When Nursing Education Reinforces a Diagnosis
Christoff Truter
Spousal caregiver
Recently someone shared an Australian nursing guide on Functional Neurological Disorder (FND) with me.
It begins with a brief history of FND before discussing neuroimaging studies, seemingly to reinforce the impression that FND has a solid scientific foundation.
However, the imaging findings presented in the guide are not specific to FND and are not used to diagnose it. At best, they demonstrate that patients experience genuine, measurable brain changes associated with their symptoms, rather than simply feigning illness. These findings do not reveal the origin of the symptoms or distinguish FND from many other neurological and psychiatric conditions.
Putting that aside, what struck me most was the tone of the guide. As I worked through it, I could not shake the impression that it had been written from a place of frustration with patients who remain sceptical of the diagnosis, and that this frustration had found its way into material intended to educate nurses.
The guide repeatedly returns to the same themes. Patients seeking alternative diagnoses. Patients who remain unconvinced. Patients searching for information that reinforces a physical explanation for their symptoms. Throughout the guide, these behaviours are framed as barriers to recovery rather than as understandable responses to uncertainty.
More fundamentally, the guide repeatedly acknowledges patient scepticism without ever engaging with it. It presents doubt as something to be managed rather than examined. At no point does it discuss what evidence would justify questioning an FND diagnosis, how clinicians should think about falsifiability, or what findings ought to prompt reconsideration. In doing so, it asks nurses to reinforce confidence in the diagnosis without equipping them to evaluate its limits.
"Many will then look elsewhere for a diagnosis, thus, consuming further resources in second opinions and unnecessary investigations."
Is this appropriate for a nursing guide?
I would argue that it is not. In fact, I think it is the opposite of what a nursing guide should be doing.
If someone has disabling symptoms, no definitive biomarker, no definitive scan, and a diagnosis based primarily on clinical interpretation using positive signs, it is entirely understandable that they would seek a second opinion, look for alternative explanations, ask questions, and continue searching for answers. That is not irrational. It is a fundamentally human response to uncertainty.
"Cover all symptoms... The more symptoms the patient has, the more likely it is that the primary symptoms will not be due to a recognised disease."
- False assumption: More symptoms do not make recognized disease less likely.
- Ignores multisystem diseases: Many established diseases naturally cause numerous symptoms.
- Overlooks comorbidity: Patients can have multiple conditions at the same time.
- Confuses uncertainty with evidence: Not having an explanation is not evidence that no recognized disease exists.
- Encourages diagnostic bias: It may lead clinicians to stop investigating organic causes prematurely.
The guide also creates an evidentiary burden that it never meets, asking readers to accept its conclusions without demonstrating the underlying assumptions.
It spends considerable time discussing patients who question the diagnosis, yet spends almost no time discussing when those questions might be justified. There is no meaningful discussion of diagnostic uncertainty, reassessment, or the circumstances under which an established FND diagnosis should be reconsidered.
"Very fixated views on an alternative diagnosis."
This is particularly surprising given the role of nurses. They are often the frontline observers of patient deterioration. They are the people most likely to notice progression, new symptoms, or changes that no longer fit the original clinical picture. A nursing guide should equip them to recognise those situations.
Instead, if a nurse is taught that scepticism, alternative diagnoses, information sources, and treatment resistance are barriers to recovery, how will that nurse interpret future events?
Will new symptoms become more evidence of FND?
Will progression simply become another manifestation of FND?
Will continued searching for answers be viewed as another illness belief?
Should nurses be encouraged to defend an existing diagnosis, or should they be encouraged to observe the patient and remain alert to the possibility that something no longer fits?
"Talk to family and friends: Explain and reinforce the diagnosis..."
"Nurses need to help facilitate and promote these plans..."
"You should not be afraid to correct terminology with patients and their families."
If my Common Phenotypes Hypothesis is correct, then this educational approach becomes particularly concerning. Rather than encouraging nurses to remain vigilant for an underlying disease, it teaches them to reinforce the diagnostic label attached to the presentation.
Consider the following thought experiment.
Imagine it is the year 2090. We discover that FND was never a single disorder at all, but rather a common neurological presentation that can arise from many different underlying diseases and biological mechanisms. In other words, FND represented a collection of phenotypes rather than a diagnosis in its own right..
How would we look back on a guide like this?
I suspect we would conclude that it taught nurses to reinforce the presentation rather than remain curious about its cause. Much like the historical perspective on hysteria, which framed complex symptoms as psychological manifestations and discouraged deeper investigation into organic causes. Instead of encouraging continual observation and reassessment, it encouraged nurses to interpret new symptoms, progression, and even patient scepticism through the existing diagnostic framework. In doing so, it inadvertently became an impediment to identifying the underlying disease.
That is the danger of treating a presentation as though it were the diagnosis itself.
A nurse's greatest value is not defending a diagnosis. It is noticing change. It is recognising when something no longer fits. It is being the person who says, "This patient is different today. We need to look again."
If FND were ultimately understood as a common presentation rather than a discrete disorder, educational material like this would have done the opposite. Rather than preserving diagnostic curiosity, it would have reinforced diagnostic closure.
That is a sobering possibility, and one worth considering whenever educational material teaches clinicians how to respond to scepticism without also teaching them when that scepticism may be justified.
