Two major problems have been highlighted which prevent the effective use of the nursing process, namely nurses inadequate understanding of the principles underpinning the nursing process and the documentation "maze" generated by the use of the nursing process and models of nursing. Doctors have tackled the problems associated with the explosion in knowledge in the medical field and the concomitant inability for doctors to keep abreast with all the latest approach to manage specific medical conditions by introducing guidelines for medical practice (Brook, 1989) and critical pathways (Greenfield et al, 1977). Integrated care pathways are increasingly becoming popular in nursing too both in the USA and the UK. Earlier evaluations of the use of this system suggest that it may rationalise the nursing process and increase its effectiveness in the delivery of nursing care. Guidelines have the potential to make nursing documentation more precise and accurate, and could act like prompts to speed up nurses decision making process in planning care for patients. Evidence-based practice can also be incorporated within guidelines or pathways.
2.4.1 Clinical guidelines and care pathways.
Chassin (1990) defines practice guidelines as "statements that describe specific manoeuvres that should or should not be undertaken in specific clinical circumstances". Practice guidelines specify good management for specific conditions. They focus on quality of care and appropriateness of practice (Lomas et al., 1989). Kosecoff et al (1987) argue that guidelines can keep physicians up to date in the face of explosion of medical knowledge. Guidelines may help to reduce variations in care of patients, contribute to reducing errors, omissions or inappropriate care in clinical practice and assist in protecting the legal liability of the physicians (Fowkes et al, 1987). However, Lomas et al (1989) found that guidelines by themselves do not improve care. They state that other incentives or removal of disincentives will also probably be required. Koseloff et al (1987) recommend that guidelines be "coupled with follow-up programs that help to translate the message into local or individual actions...".
A critical care pathway is an extension of clinical guideline, and its obvious attraction is that it can be used by all members of the multi-disciplinary team, enabling an integrated approach to care. The critical pathway is an abbreviated version of the patient's management plan, showing the critical incidents that must occur if the patient were to achieve the appropriate length of stay (Zander, 1988). The critical care pathway demonstrates how the nursing process can be adapted to make it more efficient and effective. It also enables quality assessment of care to be made. For instance, the nurse co-ordinating the care of the patient can note and record any variances firom the critical paths, explore their causes with the other nurses who have been involved in giving the care and arrange for specific action to be taken in relation to these variances (Gruiliano and Porrer, 1991). This system of care ensures that interventions take place at the appropriate point of the patient's stay in hospital and also help to avoid omissions in care. Gruiliano and Porrer (1991) argue that this model of care enables good communication to take
Chapter 2: The delivery o f nursing care
place between all those involved in the care of the patient and also promotes patient and relatives participation . The use of this approach to the care of patients with specific conditions may help to minimise the problems and confusion associated with nursing process which have been discussed earlier.
It must also be noted that carepathways/guidelines may complement and enhance individualised care, particularly as the indentification and tackling of variances are integral to this system of care (Johnson, 1997).
2.5 Conclusion.
It has been argued in this chapter that to fully understand the way nursing is organised and delivered as well as the difficulties that nurses experience in the process of care, we need to be aware of some of the salient factors which have influenced changes in nursing practice. Nursing has had a very unsettled history, with nurses having had to accept many changes in the way they deliver their care being imposed on them rather than being proactive in these changes. On the whole, nurses received little preparation to help them cope with these various developments in a competent manner, hence possibly making them less able to use the nursing process in a knowledgeable and confident way. Although the nursing process was initially hailed as an important development which would enable nurses to make that final push towards professional status and improved standard of care, its speedy introduction and the lack of consideration of its potential impact on the nurses have conspired to create a permanent state of unease with this system of delivering care, and is a potential source of many errors of omission and commission (Reid, 1987) . It is suggested that by modifying and simplifying the nursing process system of care by the provision of clinical guidelines/evidence-based health care and care pathways, much of the difficulty and confusion associated with the nursing process could be reduced.
In the next chapter, the types, sources and consequences of errors made by nurses and doctors in the delivery of care will be discussed. It will be suggested that nurses will need to become more aware of the antecedents of these errors if quality and safety in care are to improve.
CHAPTER THREE: ERRORS AND ADVERSE EVENTS IN HEALTH CARE.