curriculum will better prepare nurses to participate on the diagnostic team, and ultimately achieve better diagnostic outcomes for patients.

  • Updating an already complex, full curriculum is a challenge; however, much of the currently included content is well-aligned with the competencies needed to prepare nurses to effectively contribute on the diagnostic team and it is a matter of explicitly linking the content to the diagnostic process.

Acknowledgements:

K. Gleason receives funding from the following sources: NIH NCATS Institutional Career Development Core, KL2 TR003099, NIH NCATS Johns Hopkins Institute for Clinical and Translational Research, UL1TR003098, and AHRQ A Human Factors and Systems Approach for Understanding the Diagnostic Process and Associated Safety Hazards in the Emergency Department, R01 HS 027198. M.L. Graber receives grant funding from the Macy Foundation.

Footnotes

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Disclosures: The authorship team reports no disclosures.

Contributor Information

K. Gleason, Johns Hopkins University.

G. Harkless, University of New Hampshire.

J. Stanley, American Association of Colleges of Nursing.

A.P.J. Olson, University of Minnesota.

M.L. Graber, Society to Improve Diagnosis in Medicine.

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