Why is the nursing process used when providing client care?

Patient Education

Throughout the nursing process, a critical role of the nurse is to guide the patient and family through all the information that is needed to understand care options. The emotional context of coping with illness, of grieving the many losses, and of anticipating death can make education and learning a challenge. Nurses in palliative care and hospice roles often need to tell people information that they may not want to hear. They also need to provide or reinforce a great deal of information in a short amount of time. The need for frequent repetition of information to patients and families should be expected, and the use of written educational materials to reinforce information can be helpful. Common education needs for patients and families include information related to the following:

Disease, expectations for disease progression, and prognosis

Treatment options, including realistic, expected outcomes of treatment

Advanced care planning information and tools

Patients’ rights, especially as related to decision making and pain management

Care options, including hospice services and experimental treatments

How to provide physical caregiving (for family caregivers)

Signs of impending death

Community regulations related to dying at home

The grieving experience

Resources for grief counseling and bereavement services

The HPNA provides patient teaching sheets that address many of the foregoing needs. These can be accessed at www.hpna.org.

Overview

Individualized care plans are still being used in many facilities, although the trend is toward using clinical pathways. Care plans are based on the nursing process, critical-thinking skills, and the new North American Nursing Diagnosis Association taxonomy 11 (adopted in 2000) for nursing diagnoses. Standardized care plans save precious nursing time but still need to be individualized. “According to the guidelines from JCAHO, the client or family must be involved in the development of the care plan and it must be interdisciplinary. One reason the critical or clinical pathway is becoming more popular is the interdisciplinary approach involved in this system.”22 Both care plans and clinical pathways involve a problem-solving approach to care. Clinical pathways are most commonly developed for “high-risk or high-volume” patients (e.g., bariatric surgery) and work in concert with continuing quality of care. Variances can be documented on an individualized care plan until resolved. In today's managed-care environment, cost-effective services must be provided.

Rouse and colleagues described an optimal care path developed by their transdisciplinary team. By means of the optimal care path, both the length and the cost of stay decreased by about 17% while quality of care was unimpaired, as evidenced by a decreased percentage of wound infections and improved communication and collaboration among team members across the continuum of care.23 Preserving quality while decreasing cost, length of stay, use of intensive care, and readmission were also cited in other studies.24,25 Further, protocols and practice guidelines give specific sequential instructions for treating patients with particular problems and needs.26 Protocols are especially helpful when there is extensive use of agency or float staff who are unfamiliar with the specialty.

CDSSs in Clinical Nursing Practice

The nursing profession’s body of scientific knowledge is growing exponentially making it challenging for nurses to remain up-to-date by reading current literature and to integrate and access all of this information within the context of daily practice [47,48]. It is the expectation of professional practice that nurses base their care decisions on current research, however according to Pravikoff [49], nurses feel more comfortable referring to peers or looking online rather than using recognized databases such as CINAHL. In parallel, nurses, generally speaking, struggle to make sense of scientific literature and integrate findings into their clinical practice, especially when conflicting recommendations are proposed. Furthermore, on the care units, nurses often do not have open and free access to the journal articles if the healthcare organizations do not have annual subscriptions with multiple publishers through their libraries. Failure to consult the scientific literature contributes to a stagnation of practice, impacting the quality of care that patients receive; this leaves the nurse dependent on his/her clinical experience and accumulated knowledge base to serve as a basis for making healthcare decisions. This is not optimal practice because failure to consult contributes to higher error rates and may lead to patient harm [50]. In contrast, while novice nurses have more “up to date” knowledge, they lack the clinical experience and expertise to back their decisions. Yet regardless of clinical experience, one can quickly become obsolete if there is no investment in remaining current on new developments [51]. Ideally, in order to make good care decisions, nurses’ judgment, and evidence-based best practices should be combined with the use of CDSSs.

Progress in CDSS development is lagging behind in nursing when compared to other disciplines such as medicine [52]. And even when developed, they are not specifically engineered with nursing care in mind, but rather are an extension of existing CDSSs used for medicine [53]. Despite the developments in nursing informatics, a subspecialty that has existed since the 1980s [11], developments in innovation have been hindered primarily due to a lack of standardization in the terminology used to describe the “nursing process” or the method that nurses use to think through a clinical problem [52]. Furthermore, the early systems were designed as stand-alone programs and not integrated in the workflow [54], burdening nurses with the requirement of data input thereby increasing the effort required in using these programs and consequently, unnecessarily increasing the cognitive load rather than decreasing it as intended [55]. Repeated data entry, without the understanding or sense of the recognized benefit, quickly becomes onerous on highly acute and stressful units as individual nurses may not value the potential that data offers and “just want to get through their day” [56]. Knowing that nurses are the primary users of EHRs because they document tremendously in comparison to other healthcare professions, it is logical to assume that the development of integrated systems, that combine EHRs with CDSSs, would be user-friendly and tailored to their needs. However, today’s EHRs are complex and create an additional hurdle to the delivery of highly reliable evidence-based nursing care [56]. In addition to more systemic challenges, nurses tend to lack informatics competencies and comfort with technology [57,58,24]; this discomfort often creates fears and resistance of relinquishing control of their clinical expertise to a machine or automated CDSS [59]. In addition to the fear created, the move to more automated systems can serve to threaten nurses who, as other healthcare professionals, value their autonomy, clinical experience, and acquired intuitive reflexes.

While various standalone CDSS programs have been developed for very specific, focused uses to screen for certain diseases such as cancer [48], to prevent certain complications such as falls [60] or pressure ulcers [61], or with certain nursing specialties in mind, such as school nursing [58], overall there is a scarcity of studies evaluating CDSS-use for general nursing care [5]. Generally speaking, findings suggest that in order to significantly improve patient safety and clinical practice [57,62,63], CDSSs must be embedded in an organization’s EHR, seamlessly integrated with the nurses’ clinical workflow and available at the point of care [16,64]. The integration of systems, into one place of reference, will consequently improve communication and allow for a certain level of oversight on care and outcomes among administrators [56], and as such may result in a more cost-effective system for patients and healthcare organizations [65]. In other words, these integrated systems can provide clinicians and administrators with a “bird’s eye view” of all aspects of care in a timely manner to ensure quality of care within their institution [66].

On an individual level, nurses follow the steps of the “nursing process” (assessment, hypothesis-generation, diagnosis, goal setting, interventions, and evaluation) to address patient problems and to promote health. CDSSs support this process by making the steps involved explicit, forcing nurses to think through the process systematically [59]. In addition, steps in the nursing process can be informed by quick access to evidence-based best practices [24,58,67] that serve to help nurses consider additional information in order to avoid jumping to ill-supported conclusions prematurely and to consider a wider array of treatment options and strategies [68]. Moreover, beyond providing easy access to evidence, CDSSs have influenced nurses’ adherence to recommended guidelines [69,70]. Furthermore, when the CDSS is able to validate a nurse’s thought process [71], this instills confidence, especially in novice nurses, and may serve to reassure clinicians that they are moving forward in a competent and safe way. By combining the nurse’s expertise with the theoretical knowledge a CDSS can provide, better clinical decisions can be made then either what the nurse or computer could make alone [72]. An additional benefit of the CDSS is that the entire process of decision-making is well documented [73], including the justification for care decisions. Overall, a systematic review on CDSSs used within the context of various disease processes indicated that they improve provider performance in 64% of the 97 reviewed studies [74]. When clinicians observe direct care benefits to patients and added value to their practice [75], they are motivated and believe that CDSSs can improve efficiency [76]; but often indicate the lack of training and technology-savviness impedes their ability to use these systems [71]. Something which could be overcome in the long run through the provision of professional development on CDSSs for practicing nurses and their systematic integration in curricula for nursing students.

21.1.2 Key issues and requirements of nurses’ clothing

Cracked nipples

When a mother complains of nipple pain on nursing, the nipple should be examined in good light to look for cracks or subepithelial petechiae, which may be the precursor to cracking. Taking a thorough history about care of the breast is important to identify the use of soaps, oils, ointments, or other self-prescribed treatments. Watching the nursing process may identify abnormal positioning at the breast. The position of the crack also may identify the problem (Box 8-4).

Cracks straight across the tip of the nipple are caused by excessive dryness after original irritation of the nipple tip by poor nipple positioning against the infant’s palate (see Figure 8-15, A). Pain may be eased by correct positioning, and healing may be promoted by application of therapeutic ointments such as vitamins A and D, purified lanolin, or a synthetic hydrocorticoid (preparations of mometasone furoate or Elocon ointment), and, in extreme cases in which the crack is wide, followed by a “butterfly” bandage that brings the edges of the crack together between feedings. Local anesthetics are not appropriate, nor are nipple shields, which draw and pull the nipple. Star-shaped cracks respond to similar treatment (see Figure 8-15, B). Cracks at the base of the nipple (see Figure 8-23, C) are usually caused by sucking of the lower lip and biting, which originate with poor positioning but require checking the lower lip. Mother can gently pull it out with her thumb or relatch the infant.

Therapy is indicated for true cracks. In the precracked stage, letting the milk dry on the skin for a few moments and applying a cream between nursing are most effective. When true fissures have developed, opening both sides of the nursing brassiere at feedings and beginning to nurse on the less painful side first will permit the initial let-down to occur “atraumatically”; then the infant can be put carefully to the affected breast. When nursing must be stopped on a given breast, it sets up a chain reaction of engorgement, reduced flow, and plugging of the ducts. Changing the infant’s position, such as using a football hold or cross-cradle, may help healing by redistributing the pressure of sucking.

Hewat and Ellis68 conducted a study comparing lanolin with dried-on milk. Mothers used one treatment on one nipple and the other treatment on the opposite breast. The authors found no correlation between pain and frequency of feedings or the mother’s hair and skin color. The women reported no difference in soreness between the two treatments. Many dermatologists think that applying two treatments to different parts on the same patient may lead to mixture of therapies and noncompliance rates higher than normal. A study of antiseptic sprays by Herd and Feeney66 produced controversial results. Antiseptic sprays are rarely justified and may cause problems because the physiologic normal flora of the nipple and areola should not be artificially altered unless a culture has been done.79

In women with severe nipple cracking, the physician may prescribe topically applied synthetic corticoids, which are preferred by dermatologists. When position has been corrected and bacterial and fungal infections ruled out, application of Elocon 0.1% cream or ointment, which is antiinflammatory, antipruritic, and vasoconstrictive, can be rapidly healing. Less than 0.5% of a dose of corticoids is absorbed topically. Halobetasol propionate (Ultravate) 0.05%, another synthetic corticoid ointment, is also available by prescription. Usually a 2-day treatment is adequate, and the ointment does not need to be removed before feeding. It is important to treat the underlying cause of the original trauma to the nipple.

The application of any ointment that must be removed before nursing has disadvantages because removal is traumatic. Vitamins A and D ointment, which does not have to be removed, is occasionally effective. It contains vitamins A and D from fish liver oils in a petrolatum base. An individual would have to consume several large tubes of it at one sitting even to approach toxicity. The indiscriminate use of ointment, however, can be the cause of nipple pain, and as with many dermatologic problems, the initial treatment prescribed may be to discontinue previous treatments. Some ointments suggested as breast creams contain antibiotics, astringents, bismuth subnitrate, or petrolatum, all of which are contraindicated. These creams are available over the counter without a prescription; thus a physician should inquire about their use by the patient.

Premoistened towelettes that contain benzalkonium chloride 1:750 in 20% alcohol should not be used on a nipple or areola with or without soreness or cracks or used to cleanse. The infant could accumulate benzalkonium chloride by suckling. The infant might reject the breast because of the flavor or burning sensation in the mouth. Also, benzalkonium is usually painful for the mother.

Abstract

Background

The nursing process is a necessary guide to understanding the scientific basis and essence of nursing practice. It requires some degree of critical thinking from nurses to ensure improved collaboration, continuity of care and better health outcomes. The objective of this literature review was to identify the issues related to implementation of the nursing process in sub-Saharan African countries.

Methodology

The reviewed studies were selected from a series of original studies carried out in sub-Saharan African countries. Literature on implementation of the nursing process was sought from PubMed, CINAHL, MEDLINE, African Index Medicus data bases, and Google Scholar.

Findings

Twenty-six articles fitted the inclusion criteria and were retained. The findings reveal an enormous gap in the literature for nursing process implementation. After data analysis, three themes were identified, namely: (1) inadequate knowledge of the nursing process; (2) stressful working conditions; and (3) low staff levels (understaffing). These three issues negatively influence implementation of the nursing process in most sub-Saharan African hospitals.

Conclusion and recommendations

Although the nursing process is an essential tool in improving patient and health outcomes, it is not adequately implemented in almost all hospitals in Sub-Saharan Africa. It is recommended that nurses, midwives and nursing leaders find ways of improving the acquisition of professional knowledge on the nursing process and advocate for improved working conditions.

Implication for Mental Health Nursing

The nursing process includes four phases: diagnosis, planning, implementation and evaluation. This review is important not only for raising awareness about the importance of early psychosis preventive intervention, but also to give us an idea for its application to the nursing process. For diagnosing prodromal schizophrenia individuals, the screening criteria were nonspecific and the concept of prodromal psychosis was unfamiliar to most people. Even mental health professionals were not ready to identify at risk individuals (Liu et al., 2010). Health complaints ought to be treated seriously by mental health nurses with comprehensive general health assessments carried out as a matter of course. Even though the research in this review confirmed that all professionals including nurses, after training, can be therapists for early interventions on the prodromal schizophrenia individuals, without the clear standard for performing correct identifications, we cannot have the appropriate planning, implementing and evaluating phases to fulfill the nursing process.

The Telephone Triage Nursing Process

The nursing process is the basis of telephone triage. Telephone calls to or from patients tend to fall into one of three categories: consultative, follow-up, or surveillance.15 Consultative calls usually involve sharing information regarding lab results or scans. Follow-up calls are performed to assess the effectiveness of a therapy or an intervention. Surveillance calls, which are the most common of triage calls, are to address a specific symptom or issue that the patient is experiencing.

There are many methods of performing an assessment over the telephone. Each facility should have standard operating procedures in place for each nurse to follow. Many electronic health record systems have guidelines or algorithms available to standardize questions to ask for the most common symptoms that patients call into centers to be addressed. For example, the Oncology Nursing Society published “Telephone Triage for Oncology Nurses,”15 which outlines the most common symptoms oncology patients experience. Included in the book is a list of protocols that outline assessment criteria, including what questions to ask the patient and appropriate actions that should be taken based on the patient's responses. A sampling of policies, surveys, and standard operating procedures are also included in the text.

It is important to obtain information directly from the patient rather than a second party, such as a family member. There are situations where the nurse must obtain information from a family member or caregiver with the patient's permission/consent, but the attempt should be made to speak directly to the patient or to receive information in the patient's own words. Nurses should be certain to ask open-ended questions to gain as much information as possible, without leading the patient.

There are ways to obtain information from the patient to glean information that is clear as to what the patient is experiencing. Various models are available to aid the nurse in obtaining as much information as possible. For example the problem-oriented system PQRST (provoking factors, quality, region, severity, time, and treatment), or OLD CART assessment (onset, location, duration, characteristics, associated factors, relieving factors, and treatments). It is recommended that only one model should be used with each health care institution for consistency purposes in training and education of the workforce.

Once the patient's problem or symptom has been thoroughly assessed, the nurse can determine the appropriate steps to rectify the problem. A nursing diagnosis can be made and the nurse should identify the acuity of the encounter.

The next step is determining the care plan for the encounter. The plan of care should be based on evidence-based protocols that should be approved per institutional guidelines. The plan should involve the necessary level of care, such as a physician or advanced practice provider, if pharmacologic intervention is required or if the resolution of the issue is outside the scope of practice of the registered nurse.

Evaluation and safety netting is the final step and is critical in performing telephone triage. It is essential to confirm that the patient understands the plan of care, to identify any barriers, and to provide an opportunity for the patient to ask any further questions. In partnership, the nurse and patient should agree on the follow-up method for continuing care. Two important questions to summarize a telephone triage encounter should be: “Can you please repeat back to me what your understanding of your care plan is to help alleviate your symptom/issue of concern?” and “Is there anything that would prevent you from following through with your plan of care that we have just discussed, please?”

1 Introduction

The theory of nursing process was first introduced in 1958 (Schmieding, 1993), and has been integrated with the nursing care plan since the early 1960s (Johnson et al., 2011). From this time, the institutions of higher education at US, have commenced teaching the nursing process, but there is limited evidence of applying it in the hospitals in a practical way in the 1960s. One decade later the nursing process had been used in hospitals in US. In the UK the nursing process borrowed from the US in the 1970s and then disseminated (De La Cuesta, 1983).

Based on the nursing process, nurses describe or hypothesize the patient's actual and potential problems, health risks, and promoting opportunities (Heardman and Kamitsuru, 2014). The nurses recognize their role in the planning of the care by understanding the nursing process, thereby making the care more relevant (Stonehouse, 2017). This process now functions as the main framework of the nursing care plans in developed countries (Mahmoud and Bayoumy, 2014).

This cyclic model consists of four major steps: assessment, planning, intervention, and evaluation (Ballantyne, 2016). The model has subsequently been modified to five steps by adding the diagnosis by ANA (American Nursing Association), immediately followed by the assessment (Heardman and Kamitsuru, 2014; Johnson et al., 2011). In the assessment phase, the nurse collects comprehensive data from the patient, family, group or community. Then, the nurse converts the collected data into information in order to create structured knowledge which is known as the nursing diagnosis. At the end of this step, the identified actual and potential problems of the patient are judged by the nurse. The NANDA-based (the North American Nursing Diagnosis Association) taxonomy as the main international nursing terminology is used for classifying these identified problems (Heardman and Kamitsuru, 2014). In the planning phase, based on the priorities of patient's problems, short and long goals are set. Then, the expected outcomes will be defined to evaluate the effect of nursing interventions. The nursing outcome classification (NOC) introduced by University of Iowa, the college of nursing, is one of the standard classification systems which is widely used for selecting the outcomes in the nursing care plans (Moorhead et al., 2014). The nurse performs the care interventions based on his/her clinical judgments to meet the goals. The nursing intervention classification (NIC) is one of the comprehensive sources for categorizing the nursing interventions (Butcher et al., 2018). The evaluation of interventions is an important step for checking the achievement of goals. The measures of outcome achievement constitute the criteria of nursing care evaluation. Based on the results of this step, the cycle of the process may be repeated again (Moorhead et al., 2014). Indeed, this scientific method enables nursing professionals to provide the patient with quality care (Johnson et al., 2011).

There are various factors that affect the implementation of the nursing process According to the results of various studies, lack of nurses’ knowledge related to the execution of the process is one of these key factors in different countries (Abdelkader and Othman, 2017; Akbari and Shamsi, 2011; Ghafouri Fard, et al., 2012; Mahmoud and Bayoumy, 2014; Mbithi et al., 2018; Nouhi et al., 2010; Zamanzadeh et al., 2015).

Therefore, there is a need to put in teaching strategies for faculty and clinical nurses that can influence the implementation of the nursing process. It seems that in this way, the problems associated with the nursing process could be minimized (Mahmoud and Bayoumy, 2014; Zamanzadeh et al., 2015).

Due to the significant influences of education on increasing knowledge and skills, in this review, all educational programs in the field of nursing process or nursing care plans have been reviewed from the perspective of teaching methods and their characteristics. The purpose of this review is exploration of the teaching methods in point of fitting with the hardscrabble profession of nurses, utilization of technological process and resources, using valid educational resources, and the other characteristics.

That's way, the identified weak points of the explored teaching methods can be considered in the development of further Nursing Process Training Programs.

5.3 Implications for Practice and Future Research

In clinical nursing, nursing process including assessment, diagnosis, planning, implementation and evaluation can't be achieved without the guide of critical thinking skill. Cultivating critical thinking ability was influenced by personality trend and individual values. The assessment of critical thinking should not only emphasize on the affective dispositions and cognitive skills, personality and social environment should also be taken into consideration. Improving critical thinking ability is a prolonged process, it permeates into the periods of classroom teaching, internship and clinical work. Therefore, no matter in learning or working stage, critical thinking ability should be valued. Moreover, to evaluate the critical thinking ability, a comprehensive assessment system should be created. Further research performing blinding of data collectors and evaluating more other influence is needed.