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Understanding the nursing process Stonehouse, DP

10.12968/bjha.2017.11.8.388

Title Understanding the nursing process

Authors Stonehouse, DP

Type Article

URL This version is available at: http://usir.salford.ac.uk/46573/

Published Date 2017

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Nursing Process or Process of Care: Understanding the Nursing Process.

David Stonehouse is a Lecturer with the School of Nursing and Midwifery at Queens

University Belfast.

Abstract.

Support workers work closely with their patients and members of the multidisciplinary

team to deliver high quality care. Often this care will have been planned by a nurse

using the nursing process. It is therefore important for the support worker to

understand how the patient has been assessed and the care they are providing has

been planned. Within this article the author will be discussing the nursing process,

explaining the different stages and how these are utilised to deliver quality care.

Relevant sections of The Code of Conduct for Healthcare Support Workers and

Adult Social Care Workers in England (Skills for Care and Skills for Health, 2013) will

be highlighted. Support worker have a clear and important role in making sure the

nursing process is successful and patients receive the best quality care.

Key Words: Assessment, Evaluation, Implementation, Nursing Diagnosis, Nursing

Process, Planning, Support Workers.

Introduction

Historically the medical model was used, whereby a diagnosis was made by a doctor

and care was prescribed based on physical symptoms alone (Hamilton and Price,

2013). This ignored the holistic needs of the patient. To develop more of a problem

solving focus to nursing care (Melin-Johansson et al, 2017) the nursing process was

proposed by Yura and Walsh in 1967. It is seen as a “decision making approach that

promotes critical thinking” (Yildirim and Ozkahraman, 2011:261). It comprises a

cyclical process of four stages which are known as assessment, planning,

implementation and evaluation. A fifth stage has subsequently been added coming

immediately after assessment, namely nursing diagnosis (American Nurses

Association, 2017).

Even though the initial assessment and planning will often be performed by a nurse,

the support worker will be involved in all aspects. They will often be the person who

then implements the planned care and evaluates its appropriateness and success as

care is delivered. Ongoing assessment takes place and the support worker will be

closely involved in this. A more accurate name for the nursing process today could

be the Caring Process which would incorporate all members of the multidisciplinary

team involved in the care of the patient.

Code Words.

Within The Code of Conduct for Healthcare Support Workers and Adult Social Care

Workers in England (Skills for Care and Skills for Health, 2013), section 3.2 states

that you must “recognise and respect the roles and expertise of your colleagues both

in the team and from other agencies and disciplines, and work in partnership with

them.” By having an awareness and understanding of the nursing process allows

you to recognise and respect the role that the nurse is playing in planning care for

your patients. It also allows you to recognise the valuable contribution you make to

the nursing process. Section 6.6 states you must “actively encourage the delivery of

high quality healthcare, care and support.” Through the nursing process the patient’s

needs can be assessed, care planned and delivered and then evaluated, thereby

ensuring quality care is delivered. Section 4.2 states you must “communicate

effectively and consult with your colleagues as appropriate.” Through having

awareness of the nursing process enables you to discuss with your nursing

colleagues which care has been planned and why and what outcomes are trying to

be achieved.

Assessment

This is the first stage of the nursing process. It involves the collection of information

from the patient and their family/carers concerning their condition and perceived

problems. Hamilton and Price (2013) state that this is the cornerstone in establishing

the needs of the patient and if done well, the nursing process will be a success.

Information can be collected in a number of ways and the support worker will take an

active part in this. Good communication, both verbal and non-verbal, together with

observational skills are key.

Information gathered can be either subjective or objective, and primary or secondary

(Kozier et al, 2008). Subjective is information that the patient tells you, how they are

feeling, levels and sensation of pain. This is open to interpretation, however you

must always accept what the patient is telling you. Objective information is that which

can be measured such as blood pressure or weight. Primary information is that

which is gained from the patient themselves whereas secondary data is information

from other sources, such as family members.

Even before the nurse or support worker has seen the patient there will often be

existing notes to read or a handover to receive. This initial information will help to

guide the first stages and should give the nurse a starting point on how to approach

the patient. Identifying any communication needs and recognising if any special

adjustments need to be made. Of course in certain situations this is not always

possible, where a patient is admitted urgently to the accident and emergency

department and care must commence immediately, an initial short term assessment

will be made (Hamilton and Price, 2013).

The next part of the assessment takes place even before any words are spoken. As

you approach the patient you will be observing them and looking for any outward

signs, both positive and negative. This can be done very quickly on first seeing the

patient. Do they look in pain, do they appear to be pale or clammy? Are they

conscious and sitting up, or appear unconscious?

An assessment of the patient’s airway, breathing and circulation needs to be

performed immediately. Once these three areas have been assessed as being

stable, then the more formal assessment can take place. Observations are taken to

gain a baseline and again to identify anything abnormal which may need urgent

intervention. Pulse, respirations, blood pressure, oxygen saturations, capillary refill

time and anything else which is relevant to the patients presenting problems. These

are all recorded to be repeated and compared.

General information is gathered together with a thorough health history (Kozier et al,

2008). This includes exactly how the patient is presenting at this moment in time.

What symptoms are they describing to you? Other important questions are asked

such as is the patient allergic to anything. Models of nursing care will be used as a

tool to guide this process. These will already be established within the working

environment and form a basis for the documentation used.

The focus of the assessment is the patient and how they are experiencing their

illness and ill health. Once all the information has been collected it can be

documented and sorted (Melin-Johansson et al, 2017). Excellent record keeping is

key, so that all the information gathered is recorded and presented in a way that is

accessible to the whole multidisciplinary team.

Nursing Diagnosis

This is an extra stage to the original four and is more wide spread and common in

North America. Here the information gained from the assessment is used to identify

actual and potential problems, as well as strengths (Yildirim and Ozkahraman,

2011). Strengths might be self-caring abilities or independence in certain areas. Or

prior knowledge or experience of the illness. Actual problems are those that come

directly out of the assessment, for example pain from a fracture. Potential problems

are those that could arise from out of the problem, for example the risk of developing

a pressure sore if confined to bed (Hogston, 2011). However Peate (2013) has a

word of warning that the person making the diagnosis must have gained the

sufficient expertise and experience to do so, otherwise this could be potentially

dangerous.

Planning

The planning stage is where interventions are identified to reduce, resolve or prevent

the patient’s problems while supporting the patient’s strengths in an organised goal

directed way (Kozier et al, 2008). Care needs to be prioritised on the needs of the

patient and the seriousness of the problems identified. Hogston (2011) identifies two

steps in the planning stage, setting goals and identifying actions. Goals need to be

set, both short term and long term. SMART goals should be identified which are

Specific, Measurable, Achievable, Realistic and Timely (Hamilton and Price, 2013).

These are all done in collaboration with the patient.

In action planning the actual care that is going to be implemented needs to be clearly

stated. Hogston (2011) advises using the REEPIG criteria to ensure that care is of

the highest standards. Firstly, that the care planned is Realistic given available

resources. Secondly, that the care planned is Explicitly stated. Be clear in exactly

what needs to be done so there is no room for misinterpretation of instructions.

Thirdly, Evidence based. That there is research that supports what is being

proposed. Fourthly, that the care being planned is Prioritised. The most urgent

problems being dealt with first. Fifth, is to Involve both the patient and other

members of the multidisciplinary team who are going to be involved in implementing

the care. And lastly, Goal centred, that the care planned will meet and achieve the

goal set.

Implementation

This is where the care is delivered and more than likely it will be the support worker

who will be delivering the majority of the basic and increasingly, more advanced

care. Especially when the patient is in their own home or a community setting.

Implementation of the care occurs throughout the twenty four hour period. As each

new member of the caring team comes on duty they need to re-assess if the care

being delivered is still appropriate. Has anything new developed to change the plan

of care. How is the patient responding to the care delivered? On-going assessment

of the patient is vital and again this is where good record keeping is important

(Alfaro-LeFevre, 2010).

Evaluation

The most important part of the nursing process after the assessment is done is

evaluating has the care achieved the desired result. This should not just occur at the

end of a course of treatment or care, but should occur constantly as care is being

implimented. Evaluation at the end of a course of treatment involves reassessment

of all the plan of care to determine if the expected outcomes have been achieved

(Yildirim and Ozkahraman, 2011). Hogston (2011:16) also states that evaluation is

an “opportunity to review the entire process and determine whether the assessment

was accurate and complete, the diagnosis correct, the goals realistic and achievable,

and the prescribed actions appropriate.” With evaluation the whole process starts

again.

Issues

To perform a good assessment of a patient takes time and time must be devoted to

this crucial cornerstone. Otherwise the following stages will not have the information

required to deliver quality care. In a study by Abdelkader and Othman (2017:81) it

was found that “lack of knowledge, high patient nurse ratio/work load, and lack of

educating, training and motivating factors affected the application of the nursing

process.” These factors need to be recognised by managers and individual staff so

that sufficient time is devoted to it and knowledge and awareness is raised to the

important part this caring process plays in delivering high quality care.

Conclusion.

So to conclude, this article has highlighted the importance of planning and delivering

care using the nursing process. Support workers need to be aware of the nursing

process and more importantly involved in all stages of it. Having an awareness of

how the assessment has been carried out and what nursing diagnosis has been

reached will make the care more relevant and assist in an effective evaluation stage.

This stage should be performed constantly as care is delivered, with the process

being cyclical in nature, the patient being re-assessed and care improved and

changed to meet the on-going needs of the patient. With care being predominantly

delivered by members of a multidisciplinary team perhaps the new term of a caring

process should be adopted rather than the term nursing process?

Key Points:

1. Support workers are key members of the team in ensuring the success of the

nursing process.

2. Support workers should be involved in all aspects of the nursing process.

3. Care should be planned using SMART goals.

4. Evaluation of care should occur throughout the implementation stage.

5. The term nursing process could be seen as being misleading where Care

Process would be a more accurate term today.

References:

Abdelkader FA, Othman WNE (2017) Factors Affecting Implementation of Nursing

Process: Nurses’ Perspective. Journal of Nursing and Health science. Vol. 6 No. 3.

pp. 76-82.

Alfaro-LeFevre R (2010) Applying Nursing Process: A Tool For Critical Thinking. 7th

ed. Lippincott Williams & Wilkins: Philadelphia.

American Nurses Association (2017) The Nursing Process.

http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-You-

Need/Thenursingprocess.html (accessed 29 June 2017).

Hamilton P & Price T (2013) The Nursing Process, Holistic Assessment and

Baseline Observations. In: Brooker C, Waugh A (eds) Nursing Practice:

Fundamentals of Holistic Care. Mosby Elsevier, London. 303-336.

Hogston R (2011) Managing Nursing Care. In: Foundations of Nursing Practice:

Themes, Concepts and Frameworks. 4th ed. Palgrave Macmillan: London. pp. 2-21.

Kozier B, Erb G, Berman A, Snyder s, Lake R & Harvey S (2008) Fundamentals of

Nursing: Concept, Process and Practice. Pearson Education: London.

Melin-Johansson C, Palmqvist R, Ronnberg L (2017) Clinical Intuition in the Nursing

Process and Decision-making – a Mixed Studies Review. Journal of Clinical Nursing.

pp. 1-14.

Peate I (2013) The Student Nurse Toolkit: An Essential Guide For Surviving Your

Course. Wiley-Blackwell: Chichester.

Skills for Care and Skills for Health (2013) Code of Conduct for Healthcare Support

Workers and Adult Social Care Workers in England.

http://www.skillsforhealth.org.uk/images/services/code-of-

conduct/Code%20of%20Conduct%20Healthcare%20Support.pdf (accessed 29 June

2017).

Yildirim B Ozkahraman S (2011) Critical Thinking in Nursing Process and Education.

International Journal of Humanities and Social Science. Vol. 1 No. 13 pp. 257-262.