The advent of the nursing process, which is a holistic approach to care based on the individual patient's needs and problems, was considered as a convenient "umbrella" to initiate the necessary changes and improvement in nursing practice (Nursing Process Evaluation Group, 1986). As a result, during the late 1970's and 80's, articles extolling the virtues of the nursing process abounded in nursing journals. These articles were overwhelmingly "advocatory" in nature. A strong view was expressed that the nursing process was a tool to improve patient care
Chapter 2: The delivery o f nursing care
through the use of a more systematic and individualised approach. Surprisingly, there were hardly any confirmatory studies to support this view. In fact, the Nursing Process Evaluation Group (1986) conceded that very little was known
about the ways patients reacted to this approach of care.
2.3.1 The Stages of the Nursing Process.
The nursing process is often described as a problem-solving approach to care consisting of four interlinking stages, namely assessment, planning, implementation and evaluation (Jones, 1977; Yura & Walsh, 1978; Hargreaves,
1985).
The four stages of the nursing process are shown diagrammatically in figure 2.1.
Figure 2.1 The Relationship between the four Stages of the Nursing Process.
Nursing ---> Identify needs
History and problems
Discontinue if goals achievec Assess outcome of nursing care nursing Review care plan if goals
not met Implement
nursing care
Assessment involves taking a history of the patient’s complaint as well as making appropriate observations and physiological measurements with a view to identifying the patient's specific problems. This is a difficult stage of the nursing process and its success is dependent not only on the skills of the nurse but also on how busy the ward is. If the nurse has multiple tasks to carry out, is stressed or lack knowledge and skills, the assessment may be inadequate and certain problems may not be identified. This in turn may affect the subsequent stages of the nursing process. For instance, if a frail and poorly patient is admitted to hospital and his pressure sore risk is not initially recognised, preventative measures may not be planned for and actual pressure sores may then develop.
Planning is intimately linked with assessment. Once the nurse has identified the patient's specific actual and potential problems as a result of the assessment of the patient, she or he will then set objectives about the desired outcome for each problem. In the example of pressure sore, the nurse will write down how the development of pressure sore could be prevented.
Intervention involves carrying out the care that has been planned. This is dependent on the nurses practical knowledge, appropriate delegation of duties, resources and general management of the ward. Failure to carry out the planned care may adversely affect the patient's care.
Evaluation is concerned with making a judgement, based on available information, on whether or not the objectives of care have been achieved. If a problem has not been resolved, the nurse will have to decide whether it is due to a poorly identified problem, inaccurate objective or inappropriate interventions. Thus, evaluation is an essential step that links structure, process and outcome (Donabedian (1988)).
Chapter 2: The delivery o f nursing care
2.3.2 Application of the stages of the nursing process to a patient with chest pain.
To illustrate how the nursing process operates, the assessment and care of a patient admitted with chest pain using this system of care will now be described. On the admission of the patient, the nurse would first of all carry out a thorough assessment, encompassing an interview to determine the history of the chest pain and related factors, observations of vital signs as well as general observations and physiological measurements. This would enable the nurse to identify the patient's specific problems and needs as well (e.g. chest pain, low blood pressure, arrhythmias etc.) as prioritising them. Based on these problems and needs, a care plan would be designed with specific objectives for each problem and need (e.g. the chest pain will be relieved, blood pressure will return to normal, arrhythmias will be monitored). The care would then be implemented to achieve the objectives of the care plan. Finally, the patient would be re-assessed (i.e. the initial problems and needs would be evaluated to see whether or not they have been resolved) to ensure that the objectives of care have been achieved. A successful outcome would be the patient would be free of pain and complications, his basic needs and comfort would have been met during his period of illness ,and he would have been equipped with the knowledge to deal with some aspects of his care.
2.3.3 Problems with the Nursing Process.
Various problems have emerged when the nursing process has been examined. For instance, there have been criticisms that the nursing process has caused a proliferation of documentation. The poor quality of these records has also been highlighted regularly by the Health Commissioner in his annual reports (DoH, 1992). Official reports (e.g. DoH, 1994; DoH, 1992) have commented on the excessive and inappropriate documentation which has affected communication between staff and has sometimes led to omissions or inadequacy in care. In the
nursing records' study sponsored by the Department of Health (DoH, 1992), it was found that "some patients were charted to death but there was no evidence of action and that day to day states were deficient". The study also recommends that nurses should be more factual and precise in their description of nursing observations. In a study of the records of patients admitted with Myocardial infarction , Hale et al (1997) found no evidence of assessment of needs with regards to anxiety and health education of individual patients. They found that in all cases, the records failed to satisfy the criteria outlined in the UKCC(1993) in their document 'standards for records and records keeping'.
The hasty introduction of the nursing process may have contributed to the difficulties with its use. The fundamental aspects of the nursing process such as intellectual skills, individual accountability, and patient participation were played down when the nursing process was first introduced in the UK (De La Cuesta, 1983). In 1986, the Nursing Process Evaluation Group commented that "the problems have been brought about by the lack of understanding of and negative perception towards the nursing process....coupled with too speedy introduction to an unprepared workforce". As a result, there was more focus on explaining the documentation associated with the nursing process than in enabling the staff to understand the principles underpinning the nursing process. This may explain the nurses' apparent difficulty in operationalising the nursing process at its broad theoretical level, hence the focus on paper work associated with the nursing process. Miller (1985) has also remarked that nurses have tended to concentrate more on the procedural (i.e. method) component of the nursing process and less on its ideological (i.e. principles and beliefs) component.
It was also suggested that nurses have problems in using the nursing process because it lacks the theoretical base to explain what nursing is. For instance, it is argued that nurses cannot achieve the goals of nursing through a problem-solving
Chapter 2: The delivery o f nursing care
approach (i.e. the nursing process) if they do not have a clear concept of "what the goals are and where the boundaries of nursing lie" (Wright, 1986). As a result some nurse theorists (e.g. Roper et al, 1980; Aggleton & Chalmers, 1985; Wright, 1986) have advocated the use of explicit "model of nursing" for use with the nursing process. They suggest that a model of nursing is a conceptual explanation of what nursing is and the relationships between the various components which make nursing. They argue that a model will provide the clinical nurses with a theoretical framework for use with the nursing process to make the principles underlying the nursing process more explicit.