Handout Nursing Process

Nursing Process, Nursing Skills, and Clinical Reasoning

Characteristics of the Nursing Process • Systematic — part of an ordered sequence of activities • Dynamic — great interaction and overlapping among the five steps • Interpersonal — human being is always at the heart of nursing • Outcome oriented — nurses and patients work together to identify outcomes • Universally applicable — a framework for all nursing activities

Joannes Paulus T. Hernandez, BS (Human) Biology, BS Nursing, R.N.

The Nursing Process • One of the major guidelines for nursing practice • Helps nurses implement their roles

Characteristics of the Nursing Process (Continued) It is a GOSH approach for efficient and effective provision of nursing care.

• Integrates art and science of nursing • Allows nurses to use critical thinking • Defines the areas of care that are within the domain of nursing • It is a systematic method that directs the nurse and client as they together determine the need for nursing care, plan and implement the care, and evaluate the result.

G – oal-oriented O – rganized S – ystematic H – umanistic care

Historical Development of the Nursing Process • 1955 — nursing process term was first used by Lydia Hall • 1960’s — specific steps delineated • 1967 — Yura and Walsh published first comprehensive book on nursing process • 1973 — ANA Congress for Nursing Practice developed Standard of Practice

Problem solving and the Nursing Process • Trial-and-error problem solving • Scientific problem solving • Intuitive thinking • Critical thinking

• 1982 — state board examinations for professional nursing uses nursing process as organizing concept

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

1

Overview of the Five Steps of the Nursing Process: ASSESSING

Benefits of the Nursing Process • Patient – Scientifically based, holistic individualized patient care – Continuity of care – Clear, efficient, cost-effective plan of action • Nurse – Opportunity to work collaboratively with other healthcare workers – Satisfaction of making a difference in lives of patients – Opportunity to grow professionally

Five Steps of the Nursing Process

Overview of the Five Steps of the Nursing Process: ASSESSING It is the systematic and continuous collection, validation, and communication of client data as compared to standard. •

Activities: 1. Collection of data 2. Validation of data – data confirmation/comparing to standards 3. Organizing data 4. Analyzing data 5. Recording/documentation of data

•

Types of data: 1. Subjective data (symptoms) – described by person experiencing it 2. Objective data (signs) – can be observed and measured

•

Sources of data: 1. Primary Data – data directly gathered from the client 2. Secondary data – data gathered from client’s significant others, client’s medical records, patient’s chart, other members of the health team, and related health care literature

•

Methods of collecting data: 1. Interview – a planned communication with the client 2. Observation – the use of five senses and instruments 3. Physical Assessment – assessment for objective data and is focused primarily on the client’s functional abilities

Assessing is primarily focused on the client’s response to health problem.

Five Steps of the Nursing Process • Assessing — collecting, validating and communicating of patient data • Diagnosing — analyzing patient data to identify patient strengths and problems • Planning — specifying patient outcomes and related nursing interventions • Implementing — carrying out the plan of care

Four Types of Nursing Assessments • Comprehensive initial • Focused • Emergency • Time-lapsed

• Evaluating — measuring extent to which patient achieved outcomes

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

2

Comprehensive Initial Assessment

Time-Lapsed Assessment

• Performed shortly after admittance to hospital

• Performed to compare a patient’s current status to baseline data obtained earlier

• Performed to establish a complete database for problem identification and care planning • Performed by the nurse to collect data on all aspects of patient’s health

• Performed to reassess health status and make necessary revisions in plan of care. • Performed by the nurse to collect data about current health status of patient

Focused Assessment

Establishing Assessment Priorities

• May be performed during initial assessment or as routine ongoing data collection

• Health orientation

• Performed to gather data about a specific problem already identified, or to identify new or overlooked problems

• Developmental stage • Need for nursing

• Performed by the nurse to collect data about the specific problem

Emergency Assessment

Medical vs. Nursing Assessments

• Performed when a physiologic or psychological crisis presents

• Medical assessments

• Performed to identify life-threatening problems • Performed by the nurse to gather data about the lifethreatening problem

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

– Target data pointing to pathologic conditions • Nursing assessments – Focus on the patient’s response to health problems

3

The Skill of Nursing Observation

Successful Interview Techniques

• Determines the patient’s current responses (physical and emotional)

• Focus on the patient during the interview

• Determines the patient’s current ability to manage care • Determines the immediate environment and its safety • Determines the larger environment (hospital or community

• Listen to the patient attentively • Ask about patient’s main problem first • Pose questions and comments in appropriate manner • Avoid comments and question that impede communication • Use silence and touch appropriately

Four Phases of a Nursing Interview

Five Parts of Communication Process (Berlo)

• Preparatory phase

• The stimulus or referent

• Introduction

• The sender or source of message (encoder)

• Working phase

• The message itself

• Termination

• The medium or channel of communication • The receiver

Purpose of a Nursing Physical Assessment

Four Levels of Communication

• Appraisal of health status

• Intrapersonal

• Identification of health problems

• Interpersonal

• Establishment of a database for nursing intervention

• Small-group • Organizational

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

4

Roles of Group Members

The Helping Relationship

• Task-oriented — focus on work to be done

• Does not occur spontaneously

• Maintenance — focus on well-being of people doing work

• Characterized by an unequal sharing of information

• Self-serving — advance the needs of individual members at group’s expense

• Built on the patient’s needs

Forms of Communication

Characteristics of the Helping Relationship

• Verbal (language)

• Dynamic

• Nonverbal (body language)

• Purposeful and time limited

– Facial expressions – Posture, gait

• Person providing assistance is professionally accountable for the outcomes

– Gestures – General physical appearance – Mode of dress and grooming – Sounds – Silence

Factors Influencing Communication

Phases of the Helping Relationship

• Developmental level

• Orientation phase

• Gender

• Working phase

• Sociocultural differences

• Termination phase

• Roles and responsibilities • Space and territoriality • Physical, mental, and emotional state • Environment

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

5

Goals of the Orientation Phase

Factors that Promote Effective Communication

• Establish tone and guidelines for the relationship

• Dispositional traits

• Identify each other by name

• Rapport builders

• Clarify roles of both people • Establish an agreement about the relationship • Provide the patient with orientation to the healthcare system

Goals of the Working Phase

Dispositional Traits

• Work together to meet the patient’s needs

• Warmth and friendliness

• Provide whatever assistance is needed to achieve each goal

• Openness and respect

• Provide teaching and counseling

• Empathy • Honesty, authenticity, trust • Caring • Competence • Genuineness

Rapport Builders Goals of the Termination Phase • Specific objectives • Examine goals of helping relationship for attainment • Make suggestions for future efforts if necessary • Encourage patient to express his or her emotions about the termination

• Comfortable environment • Privacy • Confidentiality • Patient versus task focus • Utilization of nursing observations • Optimal pacing • Providing personal space

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

6

Developing Conversation Skills

Basic Components of Assertiveness

• Control the tone of your voice

• Having empathy

• Be knowledgeable about the topic of conversation

• Describing one’s feelings or the situation

• Be flexible

• Clarifying one’s expectations

• Be clear and concise

• Anticipating consequences

• Avoid words that might have different interpretations • Be truthful • Keep an open mind • Take advantage of available opportunities

Developing Listening Skills • Sit when communicating with a patient.

Blocks to Communication

• Be alert and relaxed and take your time.

• Failure to perceive the patient as a human being

• Keep the conversation as natural as possible. • Maintain eye contact if appropriate. • Use appropriate facial expressions and body gestures. • Think before responding to the patient. • Do not pretend to listen. • Listen for themes in the patient’s comments. • Use silence, therapeutic touch, and humor appropriately.

• Failure to listen • Inappropriate comments and questions • Using clichés • Using closed questions • Using questions containing the words “why” and “how” • Using questions that probe for information

Interviewing Techniques

Blocks to Communication (continued)

• Open-ended questions or comments

• Using leading questions

• Closed questions or comments

• Using comments that give advice

• Validating questions or comments

• Using judgmental comments

• Clarifying questions or comments

• Changing the subject

• Reflective questions or comments

• Giving false assurance

• Sequencing questions or comments

• Using gossip and rumors

• Directing questions or comments

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

7

Type of Questions Used in Interviews

When to Verify Data

• Closed questions — elicit specific information

• When there is a discrepancy between what the person is saying and what the nurse is observing

• Open-ended questions — allow the patient to verbalize freely

• When the data lack objectivity

• Reflective questions — encourage patient to elaborate on thoughts and feelings • Direct questions — validate or clarify information

Sources of Data • Patient • Family and significant others • Patient record • Other healthcare professionals • Nursing and other healthcare literature

Problems Related to Data Collection

Validating Inferences

• Inappropriate organization of the database

• Performing a physical examination using proper equipment and procedure

• Omission of pertinent data • Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data • Failure to establish rapport and partnership

• Using clarifying statements • Sharing inferences with other team members • Checking findings with research reports

• Recording an interpretation of data rather than observed behavior • Failure to update the database

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

8

Overview of the Five Steps of the Nursing Process: DIAGNOSING

Documentation of Data • Enter initial database into computer or record in ink on designated forms the same day patient is admitted. • Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner. • Use good grammar and standard medical abbreviations. • Whenever possible, use patient’s own words. • Avoid non-specific terms subject to individual interpretation or definition.

Overview of the Five Steps of the Nursing Process: DIAGNOSING

Objective Data vs. Subjective Data

•

It is a process which results to Nursing Diagnosis.

•

It is used to identify health care needs and prepare a Nursing Diagnosis.

•

Nursing Diagnosis is a statement of a client’s potential or actual health resulting from analysis of data.

•

Nursing Diagnosis uses PES format:

problem

P – roblem E – tiology

• Objective data – Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them

S – igns and Symptoms •

Activities: 1. Data Clustering 2. Comparing data against standards 3. Data analysis 4. Identify gaps and inconsistencies

– E.g., elevated temperature, skin moisture, vomiting • Subjective data

5. Determine health problems 6. Formulation of Nursing Diagnosis •

Types of Nursing Diagnosis: 1. Actual Nursing Diagnosis – problem is present

– Information perceived only by the affected person

2. Potential Nursing Diagnosis – problem may arise

– E.g., pain experience, feeling dizzy, feeling anxious

4. Wellness Nursing Diagnosis – transition from a specific level of wellness to a higher level of wellness

3. Possible Nursing Diagnosis – problem may be present

Prioritizing nursing diagnosis is based on what problem endagers person’s life.

Purposes of the Diagnosing Step Characteristics of Data • Complete • Factual and accurate • Relevant

• Identify how an individual, group, or community responds to actual or potential health and life processes. • Identify factors that contribute to or cause health problems (etiologies). • Identify resources or strengths the individual, group or community can draw on to prevent or resolve problems.

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

9

Purposes of the Diagnosing Step

Purposes of the Diagnosing Step Types of Diagnoses • Nursing diagnosis – Describes patient problems nurses can treat independently • Medical diagnosis – Describes problems for which the physician directs the primary treatment • Collaborative problems – Managed by using physician-prescribed and nursingprescribed interventions

Nursing Concerns and Responsibilities (Alfaro, 2004) • Monitoring for changes in health status • Promoting safety and preventing harm • Identifying and meeting learning needs • Promoting comfort and managing pain • Promoting health and well-being • Addressing problems that limit independence • Determining human responses

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

10

Four Steps of Data Interpretation and Analysis • Recognizing significant data – Comparing data to standards • Recognizing patterns or clusters • Identifying strengths and problems • Reaching conclusions

Overview of the Five Steps of the Nursing Process: PLANNING

Reaching Conclusions • No problem • Possible problem • Actual or potential nursing diagnosis • Clinical problem other than nursing diagnosis

•

Identifying beforehand the specific actions to be done before implementation of nursing interventions.

•

It is used to determine the goals of care and the course of actions to be undertaken during the implementation phase.

•

Activities: 1. Priority setting 2. Setting goals and objectives: Goals may be short-term or long term; the characteristics of a well-started behavioral objectives are as follows: S – mart M – easurable A – ttainable R – ealistic T – ime-framed 3. Identify alternative nursing care 4. Select nursing measure 5. Formulation of Nursing Care Plan (NCP) The Nursing Care Plan is made mainly as guide to individualize care.

Formulation of Nursing Diagnoses

Goal of Outcome Identification and Planning Step

• Problem — identifies what is unhealthy about patient

• Establish priorities.

• Etiology — identifies factors maintaining the unhealthy state

• Identify and write expected patient outcomes.

• Defining characteristics — identifies the subjective and objective data that signal the existence of a problem

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

• Select evidence-based nursing interventions. • Communicate the plan of care.

11

A Formal Plan of Care Allows the Nurse To:

Three Elements of Comprehensive Planning

• Individualize care that maximizes outcome achievement

• Initial

• Set priorities

• Ongoing

• Facilitate communication among nursing personnel and colleagues

• Discharge

• Promote continuity of high-quality, cost effective care • Coordinate care • Evaluate patient response • Create a record used for evaluation, research, reimbursement and legal reasons • Promote nurse’s professional development

Initial Planning • Developed by the nurse who performs the nursing history and physical assessment • Addresses each problem listed in the prioritized nursing diagnoses • Identifies appropriate patient goals and related nursing care

Ongoing Planning • Carried out by any nurse who interacts with patient • Keeps the plan up to date • States nursing diagnoses more clearly • Develops new diagnoses, • Makes outcomes more realistic and develops new outcomes as needed • Identifies nursing interventions to accomplish patient goals

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

12

Discharge Planning

Long-Term vs. Short-Term Outcomes

• Carried out by the nurse who worked most closely with patient

• Long-term — requires a longer period to be achieved and may be used as discharge goals

• Begins when the patient is admitted for treatment

• Short-term — may be accomplished in a specified period of time

• Uses teaching and counseling skills effectively to ensure home-care behaviors are performed competently

Prioritizing Nursing Diagnoses

Categories of Outcomes

• High priority — greatest threat to patient well-being

• Cognitive — describes increases in patient knowledge or intellectual behaviors

• Medium priority — non-threatening diagnoses • Low priority — diagnoses not specifically related to current health problem

• Psychomotor — describes patient’s achievement of new skills • Affective — describes changes in patient values, beliefs, and attitudes

Maslow’s Hierarchy of Human Needs

Parts of a Measurable Outcome

• Physiologic needs

• Subject

• Safety needs

• Verb

• Love and belonging needs

• Conditions

• Self-esteem needs

• Performance criteria

• Self-actualization needs

• Target time

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

13

Common Errors in Writing Patient Outcomes

Structured Care Methodologies

• Expressing patient outcome as nursing intervention

• Procedure — set of how to action steps

• Using verbs that are not observable or measurable

• Standard of care — description of acceptable level of patient care

• Including more than one patient behavior or manifestation in short-term outcomes

• Algorithm — set of steps used to make a decision

• Writing vague outcomes

• Clinical practice guideline — statement outlining appropriate practice for clinical condition or procedure

Types of Nursing Interventions

Types of Institutional Plans of Care

• Nurse-initiated — actions performed by a nurse without a physician’s order

• Kardex plans of care • Computerized plans of care

• Physician-initiated — actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders

• Case management plans of care

• Collaborative — treatments carried out by a nurse initiated by other providers

• Student plans of care

– Clinical pathways, care maps

• Concept map care plan

Actions Performed in Nurse-Initiated Interventions (Alfaro, 2002)

Problems Related to Outcome Identification and Planning

• Monitor health status

• Failure to involve patient

• Reduce risks

• Insufficient data collection

• Resolve, prevent, or manage a problem

• Nursing diagnoses developed from inaccurate or insufficient data

• Facilitate independence or assist with ADLs • Promote optimum sense of physical, psychological, and spiritual well-being

• Outcomes stated too broadly • Outcomes derived from poorly developed nursing diagnoses • Failure to write nursing order clearly • Nursing orders that do not solve problems • Failure to update the plan of care

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

14

Overview of the Five Steps of the Nursing Process: IMPLEMENTING

Outcomes for “Caregiver Home Readiness” • Willing to assume caregiver role • Knowledge about caregiver role • Demonstration of positive regard for care recipient • Participation in home care decision On-going data collection directs revision of plan of care and interventions.

• Confidence in ability to manage care at home • Knowledge of where to obtain needed equipment

Overview of the Five Steps of the Nursing Process: IMPLEMENTING •

Putting the Nursing Care Plan into action.

•

It is used to carry out the NCP and meet client’s health goals.

•

Requirements for implementation: 1. Therapeutic use of self (TUOS)

Types of Nursing Interventions • Independent nursing actions

2. Knowledge 3. Technical skills 4. Communication skills •

Nurses implement independent (nurse-prescribed), interdependent (collaborative), and dependent (physician’s-prescribed) nursing actions.

On-going data collection directs revision of plan of care and interventions.

– Nurse-initiated interventions • Protocols • Standing orders • Dependent and collaborative nursing actions – Physician-initiated interventions – Collaborative interventions

Advantages of Nursing Interventions Classifications

Implementing the Care Plan

• Standardizing nomenclature

• Organize resources

• Expanding nursing knowledge

• Anticipate unexpected outcomes/situations

• Developing information systems

• Promote self-care: teaching, counseling, advocacy

• Teaching decision making

• Assist patients to meet health outcomes

• Ensuring appropriate reimbursement • Allocating nursing resources • Communicating nursing to non-nurses • Linking nursing content

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

15

Aims of Teaching and Counseling

Teaching Acronym

• Maintaining and promoting health

• T – une into the patient

• Preventing illness

• E – dit patient information

• Restoring health

• A – ct on every teaching moment

• Facilitating coping

• C – larify often • H – onor the patient as partners in the education process

Teaching Outcomes

Factors Affecting Patient Learning

• High-level wellness and related self-care practices

• Age and developmental level

• Disease prevention or early detection

• Family support networks and financial resources

• Quick recovery from trauma or illness

• Language deficits

• Enhanced ability to adjust to developmental life changes

• Literacy level

Focus of Patient Education

Critical Developmental Areas

• Preparation for receiving care

• Physical maturation and abilities

• Preparation before discharge from health care facility

• Psychosocial development

• Documentation of patient education activity

• Cognitive capacity • Emotional maturity • Moral and spiritual development

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

16

Teaching Plans for Older Adults

Three Learning Domains

• Allow extra time

• Cognitive — storing and recalling of new knowledge in the brain

• Plan short teaching sessions • Accommodate for sensory deficits • Reduce environmental distractions

• Psychomotor — learning a physical skill • Affective — changing attitudes, values, and feelings

Cope Model

Key Points to Effective Communication

• C – reativity

• Be sincere and honest.

• O – ptimism

• Avoid too much detail and stick to the basics.

• P – lanning

• Ask for questions.

• E – xpert information

• Be a cheerleader for the patient. • Use simple vocabulary. • Vary the tone of voice. • Keep content clear. • Listen and do not interrupt.

Providing Culturally Competent Patient Education

Sources of Information

• Develop an understanding of the patient’s culture.

• Primary — patient

• Work with multicultural team.

• Secondary — medical records, patient family

• Be aware of personal assumptions, biases, and prejudices. • Understand the core cultural values of the patient or group. • Develop written material in native language of the patient. • Use testimonials of persons with same cultural background as the patient.

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

17

Teaching Strategies Assessment Parameters • Readiness to learn • Ability to learn • Learning strengths

• Lecture • Discussion • Panel discussion • Demonstration • Discovery • Role playing • Audiovisual materials • Printed materials • Programmed instruction • Web-based instruction

Promoting Compliance • Be certain that instructions are understandable and support patient goals. • Include the patient and family as partners in process. • Utilize interactive teaching strategies. • Develop interpersonal relationships with patients and their families.

Considerations for Successful Patient Teaching • Forming contractual agreements • Considering time constraints • Scheduling • Group versus individual teaching • Formal versus informal teaching • Manipulating the physical environment

Sample Teaching Strategies

Obtaining Feedback About Learning

• Cognitive domain — lecture, panel, discovery, written materials

• Reinforcing and celebrating learning

• Affective domain — role modeling, discussion, audiovisual materials

• Evaluating teaching • Revising the plan

• Psychomotor domain — demonstration, discovery, printed materials

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

18

Documentation of the Teaching-Learning Process

Variables Influencing Outcome Achievement

• Summary of the learning need

• Patient variables

• The plan

– Developmental stage

• The implementation of the plan

– Psychosocial background

• Evaluation results

• Nurse variables – Resources – Current standards of care – Research findings – Ethical and legal guides to practice

Guidelines to Patient Counseling

Common Reasons for Noncompliance

• Make everyone feel comfortable in the situation and surroundings.

• Lack of family support

• Counseling may be formal or informal.

• Lack of understanding about the benefits • Low value attached to outcomes

• Use interpersonal skills of warmth friendliness, openness, and empathy.

• Adverse physical or emotional effects of treatment

• Caring is fundamental in the counseling role.

• Inability to afford treatment

Types of Counseling

Factors to Consider When Delegating Nursing Care

• Short-term

• Patient condition

• Situational crisis

• Complexity of the action

• Long-term

• Potential for harm

• Developmental crisis

• Degree of problem-solving and innovation necessary

• Motivational

• Level of interaction required with patient • Capabilities of UAP • Availability of professional staff to accomplish workload

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

19

Overview of the Five Steps of the Nursing Process: EVALUATING

Nursing Care That Should Not Be Delegated to a UAP • Initial and ongoing nursing assessment • Determination of nursing diagnoses, plans, evaluations • Supervision and education of nursing personnel • A nursing intervention requiring professional nursing knowledge, judgment and/or skill

•

Measuring the client’s health achievements based on the goals specified.

•

It is used to determine the extent of which goals of nursing care have been achieved.

•

Activities: 1. Data collection about the client’s response 2. Compare data to outcome criteria 3. Analyze the result 4. Modify the Nursing Care Plan as necessary

To encourage further goal achievement, it is important for the nurse to evaluate client’s goal achievment as early as possible.

Five Rights of Delegation

Evaluating Step

• Right task

• Allows achievement of outcomes

• Right circumstances

• Directs nurse-patient interactions

• Right person

• Measures patient outcome achievement

• Right direction/communication

• Identifies factors to achieve outcomes

• Right supervision

• Modifies the plan of care, if necessary

Overview of the Five Steps of the Nursing Process: EVALUATING

Action Based on Outcome Achievement • Terminate plan of care • Modify plan of care • Continue plan of care

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

20

Four Types of Outcomes • Cognitive — increase in patient knowledge • Psychomotor — patient’s achievement of new skills • Affective — changes in patient values belief, and attitudes • Physiologic — physical changes in the patient

Five Classic Elements of Evaluation

Evaluating Outcomes

• Identifying evaluative criteria and standards

• Cognitive — asking patient to repeat information or apply new knowledge

• Collecting data • Interpreting and summarizing findings • Documenting judgment

• Psychomotor — asking patient to demonstrate new skill • Affective — observing patient behavior and conversation

• Terminating, continuing, or modifying the plan

• Physiologic — using physical assessment skill to collect and compare data

Evaluative Criteria vs. Standards

Variables Affecting Outcome Achievement

• Criteria — measurable qualities, attributes, or characteristics that specify skills, knowledge, or health status

• Patient

– Describe acceptable levels of performance by stating expected behaviors of nurse or patient • Standards — levels of performance accepted and expected by the nursing staff – Established by authority, custom, or consent

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

– E.g., a patient gives up and refuses treatment • Nurse – E.g., a nurse is suffering from burn-out • Healthcare system – E.g., inadequate staffing

21

Evaluative Statements • Decide how well outcome was met (met, partially met, or not met) • List patient data or behaviors that support this decision

Four Steps Crucial to Improving Performance • Discover a problem. • Plan a strategy using indicators. • Implement a change. • Assess the change and/or plan a new strategy if outcomes are not met.

Improving Professional Performance • Peer review • Quality assurance programs • Structure evaluations • Process evaluations • Outcome evaluations • Quality improvement • Nursing audit • Concurrent and retrospective evaluations

Revisions in the Plan of Care

Determining Adequacy of Evaluation Step

• Delete or modify the nursing diagnosis.

• Evaluate patient achievement of desired outcomes.

• Make the outcome statement more realistic.

• Review how the process is used.

• Adjust time criteria in outcome statement.

• Revise the plan of care if necessary.

• Change nursing interventions.

• Participate in quality-assurance programs.

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

22

Determining Adequacy of Evaluation Step

Determining Adequacy of Evaluation Step

• Evaluate patient achievement of desired outcomes.

• Evaluate patient achievement of desired outcomes.

• Review how the process is used.

• Review how the process is used.

• Revise the plan of care if necessary.

• Revise the plan of care if necessary.

• Participate in quality-assurance programs.

• Participate in quality-assurance programs.

Major Premises of Quality Improvement (Schroeder, 1994) • Focus on organizational mission • Continuous improvement • Customer orientation • Leadership commitment

Nursing Skills

• Empowerment • Collaboration/crossing boundaries • Focus on process • Focus on data and statistical thinking

Questions to Insure a Firm Commitment to Evaluation

Four Blended Skills

• What are the patient’s outcomes?

• Cognitive skills — make sense of the situation and grasp what is necessary to achieve goals

• What are nursing values? • How can these values be formalized in standards and evaluative criteria?

• Technical skills — manipulate equipment skillfully to produce desired outcome

• What data exist to determine whether criteria are met?

• Interpersonal skills — establish and maintain caring relationships that facilitate achievement of goals

• How can these data best be collected, analyzed, and interpreted?

• Ethical/legal skills — personal moral code and professional role responsibilities

• To what courses of actions do the findings lead?

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

23

Cognitively Skilled Nurses Ethically and Legally Skilled Nurses • Offer scientific rationale for patient plan of care • Select nursing interventions most likely to yield desired outcomes • Use critical thinking to solve problems creatively

• Are trusted to act in ways that advance interests of patients • Are accountable for the practice • Act as effective patient advocates • Mediate ethical conflict among patient, significant others, and healthcare team

Technically Skilled Nurses • Use technical equipment with competence and ease to achieve goals with minimal distress to patients • Creatively adapt equipment and technical procedures to needs of patients in diverse circumstances

Considerations When Posed with a Thinking Challenge • Purpose of thinking • Adequacy of knowledge • Potential problems • Helpful resources • Critique of judgment/decision

Interpersonally Skilled Nurses • Use interactions with patients and significant others and colleagues to affirm their worth • Elicit personal strengths and abilities of patients to achieve health goals

Characteristics of Interpersonal Caring • Promotion of dignity and respect of patients • Centrality of the caring relationship • Mutual enrichment of both participants in the nursepatient relationship

• Provide the healthcare team with knowledge about patient goals and expectations • Work collaborative with healthcare team as respected and credible colleagues

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

24

Developing Ethical/Legal Skills • Developing accountability • Reporting incompetent, unethical, or illegal practice

Steps in Concept Map Care Planning • Develop a basic skeleton diagram. • Analyze and categorize data. • Analyze nursing diagnoses relationships. • Identify goals, outcomes, and interventions. • Evaluate patient’s responses.

Clinical Reasoning

Critical Thinking and Clinical Reasoning • Is purposeful, informed, outcome-focused thinking • Is driven by patient, family, and community needs • Is based on principles of nursing process and scientific method • Uses both intuition and logic, based on knowledge, skills, experience • Requires strategies that make the most of human potential • Is constantly reevaluating, self-correcting, and striving to improve

Joannes Paulus T. Hernandez, B.S.H.B., B.S.N., R.N.

25