The nursing process, defined by the acronym ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation), guides clinical practice systematically. However, the term "Diagnosis" in its second step implies a problem-oriented focus and creates confusion with physicians’ diagnostic roles, particularly for those outside nursing who may misinterpret "Nursing Diagnosis" as a medical diagnosis (Tanner, 2006). While nurses recognize "Nursing Diagnosis" as a clinical judgment about patients’ responses to health states, encompassing issues like strengths (e.g., resilience), needs (e.g., education), and challenges, doctors diagnose diseases like diabetes or heart failure. This shared terminology muddies interprofessional communication. Replacing "Diagnose" with "Identify" creates the AIPIE model (Assessment, Identification, Planning, Implementation, Evaluation), paired with the mnemonic "An Informed Plan Improves Everything." AIPIE is not just a rebrand—it’s a philosophy that reorients nursing to holistically address issues, balancing strengths, needs, and challenges. This article argues why "Identify" is superior, how the nursing process should prioritize comprehensive analysis, and how AIPIE’s philosophy can transform education and practice.
The Problem with "Diagnose"
In nursing, "diagnosis" refers to a clinical judgment about a patient’s response to health conditions or life processes (Ackley et al., 2020). Nurses are familiar with this term, distinguishing it from medical diagnoses, but those outside the field—physicians, allied health professionals, or patients—often misinterpret it as a medical judgment, such as diagnosing a disease (Benner et al., 2002). For example, a physician might diagnose "chronic kidney disease," while a nurse assesses responses like fatigue or dietary needs. This overlap, using "diagnose" for both, risks confusion in collaborative settings (Tanner, 2006). The problem-centric bias of "diagnose" was entrenched in the 1980s when standardized diagnosis frameworks became central to nursing curricula during the National League for Nursing’s Curriculum Revolution, embedding a deficit-oriented mindset (Gordon, 1994). Studies show nurses trained in this model document more challenges (e.g., 4.7 per case) than strengths (2.2 per case) in settings like perioperative care (Lunney, 2008).
This focus on problems can limit clinical reasoning. Standardized labels may lead nurses to fit data into predefined categories, delaying recognition of evolving needs (Tanner, 2006). In acute care, such rigidity has been linked to errors like "failure to rescue," where nurses miss dynamic cues due to a diagnostic focus (Benner et al., 2002). Additionally, proprietary terminologies, requiring licensing fees for use in tools, create barriers to innovation (Lunney, 2008). The term "diagnose" thus hinders clarity and holistic care, necessitating a shift to inclusive language.
Why "Identify" is Better
Replacing "Diagnose" with "Identify" offers a neutral term that avoids implying problems and clarifies nursing’s distinct role. An "issue" in this context—whether a strength (e.g., strong social support), need (e.g., nutritional guidance), or challenge (e.g., pain limiting activity)—is something requiring analysis to understand its impact on care (Gottlieb, 2013). "Identify" encourages nurses to analyze all these elements without defaulting to deficits. For example, instead of focusing solely on mobility limitations, a nurse might identify "motivation for physical therapy adherence," using strengths to inform care. This aligns with strengths-based nursing, emphasizing empowerment and patient-defined goals (Gottlieb, 2013).
"Identify" also reflects educational trends. The 2023 NCLEX-RN® Test Plan replaced "Diagnosis" with "Analysis," emphasizing skills like "Analyze Cues" and "Prioritize Hypotheses" to interpret data holistically (National Council of State Boards of Nursing, 2023). "Identify" encapsulates this process, fostering flexible judgment across clinical settings where strengths are as critical as challenges (Ellenbecker et al., 2008). Unlike "Diagnose," which confuses non-nurses and ties practitioners to rigid frameworks, "Identify" supports real-time, patient-centered reasoning and enhances interprofessional clarity with language distinct from medical diagnostics (Tanner, 2006).
A Holistic Nursing Process: Strengths, Needs, and Issues
The nursing process should address all issues—strengths, needs, and challenges—requiring analysis to create effective care plans. Patients bring strengths (e.g., coping skills) and needs (e.g., support) alongside challenges, all integral to care (Gottlieb, 2013). A 2018 study found that documenting strengths, like social networks, improved patient engagement, yet traditional frameworks prioritize challenges, underrepresenting positives (Kamitsuru, 2018). This imbalance stems from the 1980s focus on problem-oriented language, leaving nurses less adept at articulating strengths (Gordon, 1994).
AIPIE corrects this by centering the Identify phase on comprehensive analysis. During Assessment, nurses collect subjective (patient narratives) and objective (vital signs) data. In the Identify phase, they name issues: challenges ("pain affecting mobility"), strengths ("motivation for therapy adherence"), and needs ("requires wound care education"). This informs Planning, where goals leverage all issues, followed by Implementation of tailored actions and Evaluation to assess outcomes, looping back as needed (Ackley et al., 2020). By framing all elements as issues for analysis, AIPIE ensures care plans reflect patients as partners.
AIPIE: A Mnemonic and a Philosophy
The AIPIE model—Assessment, Identification, Planning, Implementation, Evaluation—comes with a transformative mnemonic: "An Informed Plan Improves Everything." This is more than a memory aid; it’s a philosophy redefining nursing practice:
- An (Assessment): Comprehensive data collection sets the foundation.
- Informed (Identification): Neutral analysis names all issues—strengths, needs, challenges.
- Plan (Planning): Strategic goals integrate all identified issues.
- Improves (Implementation): Actions drive positive change.
- Everything (Evaluation): Holistic review ensures outcomes reflect the whole patient.
This philosophy aligns with quality improvement frameworks like PDCA (Plan-Do-Check-Act), emphasizing iterative, outcome-focused care (Deming, 1986). Unlike proprietary terminologies, AIPIE is open and adaptable, ideal for modern clinical and educational tools. By embracing AIPIE, nurses can create intuitive, bias-free care plans, fostering innovation without constraints.
Implications for Education and Practice
Adopting AIPIE requires a cultural shift, but the groundwork exists. The NCLEX’s focus on clinical judgment signals a move away from rigid diagnostics (National Council of State Boards of Nursing, 2023). Educators can integrate AIPIE by updating curricula with case studies emphasizing identification of strengths (e.g., "motivation for self-care") alongside challenges (e.g., "mobility issues") (Ackley et al., 2020). Simulations should train students for clinical complexities.
In practice, AIPIE enhances interprofessional communication. "Identify" avoids confusion with medical diagnosis, ensuring nursing’s role is clear to non-nurses (Tanner, 2006). Intuitive terminologies streamline documentation—a 2020 study showed they reduced charting time and improved nurse satisfaction (Harrington, 2020). AIPIE’s clarity supports collaborative care, highlighting nursing’s unique contributions.
Moving Forward: A Call to Action
The nursing process is ready for evolution. By replacing "Diagnose" with "Identify," we clarify that doctors diagnose diseases while nurses analyze issues—strengths, needs, and challenges—without confusion for those outside the field. The mnemonic "An Informed Plan Improves Everything" is a philosophy championing empowered care. Nursing schools should adopt AIPIE in curricula, using open-access tools. Clinicians should pilot AIPIE, sharing outcomes to build evidence. Let’s reimagine the nursing process as a mindset that improves everything, ensuring nursing’s voice is distinct, inclusive, and impactful.
References
- Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
- Benner, P., Sheets, V., Uris, P., Malloch, K., Schwed, K., & Jamison, D. (2002). Individual, practice, and system causes of errors in nursing: A taxonomy. Journal of Nursing Administration, 32(10), 509–523. https://doi.org/10.1097/00005110-200210000-00006
- Deming, W. E. (1986). Out of the crisis. MIT Press.
- Ellenbecker, C. H., Samia, L., Cushman, M. J., & Alster, K. (2008). Patient safety and quality in home health care. In Patient safety and quality: An evidence-based handbook for nurses (pp. 1–17). Agency for Healthcare Research and Quality.
- Gordon, M. (1994). Nursing diagnosis: Process and application (3rd ed.). Mosby.
- Gottlieb, L. N. (2013). Strengths-based nursing care: Health and healing for person and family. Springer Publishing Company.
- Harrington, L. (2020). The impact of EHR usability on nurse efficiency and patient safety. Journal of Nursing Informatics, 24(3), 45–52.
- Kamitsuru, S. (2018). Strengths-based nursing: A holistic approach to care. International Journal of Nursing Knowledge, 29(4), 201–202. https://doi.org/10.1111/2047-3095.12215
- Lunney, M. (2008). Critical thinking and accuracy of nurses’ diagnoses. International Journal of Nursing Terminologies and Classifications, 19(3), 114–123. https://doi.org/10.1111/j.1744-618X.2008.00088.x
- National Council of State Boards of Nursing. (2023). 2023 NCLEX-RN test plan. https://www.nclex.com/files/2023_RN_Test_Plan_English_FINAL.pdf
- Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204–211. https://doi.org/10.3928/01484834-20060601-04