THE WAY WE TEACH...
Nursing-Using the Nursing Process P. M. ASHWORTH and G. CASTLEDINE
Med Teach Downloaded from informahealthcare.com by University of Sydney on 12/29/14 For personal use only.
P. M . Ashworth, MSC, SRN, SCM, FRCN, is Research Programme Manager, WHO Collaborating Centre, Department of Nursing, University of Manchester, and G. Castledine, BA,.Dip.Soc. Stud., SRN, FRCN, Clinical Lecturer, Department of Nursing, University of Manchester, Oxford R d , Manchester. It has often been pointed out that the real problem of nurse numbers is not the failure to recruit or to recruit appropriately, but to retain nurses once they have started. T h e indications are that where the nursing process approach is used i n practice as well as taught, nurses (both learners and trained staff) derive more satisfaction from their work. They are then less likely to become disillusioned and/or leave nursing.
In a survey of 150 people who visited Diana AnnandaleSteiner, a counsellor at Guy’s Hospital London, 105 were nurse learners and 22 were trained nursing staff; of the total 127 nursing staff, 50 had thought of leaving nursing at some stage of the counselling; 43 came with the idea already in mind and seven subsequently considered it. Forty out of these 50 ultimately left without completing their training, or if already trained, their expected stay. As well as these 50, some of the other nurses who came for counselling were unhappy with their work, but intended to stay until they finished their training (AnnandaleSteiner 1979). Evidence of a more personal view was expressed by Kay Hawkins in the Nursing Mirror in November 1979, who as a third year student nurse decided to leave nursing because, “the system seems designed to stop nurses thinking for themselves- the method does not teach nurses to reason about what they are doing” (Hawkins 1979). What Hawkins and others seem to have been complaining about is the rigid way that nursing has focused on tasks, procedures and routines, at the expense of individuality in nursing. Since patients vary considerably, not only in their medical histories, but also in their personal life-style and specific care needs, it is highly unlikely that any one standard routine can be appropriate for everybody. The danger of introducing or maintaining tightly scheduled routines and procedures which are imposed through a rigid system of rules, is that in extreme and prolonged situations, it may have grave social and psychological effects. Both children and the elderly appear particularly susceptible to disruption of their personal routines and lack of individualized care. Yet Wells (1980) found that nursing work on geriatric
Medical Teacher V o l 3 N o 3 1981
wards was not focused on the patients’ needs. “The fact that the nurse was not focusing on the patient to discover his particular need and unique personality suggested that nursing care was unlikely to be helpful or meaningful” (Wells 1980). T h e Nursing Process The nature of nursing has been debated for years. It can be seen as a process through which the nurse acts in many ways to help people reach and maintain an optimal level of functioning: “Its primary responsibility is to assist individuals and groups (families/communities) to optimize function within varying states of health. This means that the discipline is involved in caring functions which relate to health as well as illness and which stretch from conception to death. Like medicine, it is concerned with maintaining, promoting and protecting health, caring for the sick and providing rehabilitation. It deals with the psychosomatic and psychosocial aspects of life as these affect health, illness and dying” (Hall 1979). The Nursing Process is a systematic approach to care which is based on the assumptions that (a) the patient or client is treated as an individual with specific needs and problems and (b) the patient or client is encouraged to be more involved in decisions about his nursing care and is directed towards self-care where possible. There are four main stages to the nursing process (Figure 1): 1. Assessment. 2. Planning. 3. Implementation. 4. Evaluation.
To refer to this process as the ‘nursing process’ when basically what we are referring to is the scientific approach to nursing may seem a little presumptuous. The name, however, helps to emphasize the point that this style of nursing is somewhat different from previous models of nursing care currently in use in this country. 87
patient which demand both observation and careful thought. The use of video to screen role play situations and tape recordings of different interviews can also be extremely helpful for the learner. Three important points should, however, be considered with regard to the depth of assessment:
Med Teach Downloaded from informahealthcare.com by University of Sydney on 12/29/14 For personal use only.
1. The nurse’s role, or function, in the particular health care setting. 2. The purpose of the assessment. 3. The type and intensity of the problem the client is experiencing.
Figure 1. The nursing process. While good nurses have used some parts of the nursing process to some extent in the past, it has rarely if ever been used systematically, completely, explicitly and documented.
Stage 1. Assessment This involves the gathering of information about the patient by interviewing techniques, systematic observation, reviewing the patients’ records and talking to other members of the health care team. One of the best methods of gathering information is by planned conversation with the patient, shortly after admission to the hospital. This may follow a fairly brief outline of the kind of information the nurse needs to know in order to care for her patient, or it may consist of pre-written questions. which the nurse uses as the conversation develops. The emphasis is on flexibility and the astuteness of the nurse making the assessment. She will also note carefully any changes in the patient’s physical or mental condition. Sometimes this may be done during a deliberate examination or more appropriately during nursing care. In the past, information about a patient was collected on an informal basis in a haphazard manner by nurses who usually kept much of the information in their heads and failed to pass the details on to others in the nursing team. Now the nurse making the assessment is encouraged to follow an agreed format, recording the results carefully in the nursing records. We teach this approach by several methods, one of the most popular involving the learner accompanying a skilled nurse at an interview and then discussing the event afterwards. With the use of a written teaching aid, highlighting the kind of patient information required, the learner also has some idea of the type of questions she may ask. For example, the teaching aid asks the learner certain questions about the 88
For example for many patients admitted to hospital or needing prolonged care at home it may be necessary to gather detailed information about the patient’s daily living activities, his work and home environment, ways in which these affect or are affected by the person’s health and/or disabilities, and relevant strengths, weaknesses, feeling and reactions and coping strategies, This would all be the basis for defining nursing problems/needs for nursing care, and planning effectively. However, for short-term care less information may be needed. It is hardly necessary to collect full information on eating habits from a person admitted for a few hours for dental extraction- unless there is some specific indication. An outline of the criteria which are used in one approach is included in Figure 2. The final part of making an assessment involves the statement of the patient’s problems. This often causes difficulties for nurses who become confused as to the difference between the patient’s medical problem and his need for nursing care. A nursing problem can be defined as any condition or situation in which a patient requires nursing assistance or help to attain, maintain, or regain a state of health which is desirable for him, or to achieve a peaceful death. For example, if a patient has a chest infection, what is it about his chest infection which causes him to have difficulty? Is the difficulty in coughing up sputum, reluctance to take a high fluid diet, or perhaps difficulty in breathing unless sitting upright? When stating the patient’s problem the learner is encouraged to state what she thinks is the cause. Problem identification is not easy and requires practice in the classroom as well as in the clinical situation. One helpful exercise is to present a learner with the assessment details of a patient and then encourage her to identify the problems.
Stage 2 . Planning Once the patient’s problems have been identified the next stage is to consider the methods and techniques necessary to meet these problems. This involves writing out a brief, concise and precise care plan for the patient. This is generally organized under the following headings: Patients nursing problem- the patient’s problem as identified by the nurse on consultation with the patient following a nursing assessment. Date identified- the date the nurse has identified the patient’s problem.
Medical Teacher V o l 3 No 3 1981
If possible the patient will also be closely consulted about the nurse’s plans of action.
Med Teach Downloaded from informahealthcare.com by University of Sydney on 12/29/14 For personal use only.
Written plans of action should, where possible, be based on scientific rationale and nursing research findings. It is a helpful exercise to include a column headed ‘Rationale for Nursing Action’, for learners, especiallywhen they are writing their nursing care studies in the classroom. Wherever possible, the nurse’s actions relating to the patient’s problems should be written in terms of staff behaviour and what the staff will do or help the patient to do. Writing objectives for the intended results of nursing actions also requires practice, and exercises constructed in the classroom can help. On one ward we changed the heading on the care plan from ‘Objective’,to ‘Expected Outcome’. This helped many learners get over the difficulty of deciding what was a goal and what was an objective. ‘Desired Outcome’ may be preferred, as sometimes a particular outcome may be planned and hoped for, but not necessarily expected. Standard nursing care plans may be developed (Mayers 1978) and used, for example, in the preoperative preparation of patients. “A standard care plan is a protocol for care that is likely to be applicable to most patients of a certain diagnostic or other category” (Mayers 1978). There is a danger, however, that standard nursing care plans will become the norm and used instead of individually created plans of patient care. It is important therefore to review and update them regularly, evaluating the patient’s involvement and individual needs. If this is not done there is a danger that nursing could be defined in terms of “what nurses did rather than in the areas of health problems they were prepared to identify and manage. Taking the initiative and creative thinking usually were not considered a part of the nursing role” (Carnevali 1979). The whole emphasis should be on planning nursing care to meet the needs of each individual person, although each nurse usually cares for several people.
Stage III. Implementation
Figure 2. A n example of criteria used f o r gathering information about the patient. Objective to be reached by specified date/time-the objective the nurse is hoping the patient will achieve by a certain date and time. Achievement of this objective may not solve the overall problem but will go some way towards this. For example, the patient’s overall problem may be that he cannot walk unaided, and the first objective is to get him to take one or two steps on his own without any form of aid. Plan of nursing invention-the proposed nursing care which the nurse feels is most appropriate for the patient. Medical Teacher Vol3 No 3 1981
Implementation basically means carrying out the nursing care plan. There should be some facility available for the nurse who is working with the patient to comment and report on the patient’s progress. Information should be sought regarding the patient’s subjective feelings about his progress plus the nurse’s critical, objective observations. Careful reporting back to all those involved in caring for the patient helps provide a continuity of evaluation and continuity of care. One method we have found helpful is to allocate a learner to a trained member of staff whose responsibility it is to work with the learner and one or more patients, regularly up-dating the nursing records. Teacher and learner therefore work very closely together, with the trained nurse taking overall responsibility, but with each continuing patient care while the other is off duty. On a ward with a slower turn-over of patients, this system works very well. In other situations the ward sister would have to control carefully the allocation and daily assign89
ment of her nurses to patients. Team nursing may help where at least one member of, say, a team of four would be on duty and able to provide some form of continuity of patient care. It is important, however, which ever team member is available that she gives the report on that particular patient.
Med Teach Downloaded from informahealthcare.com by University of Sydney on 12/29/14 For personal use only.
Stage ZV. Evaluation Recorded evaluation is an important part of the documentation of nursing care. Often in practice it consists of on-going progress notes which are related (by numbers or other means) to the individual problems identified. The record should show the patient’s response to nursing care and indicate whether each problem is solved, or progress towards solution is evident, or progress is unsatisfactory. It therefore provides the basis for decisions on continuing or modifying the care plan, or may indicate the need to redefine the problems. Sometimes, particularly with long-stay patients, nurses like to have dated evaluations recorded intermittently alongside the care plan, or on a separate sheet so that it is easy to see a summary of progress. There are five major sources of data which are available for evaluating nursing care:
Direct observation in which the nurse reports very carefully what she either sees, hears, touches, smells or tastes. Nurse learners can be encouraged to observe certain activities going on in a given clinical situation, then to report back their findings. The end product of nursing intervention can be carefully analysed. For example, what is the state of a patient’s pressure sore now that the nurse has finished her course of planned treatment? Examination of the nursing records to see if the proposed outcomes of nursing care were achieved or not. The reports made by other people, especially patients, about nursing care are another helpful source of information. Reports made by nursing staff themselves are an important source of data about the quality of nursing care that they feel they have achieved. The use of a nursing audit may help to streamline the evaluation of the whole of the nursing process so that on discharge or transfer of a patient to another situation a random selection of patients’ nursing care records could be carefully reviewed and evaluated to see if the proper information was gathered. If it was used, were the correct needs identified? Was the plan of care communicated to the staff on a 24-hour basis? Were short-term and long-term goals achieved? Was there evidence that the care was individualized and how smooth was the transfer? Teaching the Nursing Process The nursing process should not be taught in isolation as an academic exercise in a school of nursing. The way to teach nursing using this approach is by integrating the concept into the delivery of nursing care on one or more wards or in an individual’s home. This requires from the 90
trained staff commitment to using the nursing process approach in practice. It may require considerable changes which may not be easy for those who have been taught and have practised in more traditional ways. Change should be introduced gradually, perhaps initially encouraging nurses to improve their present report and record writing, along the lines of stating the patient’s needs or problems. Nurse/patient allocation is another important step towards using this approach in nursing care. This can be achieved on a daily or longer-term basis by allocating the nurses to groups of patients and encouraging them to be responsible and accountable for their patients’ daily plans of care. Some aspect of a patient’s care may have to be fulfilled by a more experienced member of the ward team, for example patient counselling, but the learner can still be involved as an interested observer. Consequences of using the Nursing Process Approach In some settings nurses are now starting to present their findings and conclusions about patients in a more confident and thoughtful manner. By using the nursing process they are becoming more objective in their contributions to discussions and decisions. Case conferences and ward rounds are more eventful and rewarding for nurses because they feel they have a more positive contribution to make. “Nurses are communicating their belief that nursing care is significant and complex, that it can be highly important to patient well-being and that consumers deserve as good nursing care as medical, dental, or other types of health care. Good care is not equated with haphazard, unplanned care. Therefore planning is emerging as critical thinking and decisionmaking behaviour necessary to nursing’s professional integrity rather than busy work done at the demand of others” (Carnevali 1979). Some of the benefits expressed by students using this approach in their nursing care are: ‘achievement’ and a ‘greater sense of job satisfaction’, ‘get to know more about our patients’, ‘improves interpersonal relations’ and ‘makes one feel one is making a more significant contribution to the health care team and patient care’. It has been suggested that “nothing could be more helpful to nurses than collecting and studying clinical nursing plans used for their patients” (Henderson and Nite 1978). Certainly, this appears to be helpful both in learning and improving nursing practice. Conclusion Wells (1980) sums up the problems facing nursing today when she says: “The central problem in geriatric nursing is the central problem in all of nursing: nurses do not know why they do what they do. It is not helpful to anyone if nurses base their work on principles of trial and error, custom and habit. Training has encouraged nurses to perform ritualistic routines without thinking of the effect of such routines on patient care. Nurses have not been taught how to identify problems in patient care, how to take Medical Teacher Yo13 No 3 1981
action to solve such problems, or how to evaluate the effects of nursing action. To do this nurses must be educated in problem-solving techniques, and focused on the patient” (Wells 1980). Using the nursing process approach appears to have a double advantage: the benefits to patients seem to include not only more effectively planned care, but also happier nurses who remain longer in practice and thus contribute to continuity and high quality care. Something which seems to benefit both nurses and patients/ clients must be worth trying.
Med Teach Downloaded from informahealthcare.com by University of Sydney on 12/29/14 For personal use only.
References Annandale-Steiner, D., Unhappiness is the nurse who expected more, Nursing Mirror, 1979, 149, No. 22, 34-36. Carnevali, D., Nursing care planning in profession practice, in Current Perspectives in Nursing Management, Ed. A . Marriner, C . V. Mosby, London, 1979. Hall, D. C., A Position Paper on Nursing, Euro/Nurs/75.1. Rev. l . , World Health Organization, March 1979. Hawkins, K., Why I’m giving up nursing, Nursing Mirror, 1979, 149, No. 21, 10. Henderson, V. and Nite, G . , Principles and Practice of Nursing (6th edn), Collier and MacMillan, West Drayton, Middlesex, 1978. Mayers, M. C . , A Sytematic Approach to the Nursing Care Plan (2nd edn), Appleton-Century-Crofts, New York, 1978. Wells, T. J., Problems in Genutric Nursing Care, Churchill Livingstone, Edinburgh/London/New York, 1980.
Microelectronics in Education The application of microelectronics in educational support of health systems, was the subject of an informal meeting organized by the World Health Organization and held in September of last year. Copies of the report of the meeting (unpublished WHO document HMD/80.4), describing the ways in which microelectronics can be used in education through such devices as gaming, simulation and computer-assisted learning, can be obtained from HMD/ECS, World Health Organization, 1211 Geneva 27, Switzerland.
Courses for Medical Teachers The following courses for medical teachers and teachers of other health care workers will be held at the Centre for Medical Education, The University, Dundee, Scotland from 31 August to 18 September, inclusive: 1. Teaching Methods (31 August-4 September) 2. Assessment in Medical Education (7-11 September)
3. The Objective Structured Clinical Examination: A Workshop for Medical and Dental Teachers (10-11 September) 4. Project Work-for those who have attended Course 1 and/or Course 2.
Medical Teacher V o l 3 No 3 1981
MAVIS Medical Audio Visual Aids Information Service Do you teach undergraduate medical students? Do you organize postgraduate meetings? Do you teach nurses and other paramedical staff? Are you thinking of producing your own audio visual programmes? Have you thought of using audiovisual programmes for your own continuing education?
. . . then you might find it useful to have a list of all the audiovisual programmes in your area of interest. In the Medical Audio Visual Aids Information Service we have indexed over 10,000 programmes from approximately 1,000 catalogues obtained from British universities, societies and institutions, pharmaceutical companies and other commercial companies.
If you are interested write for further details to: Veronica F. Barker Senior Information Officer Centre for Medical Education University of Dundee Dundee D D I 4HN Tel: 0382-23181 ext 617 This service has received support from Update Publications Ltd and The Wellcome Foundation L td.
91
Nursing-Using the Nursing Process P. M. ASHWORTH and G. CASTLEDINE
Med Teach Downloaded from informahealthcare.com by University of Sydney on 12/29/14 For personal use only.
P. M . Ashworth, MSC, SRN, SCM, FRCN, is Research Programme Manager, WHO Collaborating Centre, Department of Nursing, University of Manchester, and G. Castledine, BA,.Dip.Soc. Stud., SRN, FRCN, Clinical Lecturer, Department of Nursing, University of Manchester, Oxford R d , Manchester. It has often been pointed out that the real problem of nurse numbers is not the failure to recruit or to recruit appropriately, but to retain nurses once they have started. T h e indications are that where the nursing process approach is used i n practice as well as taught, nurses (both learners and trained staff) derive more satisfaction from their work. They are then less likely to become disillusioned and/or leave nursing.
In a survey of 150 people who visited Diana AnnandaleSteiner, a counsellor at Guy’s Hospital London, 105 were nurse learners and 22 were trained nursing staff; of the total 127 nursing staff, 50 had thought of leaving nursing at some stage of the counselling; 43 came with the idea already in mind and seven subsequently considered it. Forty out of these 50 ultimately left without completing their training, or if already trained, their expected stay. As well as these 50, some of the other nurses who came for counselling were unhappy with their work, but intended to stay until they finished their training (AnnandaleSteiner 1979). Evidence of a more personal view was expressed by Kay Hawkins in the Nursing Mirror in November 1979, who as a third year student nurse decided to leave nursing because, “the system seems designed to stop nurses thinking for themselves- the method does not teach nurses to reason about what they are doing” (Hawkins 1979). What Hawkins and others seem to have been complaining about is the rigid way that nursing has focused on tasks, procedures and routines, at the expense of individuality in nursing. Since patients vary considerably, not only in their medical histories, but also in their personal life-style and specific care needs, it is highly unlikely that any one standard routine can be appropriate for everybody. The danger of introducing or maintaining tightly scheduled routines and procedures which are imposed through a rigid system of rules, is that in extreme and prolonged situations, it may have grave social and psychological effects. Both children and the elderly appear particularly susceptible to disruption of their personal routines and lack of individualized care. Yet Wells (1980) found that nursing work on geriatric
Medical Teacher V o l 3 N o 3 1981
wards was not focused on the patients’ needs. “The fact that the nurse was not focusing on the patient to discover his particular need and unique personality suggested that nursing care was unlikely to be helpful or meaningful” (Wells 1980). T h e Nursing Process The nature of nursing has been debated for years. It can be seen as a process through which the nurse acts in many ways to help people reach and maintain an optimal level of functioning: “Its primary responsibility is to assist individuals and groups (families/communities) to optimize function within varying states of health. This means that the discipline is involved in caring functions which relate to health as well as illness and which stretch from conception to death. Like medicine, it is concerned with maintaining, promoting and protecting health, caring for the sick and providing rehabilitation. It deals with the psychosomatic and psychosocial aspects of life as these affect health, illness and dying” (Hall 1979). The Nursing Process is a systematic approach to care which is based on the assumptions that (a) the patient or client is treated as an individual with specific needs and problems and (b) the patient or client is encouraged to be more involved in decisions about his nursing care and is directed towards self-care where possible. There are four main stages to the nursing process (Figure 1): 1. Assessment. 2. Planning. 3. Implementation. 4. Evaluation.
To refer to this process as the ‘nursing process’ when basically what we are referring to is the scientific approach to nursing may seem a little presumptuous. The name, however, helps to emphasize the point that this style of nursing is somewhat different from previous models of nursing care currently in use in this country. 87
patient which demand both observation and careful thought. The use of video to screen role play situations and tape recordings of different interviews can also be extremely helpful for the learner. Three important points should, however, be considered with regard to the depth of assessment:
Med Teach Downloaded from informahealthcare.com by University of Sydney on 12/29/14 For personal use only.
1. The nurse’s role, or function, in the particular health care setting. 2. The purpose of the assessment. 3. The type and intensity of the problem the client is experiencing.
Figure 1. The nursing process. While good nurses have used some parts of the nursing process to some extent in the past, it has rarely if ever been used systematically, completely, explicitly and documented.
Stage 1. Assessment This involves the gathering of information about the patient by interviewing techniques, systematic observation, reviewing the patients’ records and talking to other members of the health care team. One of the best methods of gathering information is by planned conversation with the patient, shortly after admission to the hospital. This may follow a fairly brief outline of the kind of information the nurse needs to know in order to care for her patient, or it may consist of pre-written questions. which the nurse uses as the conversation develops. The emphasis is on flexibility and the astuteness of the nurse making the assessment. She will also note carefully any changes in the patient’s physical or mental condition. Sometimes this may be done during a deliberate examination or more appropriately during nursing care. In the past, information about a patient was collected on an informal basis in a haphazard manner by nurses who usually kept much of the information in their heads and failed to pass the details on to others in the nursing team. Now the nurse making the assessment is encouraged to follow an agreed format, recording the results carefully in the nursing records. We teach this approach by several methods, one of the most popular involving the learner accompanying a skilled nurse at an interview and then discussing the event afterwards. With the use of a written teaching aid, highlighting the kind of patient information required, the learner also has some idea of the type of questions she may ask. For example, the teaching aid asks the learner certain questions about the 88
For example for many patients admitted to hospital or needing prolonged care at home it may be necessary to gather detailed information about the patient’s daily living activities, his work and home environment, ways in which these affect or are affected by the person’s health and/or disabilities, and relevant strengths, weaknesses, feeling and reactions and coping strategies, This would all be the basis for defining nursing problems/needs for nursing care, and planning effectively. However, for short-term care less information may be needed. It is hardly necessary to collect full information on eating habits from a person admitted for a few hours for dental extraction- unless there is some specific indication. An outline of the criteria which are used in one approach is included in Figure 2. The final part of making an assessment involves the statement of the patient’s problems. This often causes difficulties for nurses who become confused as to the difference between the patient’s medical problem and his need for nursing care. A nursing problem can be defined as any condition or situation in which a patient requires nursing assistance or help to attain, maintain, or regain a state of health which is desirable for him, or to achieve a peaceful death. For example, if a patient has a chest infection, what is it about his chest infection which causes him to have difficulty? Is the difficulty in coughing up sputum, reluctance to take a high fluid diet, or perhaps difficulty in breathing unless sitting upright? When stating the patient’s problem the learner is encouraged to state what she thinks is the cause. Problem identification is not easy and requires practice in the classroom as well as in the clinical situation. One helpful exercise is to present a learner with the assessment details of a patient and then encourage her to identify the problems.
Stage 2 . Planning Once the patient’s problems have been identified the next stage is to consider the methods and techniques necessary to meet these problems. This involves writing out a brief, concise and precise care plan for the patient. This is generally organized under the following headings: Patients nursing problem- the patient’s problem as identified by the nurse on consultation with the patient following a nursing assessment. Date identified- the date the nurse has identified the patient’s problem.
Medical Teacher V o l 3 No 3 1981
If possible the patient will also be closely consulted about the nurse’s plans of action.
Med Teach Downloaded from informahealthcare.com by University of Sydney on 12/29/14 For personal use only.
Written plans of action should, where possible, be based on scientific rationale and nursing research findings. It is a helpful exercise to include a column headed ‘Rationale for Nursing Action’, for learners, especiallywhen they are writing their nursing care studies in the classroom. Wherever possible, the nurse’s actions relating to the patient’s problems should be written in terms of staff behaviour and what the staff will do or help the patient to do. Writing objectives for the intended results of nursing actions also requires practice, and exercises constructed in the classroom can help. On one ward we changed the heading on the care plan from ‘Objective’,to ‘Expected Outcome’. This helped many learners get over the difficulty of deciding what was a goal and what was an objective. ‘Desired Outcome’ may be preferred, as sometimes a particular outcome may be planned and hoped for, but not necessarily expected. Standard nursing care plans may be developed (Mayers 1978) and used, for example, in the preoperative preparation of patients. “A standard care plan is a protocol for care that is likely to be applicable to most patients of a certain diagnostic or other category” (Mayers 1978). There is a danger, however, that standard nursing care plans will become the norm and used instead of individually created plans of patient care. It is important therefore to review and update them regularly, evaluating the patient’s involvement and individual needs. If this is not done there is a danger that nursing could be defined in terms of “what nurses did rather than in the areas of health problems they were prepared to identify and manage. Taking the initiative and creative thinking usually were not considered a part of the nursing role” (Carnevali 1979). The whole emphasis should be on planning nursing care to meet the needs of each individual person, although each nurse usually cares for several people.
Stage III. Implementation
Figure 2. A n example of criteria used f o r gathering information about the patient. Objective to be reached by specified date/time-the objective the nurse is hoping the patient will achieve by a certain date and time. Achievement of this objective may not solve the overall problem but will go some way towards this. For example, the patient’s overall problem may be that he cannot walk unaided, and the first objective is to get him to take one or two steps on his own without any form of aid. Plan of nursing invention-the proposed nursing care which the nurse feels is most appropriate for the patient. Medical Teacher Vol3 No 3 1981
Implementation basically means carrying out the nursing care plan. There should be some facility available for the nurse who is working with the patient to comment and report on the patient’s progress. Information should be sought regarding the patient’s subjective feelings about his progress plus the nurse’s critical, objective observations. Careful reporting back to all those involved in caring for the patient helps provide a continuity of evaluation and continuity of care. One method we have found helpful is to allocate a learner to a trained member of staff whose responsibility it is to work with the learner and one or more patients, regularly up-dating the nursing records. Teacher and learner therefore work very closely together, with the trained nurse taking overall responsibility, but with each continuing patient care while the other is off duty. On a ward with a slower turn-over of patients, this system works very well. In other situations the ward sister would have to control carefully the allocation and daily assign89
ment of her nurses to patients. Team nursing may help where at least one member of, say, a team of four would be on duty and able to provide some form of continuity of patient care. It is important, however, which ever team member is available that she gives the report on that particular patient.
Med Teach Downloaded from informahealthcare.com by University of Sydney on 12/29/14 For personal use only.
Stage ZV. Evaluation Recorded evaluation is an important part of the documentation of nursing care. Often in practice it consists of on-going progress notes which are related (by numbers or other means) to the individual problems identified. The record should show the patient’s response to nursing care and indicate whether each problem is solved, or progress towards solution is evident, or progress is unsatisfactory. It therefore provides the basis for decisions on continuing or modifying the care plan, or may indicate the need to redefine the problems. Sometimes, particularly with long-stay patients, nurses like to have dated evaluations recorded intermittently alongside the care plan, or on a separate sheet so that it is easy to see a summary of progress. There are five major sources of data which are available for evaluating nursing care:
Direct observation in which the nurse reports very carefully what she either sees, hears, touches, smells or tastes. Nurse learners can be encouraged to observe certain activities going on in a given clinical situation, then to report back their findings. The end product of nursing intervention can be carefully analysed. For example, what is the state of a patient’s pressure sore now that the nurse has finished her course of planned treatment? Examination of the nursing records to see if the proposed outcomes of nursing care were achieved or not. The reports made by other people, especially patients, about nursing care are another helpful source of information. Reports made by nursing staff themselves are an important source of data about the quality of nursing care that they feel they have achieved. The use of a nursing audit may help to streamline the evaluation of the whole of the nursing process so that on discharge or transfer of a patient to another situation a random selection of patients’ nursing care records could be carefully reviewed and evaluated to see if the proper information was gathered. If it was used, were the correct needs identified? Was the plan of care communicated to the staff on a 24-hour basis? Were short-term and long-term goals achieved? Was there evidence that the care was individualized and how smooth was the transfer? Teaching the Nursing Process The nursing process should not be taught in isolation as an academic exercise in a school of nursing. The way to teach nursing using this approach is by integrating the concept into the delivery of nursing care on one or more wards or in an individual’s home. This requires from the 90
trained staff commitment to using the nursing process approach in practice. It may require considerable changes which may not be easy for those who have been taught and have practised in more traditional ways. Change should be introduced gradually, perhaps initially encouraging nurses to improve their present report and record writing, along the lines of stating the patient’s needs or problems. Nurse/patient allocation is another important step towards using this approach in nursing care. This can be achieved on a daily or longer-term basis by allocating the nurses to groups of patients and encouraging them to be responsible and accountable for their patients’ daily plans of care. Some aspect of a patient’s care may have to be fulfilled by a more experienced member of the ward team, for example patient counselling, but the learner can still be involved as an interested observer. Consequences of using the Nursing Process Approach In some settings nurses are now starting to present their findings and conclusions about patients in a more confident and thoughtful manner. By using the nursing process they are becoming more objective in their contributions to discussions and decisions. Case conferences and ward rounds are more eventful and rewarding for nurses because they feel they have a more positive contribution to make. “Nurses are communicating their belief that nursing care is significant and complex, that it can be highly important to patient well-being and that consumers deserve as good nursing care as medical, dental, or other types of health care. Good care is not equated with haphazard, unplanned care. Therefore planning is emerging as critical thinking and decisionmaking behaviour necessary to nursing’s professional integrity rather than busy work done at the demand of others” (Carnevali 1979). Some of the benefits expressed by students using this approach in their nursing care are: ‘achievement’ and a ‘greater sense of job satisfaction’, ‘get to know more about our patients’, ‘improves interpersonal relations’ and ‘makes one feel one is making a more significant contribution to the health care team and patient care’. It has been suggested that “nothing could be more helpful to nurses than collecting and studying clinical nursing plans used for their patients” (Henderson and Nite 1978). Certainly, this appears to be helpful both in learning and improving nursing practice. Conclusion Wells (1980) sums up the problems facing nursing today when she says: “The central problem in geriatric nursing is the central problem in all of nursing: nurses do not know why they do what they do. It is not helpful to anyone if nurses base their work on principles of trial and error, custom and habit. Training has encouraged nurses to perform ritualistic routines without thinking of the effect of such routines on patient care. Nurses have not been taught how to identify problems in patient care, how to take Medical Teacher Yo13 No 3 1981
action to solve such problems, or how to evaluate the effects of nursing action. To do this nurses must be educated in problem-solving techniques, and focused on the patient” (Wells 1980). Using the nursing process approach appears to have a double advantage: the benefits to patients seem to include not only more effectively planned care, but also happier nurses who remain longer in practice and thus contribute to continuity and high quality care. Something which seems to benefit both nurses and patients/ clients must be worth trying.
Med Teach Downloaded from informahealthcare.com by University of Sydney on 12/29/14 For personal use only.
References Annandale-Steiner, D., Unhappiness is the nurse who expected more, Nursing Mirror, 1979, 149, No. 22, 34-36. Carnevali, D., Nursing care planning in profession practice, in Current Perspectives in Nursing Management, Ed. A . Marriner, C . V. Mosby, London, 1979. Hall, D. C., A Position Paper on Nursing, Euro/Nurs/75.1. Rev. l . , World Health Organization, March 1979. Hawkins, K., Why I’m giving up nursing, Nursing Mirror, 1979, 149, No. 21, 10. Henderson, V. and Nite, G . , Principles and Practice of Nursing (6th edn), Collier and MacMillan, West Drayton, Middlesex, 1978. Mayers, M. C . , A Sytematic Approach to the Nursing Care Plan (2nd edn), Appleton-Century-Crofts, New York, 1978. Wells, T. J., Problems in Genutric Nursing Care, Churchill Livingstone, Edinburgh/London/New York, 1980.
Microelectronics in Education The application of microelectronics in educational support of health systems, was the subject of an informal meeting organized by the World Health Organization and held in September of last year. Copies of the report of the meeting (unpublished WHO document HMD/80.4), describing the ways in which microelectronics can be used in education through such devices as gaming, simulation and computer-assisted learning, can be obtained from HMD/ECS, World Health Organization, 1211 Geneva 27, Switzerland.
Courses for Medical Teachers The following courses for medical teachers and teachers of other health care workers will be held at the Centre for Medical Education, The University, Dundee, Scotland from 31 August to 18 September, inclusive: 1. Teaching Methods (31 August-4 September) 2. Assessment in Medical Education (7-11 September)
3. The Objective Structured Clinical Examination: A Workshop for Medical and Dental Teachers (10-11 September) 4. Project Work-for those who have attended Course 1 and/or Course 2.
Medical Teacher V o l 3 No 3 1981
MAVIS Medical Audio Visual Aids Information Service Do you teach undergraduate medical students? Do you organize postgraduate meetings? Do you teach nurses and other paramedical staff? Are you thinking of producing your own audio visual programmes? Have you thought of using audiovisual programmes for your own continuing education?
. . . then you might find it useful to have a list of all the audiovisual programmes in your area of interest. In the Medical Audio Visual Aids Information Service we have indexed over 10,000 programmes from approximately 1,000 catalogues obtained from British universities, societies and institutions, pharmaceutical companies and other commercial companies.
If you are interested write for further details to: Veronica F. Barker Senior Information Officer Centre for Medical Education University of Dundee Dundee D D I 4HN Tel: 0382-23181 ext 617 This service has received support from Update Publications Ltd and The Wellcome Foundation L td.
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