The purpose of this essay is to discuss the importance of problem solving following the steps of the nursing process, (NP).The nursing process is used to identify, prevent and treat actual or potential health problems, (Wilkinson, 2007) enabling the nurse to plan care for a patient on an individual basis using. a systematic, step by step approach (Palgrave 2006) ,supported by models or philosophies such as:
Roper – Logan -Teirney, Model of Nursing and Roy’s adaptation model. The NP is a method of problem solving therefore I will use the term the NP throughout the essay. Focusing on the four major steps, assessment, planning, implementation, and evaluating. Discussing the importance of continuity of care and why the patients’ needs may not be fully met if the NP is not followed. I will also be discussing why critical thinking is important in decision making and problem solving. The NP helps the nurse develop an understanding of the patients, differing from the medical process by treating the patient holistically. Addressing not only the patients’ physical emotional and mental health but also their interests, values, beliefs ethnic religious and cultural background; identifying which of these factors are important to a patients’ health (Richardson, 2008). I will be critically analysing these anticipating complications and commencing actions making sure appropriate treatment is carried out. The NP is a dynamic process changing as the patient’s needs and/or health changes (Wilkinson 2007). All steps should be reassessed on a regular basis. The NP helps form an important therapeutic role in addition to formulating the best care for the patient.
The first part of the NP is the assessment; it is an ongoing process helping to identify patient needs, once these needs are established they can be incorporated in to the planning implementation and evaluations stages.(Kozier et al 2008). To give the patient the best possible care the nurse must always have a specific aim in mind, considering how it applies to the individual patient ensuring that the patient is being cared for as a whole based on their individual needs. The assessment should be carried out soon after admission within 24 hours if possible. The length of time before reassessment is performed depends on the care setting a patient in Intensive care could be reassessed as much as every 15 minutes. (Kobs 1997). Ideally the assessment should be continuous, observing and noting changes in the patient’s condition and updating accordingly. Most trusts have set criteria in the form of a care plan, although they may vary between hospitals or even wards in the same hospital. (Richardson,2008)The main disadvantage of the pre printed care plans is that it can be used as a checklist, the nurse only asking closed questions simply ticking the relevant boxes, not utilising her experience and knowledge. This inaccuracy could be due to a number of reasons such as the nurse being short on time, or as stated by Nancy Roper ‘discussing some of the activities of living such as sexuality can make the nurse feel uncomfortable assuming that the patient feels the same’. On the other hand, the advantages are evident in that they are in line with the original model and create a systematic guide, incorporating all the steps necessary for patient care. If used correctly the assessment process helps the nurse obtain an all round holistic picture of the patient. During the initial interview here are two types of data to collect. Objective data, which is, observable and measurable, and subjective data which only the patient can describe and explain.(Wilkinson, 2007) Both types of data are of equal importance, although it is probably easier to obtain objective data as the patient may feel awkward or embarrassed about discussing certain things and should be encouraged, by asking further open questions. Confidentiality should be emphasised at this point, informing the patient of their right to confidentiality. (NMC,2008) The nurse, explaining to the patient why so much information is needed. Both types of data can be from either a primary or secondary source. Primary data is information that only the patient can give, secondary data can be from the patients’ family, or discussions with members of the MDT. The medical notes, including, previous reports and test results. are also a useful way of obtaining information, saving the patient from unnecessary questioning. It should be mentioned that the NP although important for patient care, is not an interrogation. Perception and intuition as to the mood or condition of the patient should be observed. If the patient is in pain or unwell, the assessment process should be discontinued, then completed at a later stage.. Essential information can be obtained from the secondary sources mentioned. This is where the nurses’ ability to think critically is important. Emerson, (2007) states that Critical thinking in nursing is an essential component of professional accountability and quality nursing care (Tanner,2000 cited in Emerson 2007 p133) states that many nurse educators are reported to recognize that critical thinking is closely related to the nursing process However the definition of (Scheffer and Rubenfield 2000 cited in Emerson 2007p133) sees critical thinking as more than just a cognitive activity, incorporating creativity and intuition It could be argued that both are right the nursing process incorporates both cognitive and affective aspects. The cognitive approach allows the nurse to call to mind her experience and knowledge, at the same time using creativity to read between the lines and ask more open questions gaining more information.
Planning is the second stage of the nursing process the phases are interdependent and over lapping therefore the effectiveness of this stage depends on the quality and comprehensiveness of the assessment. (Wilkinson, 2007) Establishing goals, interventions and outcomes is the aim of the planning stage. (Kozier, et al 2008)Planning should begin soon after the initial assessment is carried out, usually by the nurse taking the assessment. All nurses who care for the patient should take part in the ongoing planning, amending if circumstances change. Although accurate documentation is an essential part of the registered nurse and health care assistants role (HCA) (RCN 2009) in many wards HCA provide much of the physical care and may not have not been taught the significance of a care plan and may not report changes, or document correctly. (Hartig,1998). It is important to remember the care plan is important in the continuity of care of the patient and may be referred to by members of the multi disciplinary team (MDT). The planning stage determines the problems and establishes the risks and priorities (Wilkinson,2007) The patient should be involved as much as possible in this stage. The nurse not making assumptions about the patients problems, needs and abilities but should confer with the patient, giving the patient the opportunity to contribute to their care planning. Although in some cases the nurse may need to utilise her skills and knowledge advising the patient on certain aspects of their health, the patient not relishing the importance of a problem or need. Again sensitivity and empathy are important at this step, not just simply treating interventions as a series of tasks but to treat the person holistically explaining why the planned interventions are important. For example if a person as pressure ulcers, it should be explained why mobility is important also emphasising the importance of good nutrition explaining that referral to a dietician may be necessary
Implementation is the next step involving putting the plan into action. (Burns et al 2005) The nurse implements the plan of care by initiating planned nursing interventions to achieve patient-centred goals (Quan 2009) In addition it is the nurse’s responsibility to delegate specific tasks to appropriate members of staff (Daniels, 2004), ensuring that all the activities have been implemented according to the care plan. It is not necessarily the nurse who initiated the care plan who should be accountable; as all qualified nurses are accountable and must always be able to justify action and omissions (NMC,2009) for that reason the nurse caring for the patient, when the task is carried out is responsible. It is therefore in the nurses’ best interests to validate and respond to adverse findings or patients responses. (Kozier et al,2008) Not only to protect herself but for the implications to the patients welfare and safety. However other professionals contributing to the care are also accountable. Before Implementation the patient must be reassessed, to make sure an intervention is still needed. It would be unfair and unethical to subject a person to unnecessary treatments, referring to other members of the MDT if there is any doubt. It is central to the nurses’ role to understand the rationale behind the intervention, and be up to date with current research, having an understanding of any side effects and contraindications that could put the patient at risk. (Kozier et al 2008) Looking at the patient as a person not just their medical needs is also a fundamental skill in nursing. Respecting their beliefs and values, when considering interventions, adapting interventions to the patients needs if required. For example a person with pressure ulcers who needs to be turned regularly may ask if they can be left undisturbed when their relatives come to visit, this request must be adhered too if possible. Obviously all requests aren’t as simple and sometimes medical needs or time restraints are a concern. Explaining to the patient that all efforts will be made to comply with their wishes, however it may not be possible. Relating to the patient in this way will show respect for their request, and hopefully they will understand why it isn’t always feasible. It is better to explain this initially, rather than agree with a request knowing that it can’t always be honoured. Going back on an agreement could damage the nurse patient relationship causing friction between them.395
Evaluation is the fourth step of the NP and is used to determine the effectiveness of the Care plan establishing if outcomes have been met, whether they should be continued or changed (Kozier et al 2008). .Lynda Juall (2009) states that, evaluation may be the most difficult stage of the NP. Describing evaluation as a step may be incorrect, since evaluation should be a continues process, mentally taking notes and evaluating throughout the implementation stage. Although the nurse may be busy and have more than one patient to attend to, it is vital that all observations and actions are documented, so that other nurses and members of the MDT can judge the efficiency of an intervention. Protecting the patient from procedures that may be ineffective or no longer needed.(Wilkinson,2007) It is also important to differentiate between relevant and irrelevant data. At the assessment stage two types of data were gathered,. objective data which is easy to assess and interpretate, and subjective data which is more difficult to evaluate especially if a patient has cognitive impairment of any kind.. Therefore during evaluation nurses tends to concentrate on objective measurable data, (CMFT, 2009). All members of the MDT should be consulted including the patient, when decideding if outcomes have been met. It is vital that Evaluation leads back to Assessment and the whole process begins again. (Quan, 2007)225
As stated in the introduction of this essay the NP is a systematic guide to problem solving, involving critical thinking and communication skills, as well as a sound theory and medical based understanding. If the NP was just a case of ticking boxes it would still be a valid way of gaining information relating to patient care, although it would not necessarily solve any problems, only giving a general picture of the patients circumstances. Each patient is an individual and come with their own set of unique problems. Every time the NP is carried out it should be patient centred and related to giving the patient the best possible care. A problem may not be discovered at any one stage it is only when the whole process is viewed collectively that a problem may be apparent. Each step of the NP depends on the accuracy of the previous step, making sure sufficient accurate data is gathered to support each stage. For the NP to be effective, reassessing goals and interventions needs to be continuous and ongoing patients needs can change very quickly and the nurse needs to update the priorities when problems arise.
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