NursingProcessNursingProcess

Objectives:Objectives: IntroducethehistoryofnursingprocessIntroducethehistoryofnursingprocess DiscusspurposeofnursingprocessDiscusspurposeofnursingprocess

IncludingphilosophyIncludingphilosophy DiscussnursingmodelsinrelationtoDiscussnursingmodelsinrelationto

assessmentassessment DiscussdefensibledocumentationDiscussdefensibledocumentation CriticismofprocessCriticismofprocess SummarySummary

NursingProcessNursingProcess

n n AssessmentAssessment

n n PlanningPlanning

n n ImplementationImplementation

n n EvaluationEvaluation

TheNursingProcessTheNursingProcessThetermThetermNursingProcessNursingProcesscametotheUKcametotheUK

inthe1970inthe1970sandcametobeunderstoodsandcametobeunderstoodas:as:

n n AformofdocumentationAformofdocumentationn n Asameansoforganisingwork,thatisAsameansoforganisingwork,thatis

patientallocationorprimarynursingpatientallocationorprimarynursingn n AsaneducationaltooltohelpachieveAsaneducationaltooltohelpachieve

patientcentrednursingpatientcentrednursingn n AsaphilosophytohelpnursingattainAsaphilosophytohelpnursingattain

professionalstatusbyofferinganprofessionalstatusbyofferinganalternativetothemedicalmodel.alternativetothemedicalmodel.

ThenursingprocessisThenursingprocessisAnorganised,Anorganised,systematicanddeliberateapproachsystematicanddeliberateapproachtonursingwiththeaimofimprovingtonursingwiththeaimofimprovingstandardsinnursingcarestandardsinnursingcareRushS,RushS,FergyFergyS&S&WeelsWeelsD(1996)D(1996)

Itusesasystematic,holistic,problemItusesasystematic,holistic,problemsolvingapproachinpartnershipwithsolvingapproachinpartnershipwiththepatientandtheirfamilythepatientandtheirfamily

NursingModelsNursingModelsAllmodelshave4corecomponents,Allmodelshave4corecomponents,n nTheperson,Theperson,n nTheirenvironment,Theirenvironment,n nHealthandHealthandn nNursingNursing(butallhavedifferentemphasis)(butallhavedifferentemphasis)

ThePersonThePersonn nBody(physical/biological)Body(physical/biological)

n nActivitiesofdailylivingActivitiesofdailyliving

n nGeneticmakeGeneticmakeupupgendergender

n nNature/NurtureNature/Nurture

Mind(psychological)Mind(psychological)

n n Healthy,impairedordamagedHealthy,impairedordamagedn n IntellectIntellectn n AttitudesAttitudesn n EffectofillnessEffectofillnessstress,fears,stress,fears,memoriesmemories

n n EmotionalsupportEmotionalsupport

SocialSocialFamilyandfriendsFamilyandfriendsWorkWorkPlayPlayEffectsofillness(e.g.financial)Effectsofillness(e.g.financial)

SpiritSpirit

n n BeliefsystemsaboutthemeaningofBeliefsystemsaboutthemeaningoflife,death,hope,suffering,life,death,hope,suffering,

n n itmayinvolveorganisedreligion,itmayinvolveorganisedreligion,othercustomsorothercustomsorNewageNewagespirituality.spirituality.

EnvironmentEnvironmentHome,neighbours,Home,neighbours,neighbourhood,work,socialneighbourhood,work,socialactivities,town,county,countryactivities,town,county,countryandpoliticalfactorsandpoliticalfactors

HealthHealth

Thecompletestateofphysical,Thecompletestateofphysical,psychologicalandsocialwellpsychologicalandsocialwellbeingbeingWorldWorld

healthorganisation1946healthorganisation1946Healthcarecontinuum(likedtoage)Healthcarecontinuum(likedtoage)OptimumhealthOptimumhealth IllhealthIllhealthIndependenceIndependence DependenceDependenceAdaptationAdaptation MaladaptionMaladaptionSelfSelfcarecare RelianceonothersRelianceonothers

HumanNeedsModel:RoperLoganHumanNeedsModel:RoperLogan&Tierney&TierneysModel(1980)(activitiessModel(1980)(activities

ofdailylivingofdailylivingThisisthemainoneusedinBritainThisisthemainoneusedinBritainandhas5dimensions:andhas5dimensions:

n n Physiological,Physiological,n n psychological,psychological,n n sociosociocultural,cultural,n n politicopoliticoeconomicaleconomicaln n andenvironmental.andenvironmental.

Thereare12activities,someofThereare12activities,someofwhichareessentialsuchasbreathingwhichareessentialsuchasbreathingandothersthatwhichenhancetheandothersthatwhichenhancethequalityoflife.qualityoflife.

Itshouldbecarriedout:Itshouldbecarriedout:n n ByorunderthesupervisionoftheByorunderthesupervisionoftheNamedNurseNamedNurse

n n WiththeagreementandcoWiththeagreementandcooperationofthepatientoperationofthepatient

n n BeevidencebasedandfollowBeevidencebasedandfollowNationalandTrustPolicyandNationalandTrustPolicyandguidelinesguidelines

n n MustusetheMustusetheNMCNMCssStandardsforStandardsforrecordkeepingrecordkeepingandandCodeofCodeofprofessionalconductprofessionalconduct

ThepurposeofcareplanningThepurposeofcareplanningn n ItisalegaldocumentItisalegaldocumentn n ShowsaccountabilityShowsaccountabilityThecareplanThecareplanisadocumentthatidentifiesthecareisadocumentthatidentifiesthecaretobegiven,andarecordthatshowstobegiven,andarecordthatshowswhoplannedandgavethatcarewhoplannedandgavethatcare

n n ItshouldguidetheworkofothersItshouldguidetheworkofothersandbeabasisforcontinuityofcareandbeabasisforcontinuityofcare

n n ShouldshowalogicalandsystematicShouldshowalogicalandsystematicflowofideasthroughfromtheinitialflowofideasthroughfromtheinitialassessmenttothefinalevaluationassessmenttothefinalevaluation

AssessmentAssessmentWhatcomponentsareneededforasuccessfulassessmentWhatcomponentsareneededforasuccessfulassessmentn n GoodcommunicationGoodcommunicationn n AsystematicapproachtodatacollectionAsystematicapproachtodatacollectionn n InterpretationInterpretationbasedonnursingknowledgebasedonnursingknowledgeObjective(scientificQuantitative)Objective(scientificQuantitative)n n EmpiricsEmpiricsmeasurementofknowledgewithmeasurementofknowledgewith

scientificfactscientificfactSubjective(Art,Qualitative)Subjective(Art,Qualitative)n n AestheticsAestheticsgainedthroughempathyandishowagainedthroughempathyandishowa

nursebecomessensitivetoapatientnursebecomessensitivetoapatientspain,spain,worryorjoyworryorjoy

n n EthicsEthicsconcernedwithmotivation,morality,concernedwithmotivation,morality,humanrightsandlawhumanrightsandlaw

n n PersonalknowledgePersonalknowledgeawarenessthatthenurseawarenessthatthenursehasanimpactonpatientcarehasanimpactonpatientcare

SourcesofDataSourcesofData1.1. NonverbalobservationNonverbalobservation

n n SightSightPhysical,psychological(andsocial)Physical,psychological(andsocial)n n TouchTouchSkintemp,hydration,pulse/BPSkintemp,hydration,pulse/BPn n SoundSoundBreathBreathwheeze,wheeze,stridorstridorn n SmellSmellbreathbodyfluidsinfections,gangrenebreathbodyfluidsinfections,gangrene

2.2.VerbalCommunicationVerbalCommunicationn n Patients/clientsPatients/clientsn n Familyandfriends(Meaningfulothers)Familyandfriends(Meaningfulothers)n n NursingcolleaguesNursingcolleaguesn n MedicalcolleaguesMedicalcolleaguesn n OthermembersofmultidisciplinaryteamOthermembersofmultidisciplinaryteam

3.3.WrittenrecordsWrittenrecordsn n G.PLetterG.PLettern n TransferletterTransferlettern n OldnotesOldnotes

CommunicationCommunicationWhyaregoodcommunicationskillsrequired?Whyaregoodcommunicationskillsrequired?n n ToestablishandmaintainarelationshipwithToestablishandmaintainarelationshipwith

patientsandtheirfamiliespatientsandtheirfamiliesn n ToencouragepatientstodescribeallrelevantToencouragepatientstodescribeallrelevant

aspectsoftheirproblemsaspectsoftheirproblemsn n TogetandgiveaccurateinformationTogetandgiveaccurateinformationn n TousetimeandopportunityeffectivelyTousetimeandopportunityeffectivelyn n ToimprovepatientsatisfactionwiththecareToimprovepatientsatisfactionwiththecare

givengivenn n ToimprovethrustandcooperationwiththecareToimprovethrustandcooperationwiththecaren n ToreducenegativeemotionsandfearToreducenegativeemotionsandfear

GuidetoasuccessfulassessmentGuidetoasuccessfulassessmentn n PrepareadequatelyPrepareadequatelyn n IntroduceyourselfIntroduceyourselfpreparepatientpreparepatientn n UsenonUsenonverbalcommunicationverbalcommunicationn n BecourteousBecourteousn n Usesensitivity,compassionandempathyUsesensitivity,compassionandempathyn n Usefocusedquestions(openedandUsefocusedquestions(openedand

closed)closed)n n ListenListenn n ClarifyClarifyn n SummarisewhattheydescribeSummarisewhattheydescriben n MakenotesMakenotesn n reflectreflect

PlanningPlanningEffectiveplanningdependsonthequalityEffectiveplanningdependsonthequality

andcomprehensivenessoftheassessmentandcomprehensivenessoftheassessmentn n DeterminetheproblemsDeterminetheproblemsn n EstablishtherisksandprioritiesEstablishtherisksandprioritiesHowillHowill

arethey?arethey?n n Cantheybreathadequately(safeairway?)Cantheybreathadequately(safeairway?)n n Aretheyinpain?(physical/psychological)Aretheyinpain?(physical/psychological)n n Cantheymaintainasafeenvironment?IfCantheymaintainasafeenvironment?If

notwhynot?(Drugs,drink,mentalornotwhynot?(Drugs,drink,mentalorpsychologicalproblem?)psychologicalproblem?)

n n NonNoncompliancewithmedicaladvicecompliancewithmedicaladvice

Writingacareplan(s)Writingacareplan(s)ThinkaboutThinkaboutn n Whoisitfor?(ThepatientandothermembersofWhoisitfor?(Thepatientandothermembersof

nursingteam)nursingteam)n n WhataretheshortWhataretheshorttermandlongtermgoals?termandlongtermgoals?n n HowcanyoudeterminethatyouhavereachedHowcanyoudeterminethatyouhavereached

thegoals?(measurable)thegoals?(measurable)n n Howwillthepatientknowhe/shehasachievedHowwillthepatientknowhe/shehasachieved

thegoals?(realistic)thegoals?(realistic)n n Whoisinvolvedinthedeliveryofthecare?(TheWhoisinvolvedinthedeliveryofthecare?(The

patient(andfamily),yourself,thenursingteam,patient(andfamily),yourself,thenursingteam,medicalstaff,multidisciplinaryteam,labs,medicalstaff,multidisciplinaryteam,labs,investigations,proceduresetc)investigations,proceduresetc)

n n HowquicklyistheproblemlikelytochangeHowquicklyistheproblemlikelytochangeHowHowsoonwillyouneedtoresoonwillyouneedtoreevaluatetheplan?evaluatetheplan?

n n HowmanyproblemsarethereHowmanyproblemsarethereWhichorderofpriority?Whichorderofpriority?

n n HowcanyouprovethattheyareHowcanyouprovethattheyareevidencebased(whatresourcesdoevidencebased(whatresourcesdoyouneed?)(corecareplansVsyouneed?)(corecareplansVsindividualisedones)individualisedones)

ImplementingImplementinga)a) Atthestartoftheshift,duringhandoverandAtthestartoftheshift,duringhandoverand

whenyoufirstmeetthem,thinkaboutwhetherwhenyoufirstmeetthem,thinkaboutwhethertheoralreportmatchesthepatientsactualtheoralreportmatchesthepatientsactualconditioncondition

b)b) ComparethistowhatyoualreadyknowoftheComparethistowhatyoualreadyknowofthepatientandtotheexistingcareplanspatientandtotheexistingcareplans

c)c) HasanythingchangedforbetterorworseHasanythingchangedforbetterorworsed)d) Decide:Decide:WhataretheprioritiesforlookingafterthisWhataretheprioritiesforlookingafterthis

patient?patient? Istheirconditionstable?WhatobservationsIstheirconditionstable?Whatobservations

needdoingneeddoinghowoftenhowoften Aretheygoingoffthewardtests/investigations/Aretheygoingoffthewardtests/investigations/

operationsoperations Aretheybeingdischarged?WhenaretheyAretheybeingdischarged?Whenarethey

going?Iseverythingready?going?Iseverythingready?

RepeatthisRepeatthisprocessforalltheprocessforallthepatientsyouarelookingafter.patientsyouarelookingafter.

f)f) WhatroutineworkmustbedoneandWhatroutineworkmustbedoneandwhenshouldthisbedonewhenshouldthisbedone

g)g) WhoisgoingtodothisworkWhoisgoingtodothisworkareyouonareyouonyourownordoyouhaveaClinicalyourownordoyouhaveaClinicalsupportworkerwithyou?Howwilltheysupportworkerwithyou?Howwilltheygiveyoufeedback?giveyoufeedback?

h)h) WhoisavailabletogiveyouhelporWhoisavailabletogiveyouhelporadviceifneeded?(seniornurseadviceifneeded?(seniornursemedicalmedicalteam)team)

i)i) HowareyougoingtoorganisetheworkHowareyougoingtoorganisetheworkTIMEMANAGEMENTTIMEMANAGEMENT

j)j) Whatresourcesdoyouneed?Whatresourcesdoyouneed?

Evaluation.Evaluation.n n MENTALMENTALOngoingthroughoutOngoingthroughout

implementationimplementation

n n WRITTEN(thisshouldpreferablybedoneWRITTEN(thisshouldpreferablybedonewiththepatientpresentinordertogetwiththepatientpresentinordertogetaccuratefeedback)accuratefeedback)

n n Mustbecarriedoutatleasttwicein24hoursMustbecarriedoutatleasttwicein24hoursn n Andwheneveranyincidentoccurs.(date,timeAndwheneveranyincidentoccurs.(date,timesignature)signature)

n n WriteageneralstatementaboutpatientWriteageneralstatementaboutpatientsconditionscondition(better,same,worse)(better,same,worse)

n n EvaluateeachcareplaninturnandbynumberEvaluateeachcareplaninturnandbynumber

n n PersonalisePersonaliseusepatientusepatientsownwordssownwordsappropriateappropriate

n n StatewhatcareyouhavegivenStatewhatcareyouhavegivenCareofCareofplannedplannedoranyvariation/commente.g.oranyvariation/commente.g.pressureareacaregivenskinslightlyredpressureareacaregivenskinslightlyredononsacrumsacrum

n n AmendthecareplanifcircumstancesAmendthecareplanifcircumstanceshavechangedhavechanged

n n DiscontinuecareplansiftheDiscontinuecareplansifthegoal(sgoal(s)have)havebeenreachedbeenreached

n n LegallyLegallyifthecaregivenhasnotbeenifthecaregivenhasnotbeenrecordedthanithasnrecordedthanithasntoccurred!toccurred!

Criticismsofthenursingprocess&Criticismsofthenursingprocess&RoperLogan&TierneyRoperLogan&TierneysModelsModel

AssessmentAssessmentn n ItisonlyaItisonlyasnapshotsnapshotandisoftennotreferredandisoftennotreferred

toaftertheinitialassessmentorupdatedtoaftertheinitialassessmentorupdatedn n ThereisthedangerofaThereisthedangerofareductionistreductionistapproachapproach

inwhichpatientsaremadetoinwhichpatientsaremadetofitfitintotheboxesintotheboxesratherthanallowingflexibilityratherthanallowingflexibility

n n ItisonlyoneamongseveralnursingassessmentItisonlyoneamongseveralnursingassessmenttools(tools(waterlowwaterlow,moving&handling,nutrition,,moving&handling,nutrition,painetc)inadditiontoothermedical.painetc)inadditiontoothermedical.ParamedicalrecordsParamedicalrecords

n n PatientsmaylieorconcealPatientsmaylieorconcealincriminatingincriminatingororembarrassinginformationembarrassinginformation

n n Psychological,sexual,spiritualorissuesPsychological,sexual,spiritualorissuessurroundingdeathmaynotbementionedsurroundingdeathmaynotbementioned

PlanningandGivingCarePlanningandGivingCaren n ThepatientThepatientsmaynotbeconsulted,smaynotbeconsulted,

empoweredtocooperate,orempoweredtocooperate,orcomplientcomplientinintheircaretheircare

n n WithincreasingskillmixWithincreasingskillmixCSWCSWssnownowprovidemostofthephysicalcare,Buttheprovidemostofthephysicalcare,Buttheoftenhavenotbeentaught(orexpected)oftenhavenotbeentaught(orexpected)toreadcareplans,maynotreportbacktoreadcareplans,maynotreportback(orrealisethesignificanceof)changesto(orrealisethesignificanceof)changestotheRNwhoiswritingtheevaluationandtheRNwhoiswritingtheevaluationandmayormaynotdocumentthecaretheymayormaynotdocumentthecaretheyhavegivenhavegiven

n n PatientcareisfragmentedPatientcareisfragmentedtasknursingtasknursingratherthanholisticnursingratherthanholisticnursing

EvaluationEvaluationn n ThereisnotenoughtimeThereisnotenoughtimen n ItisjustpaperworkthattakesnursesItisjustpaperworkthattakesnurses

awayfromhandsawayfromhandsononcarecaren n Wearebadatreading:socareplansareWearebadatreading:socareplansare

notconsultednotconsultednursesrelyonverbalnursesrelyonverbalhandoversandtheirnotes.(Butthesearehandoversandtheirnotes.(Buttheseareonlyasgoodastheindividualsmemoryonlyasgoodastheindividualsmemoryandcontinuityofcareandcontinuityofcare

n n EvaluationtendstoconcentrateonEvaluationtendstoconcentrateonobjectivemeasurableactivityobjectivemeasurableactivityitmaynotitmaynotbeappropriatetodescribebeappropriatetodescribetherapeutictherapeuticcareinterventionsorsetmeasurablegoalscareinterventionsorsetmeasurablegoals

OtherModelsOtherModelsTheseincludeTheseincluden n Nightingale(1859)Nightingale(1859)n n MedicalmodelMedicalmodeln n Henderson(1966)Henderson(1966)n n Systemsmodel:usedinUSASystemsmodel:usedinUSAn n DevelopmentmodelsDevelopmentmodelsn n MaslowMaslow(1970)(1970)HierarchyofneedsHierarchyofneedsn n BurfordBurfordNursingDevelopmentUnitNursingDevelopmentUnit

? ? Any Any

Questions Questions

FurtherReading:FurtherReading:BowmanG.S,ThompsonD&BowmanG.S,ThompsonD&SuttinSuttinT(1983)T(1983)NursesattitudesNursesattitudes

towardsthenursingprocesstowardsthenursingprocessJournalofAdvancedNursingJournalofAdvancedNursing8(2)p.1258(2)p.125129129

BradenS(1998)BradenS(1998)Evaluatingnursinginterventions:AtheoryEvaluatingnursinginterventions:AtheorydrivenapproachdrivenapproachSagepublicationsLondonSagepublicationsLondon

CohenE,CohenE,GestaGestaT(2001)T(2001)NursingcasemanagementfromNursingcasemanagementfromessentialtoadvancedpracticeapplicationessentialtoadvancedpracticeapplication3rdedition3rdeditionMosbyMosbyUSAUSA

FaulknerA(2000)FaulknerA(2000)Nursing:ThereflectiveapproachtoadultNursing:Thereflectiveapproachtoadultpracticepractice2ndEdition2ndEditionBailliereBailliereTindallTindallCheltenhamCheltenham

HincliffHincliffS,NormanS,S,NormanS,SchoberSchoberJ(1998)J(1998)NursingpracticeandNursingpracticeandhealthcare:Afoundationtexthealthcare:Afoundationtext 3rdeditionArnoldOxford3rdeditionArnoldOxford

n n KowalakKowalakJ&HughesAetal(2002)J&HughesAetal(2002)BestpracticesBestpracticesaguidetoexcellenceinnursingcareaguidetoexcellenceinnursingcareLippincottLippincottWilliams&Williams&WlikinsWlikins

n n LeahyJ,LeahyJ,KizilayKizilayP(1998)P(1998)FoundtionsFoundtionsofnursingofnursingpractice:Anursingprocessapproachpractice:AnursingprocessapproachSaundersSaundersPhiladelphiaPhiladelphia

n n LittlejohnC,(2002)LittlejohnC,(2002)ArenursingmodelstoblameArenursingmodelstoblameforlowmorale?forlowmorale?NursingStandardNursingStandardVolVol16(17)16(17)p.39p.394141

n n MasonC(1999)MasonC(1999)GuidetopracticeorGuidetopracticeorloadofloadofrubbishrubbish?Theinfluenceofcareplansonnursing?TheinfluenceofcareplansonnursingpracticeinfiveclinicalareasinNorthernIrelandpracticeinfiveclinicalareasinNorthernIrelandJournalofAdvancedNursingJournalofAdvancedNursingVolVol29(2)P.38029(2)P.380387387

RoperW,LoganW,&TierneyA(1990)RoperW,LoganW,&TierneyA(1990)TheelementsofnursingbasedonaTheelementsofnursingbasedonamodeloflivingmodelofliving3rdeditionChurchill,3rdeditionChurchill,LivingstonLondonLivingstonLondon

SwashM(2002)SwashM(2002)HutchinsonHutchinsonsclinicalsclinicalmethodsmethods21steditionSaunders21steditionSaundersEdiburghEdiburgh

WalshM(2001)WalshM(2001)ModelsandcriticalModelsandcriticalpathwaysinclinicalnursingpathwaysinclinicalnursingBailliereBailliereTindallTindallCheltenhamCheltenham