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Effect of an instructional program on the use of the nursing process in practice Boyle, Barbara Ann Joyce 1976

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THE EFFECT OF AN INSTRUCTIONAL  PROGRAM ON THE USE OF  THE NURSING PROCESS IN PRACTICE  by BARBARA ANN JOYCE BOYLE B.Sc.  N., U n i v e r s i t y o f A l b e r t a ,  A THESIS SUBMITTED  1969  IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING  IN THE FACULTY OF GRADUATE STUDIES (School  We a c c e p t t h i s required  o f Nursing)  t h e s i s as conforming  to the  standard  THE UNIVERSITY OF BRITISH COLUMBIA June  (cT)  1976  Barbara^ Boyle  1976  In presenting t h i s thesis i n p a r t i a l f u l f i l l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study.  I f u r t h e r agree that permission f o r extensive copying  of t h i s thesis f o r s c h o l a r l y purposes may be granted by the Head of my Department or by his r e p r e s e n t a t i v e s .  I t i s understood that  copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n permission.  BARBARA ANN JOYCE BOYLE  School of Nursing The U n i v e r s i t y of B r i t i s h Columbia Vancouver, B r i t i s h Columbia Date  September 4th., 19,76  V6T 1W5  ABSTRACT  The purpose o f t h i s study was t o examine the e f f e c t o f an i n s t r u c t i o n a l program on the u t i l i z a t i o n o f the n u r s i n g process by graduate nurses i n the p r a c t i c e a r e a , and on the a t t i t u d e o f the graduate nurse toward the n u r s i n g p r o c e s s . P a t i e n t records were a u d i t e d before and a f t e r completion of an i n s t r u c t i o n a l program t o determine the e x t e n t t o which the n u r s i n g process was being used.  A q u e s t i o n n a i r e t o determine  a t t i t u d e toward the n u r s i n g process t h a t was h e l d by the graduate nurse, was administered t o the study and c o n t r o l groups before and a f t e r completion o f the i n s t r u c t i o n a l program. I t was hypothesized t h a t there would be no measurable difference i n : 1.  the frequency with which a d e f i n e d data base i s obtained on individual patients;  2.  the number o f p a t i e n t problems i d e n t i f i e d ;  3.  the number o f p a t i e n t problems which are c o n s i s t e n t with established c r i t e r i a ;  4.  the planning phase o f the n u r s i n g p r o c e s s ;  5.  the implementing phase o f the n u r s i n g p r o c e s s ;  6.  the e v a l u a t i n g phase o f the n u r s i n g p r o c e s s ; o r  7.  the way i n which the graduate nurse views the n u r s i n g p r o c e s s , before and a f t e r completion o f an i n s t r u c t i o n a l program by such graduate nurses. ii  A l l seven n u l l hypotheses were r e t a i n e d , although there was a s t a t i s t i c a l s i g n i f i c a n c e obtained i n three o f the c r i t e r i a i n the planning phase between the comparison groups of nurses.  Those  nurses having been exposed to the i n s t r u c t i o n a l program, scored higher as a group on the f o l l o w i n g c r i t e r i a .  These were:  1.  expected behavioural outcomes are e s t a b l i s h e d ;  2.  the expected behavioural outcomes are r e a l i s t i c ; and  3.  the expected behavioural outcomes are r e l a t e d to p a t i e n t problems i d e n t i f i e d i n the assessment  phase.  From t h i s study other v a r i a b l e s have been i d e n t i f i e d conc e r n i n g the use o f the n u r s i n g process by graduate nurses i n the c l i n i c a l area and t h e i r a t t i t u d e toward i t . However, the major l i m i t a t i o n o f the study was thought to be the i n a b i l i t y to compare each nurse's performance, i n the study group, i n the use of the n u r s i n g process before and a f t e r completion of the i n s t r u c t i o n a l program.  TABLE OF CONTENTS Page ABSTRACT  i i  TABLE OF CONTENTS  .........  iv  LIST OF TABLES .  viii  LIST OF FIGURES  ix  ACKNOWLEDGEMENTS  .......  x  ............  1  Chapter I.  INTRODUCTION TO THE STUDY INTRODUCTION  1  THE PURPOSE OF THE STUDY  .  THE PROBLEM  4  Statement o f the Problem S p e c i f i c O b j e c t i v e s o f the Study . . . . . . .  4 5  S i g n i f i c a n c e o f the Problem  5  .........  6  ASSUMPTIONS DEFINITIONS  6  .....  Nursing Process Graduate Nurse P a t i e n t Problem . . . . Defined Data Base LIMITATIONS ..... SUMMARY II.  3  7 7 7 7 8 8  REVIEW OF THE LITERATURE  10  INTRODUCTION  '. .  10  HISTORICAL DEVELOPMENT OF THE NURSING PROCESS. . .  10  iv  Chapter  Page  THE NURSING PROCESS .  11  ASSESSMENT  14  Nursing H i s t o r y and Assessment C r i t e r i a . . . . Problem L i s t . . PLANNING  III.  .'  14 17 • 18  IMPLEMENTATION  21  EVALUATION  22  METHOD OF RECORDING THE NURSING PROCESS . . . . . .  23  SUMMARY  26  METHODOLOGY  28  OVERVIEW  28  RESEARCH DESIGN  29  Sample Hypotheses . . . . . Independent V a r i a b l e Dependent V a r i a b l e  29 32 33 33  PRETEST  34  C r i t e r i a Used i n A u d i t i n g P a t i e n t Records . . . Judges Used i n A u d i t i n g P a t i e n t Records . . . . A t t i t u d e Scale INSTRUCTIONAL PROGRAM  ...  P r e - e s t a b l i s h e d O b j e c t i v e s f o r the Graduate Nurse Phases o f the I n s t r u c t i o n a l Program POST-TEST  35 37 37 40 46 47 49  SUMMARY  ...... v  49  Chapter  IV.  Page  ANALYSIS OF THE DATA .  . 50  INTRODUCTION  50  ASSESSMENT  50  Hypothesis 1 Results Hypothesis 2 Results Hypothesis 3  51 51 52 52 52  Results  52  PLANNING . .  53  Hypothesis 4  53  Results  53  IMPLEMENTATION  57  Hypothesis 5  57  Results  57  EVALUATION  . . . . 59  Hypothesis 6  59  Results  59  ATTITUDE TOWARD THE NURSING PROCESS  60  Hypothesis 7 Results ..... DISCUSSION OF LIMITATIONS Method o f Recording the Nursing Process . . . . U n i f i e d Front ..... Time i n the C l i n i c a l Area Number o f Role Models SUMMARY EFFECTIVENESS OF THE INSTRUCTIONAL PROGRAM . . . . .  60 61 62 63 64 64 65 66 65  vi  Chapter  V.  Page  SUMMARY, CONCLUSIONS, AND IMPLICATIONS FOR RESEARCH AND PRACTICE  67  SUMMARY  67  CONCLUSIONS  69  IMPLICATIONS FOR RESEARCH  69  Recommendations  70  IMPLICATIONS FOR PRACTICE  71  Recommendations  71  SUMMARY FOOTNOTES  «  a  e  72 *  .  a  «  a  o  o  o  «  0  o  o  o  a  a  e  e  «  o  «  o  «  73  »  BIBLIOGRAPHY  86  APPENDIX A - FORM OF CONSENT APPENDIX B - PATIENT RECORDS APPENDIX C - QUESTIONNAIRE  . 93 .  .....  96  . . . . . . . . . . . . . . . . 101  APPENDIX D - COMMUNICATION TO PANEL OF EXPERTS  . . . . . . 105  APPENDIX E - WRITTEN INFORMATION ON THE NURSING PROCESS . . 107  vii  LIST OF TABLES Table I.  II.  III.  IV.  V.  VI.  VII.  VIII.  IX.  Page P a r t i c i p a n t s and Non P a r t i c i p a n t s i n the C l i n i c a l Area From Which the Study Group was S e l e c t e d  30  P a r t i c i p a n t s and Non P a r t i c i p a n t s i n the C l i n i c a l Area From Which the Control Group was S e l e c t e d . . ,  31  Results Obtained by a Panel o f Three A u d i t i n g P a t i e n t Records Using the Established Criteria  Judges .....  39  Scores Obtained From Respondents on the T e s t Retest o f the Q u e s t i o n n a i r e Measuring A t t i t u d e Toward the Nursing Process  40  Results o f the P a t i e n t Records Audited Using the C r i t e r i a E s t a b l i s h e d f o r the Assessment Phase o f the Nursing Process . , . .  51  Results of the P a t i e n t Records Audited Using C r i t e r i a E s t a b l i s h e d f o r the Planning Phase of the Nursing Process .....  55  Results of the P a t i e n t Records Audited Using the C r i t e r i a E s t a b l i s h e d f o r the Implementation Phase of the Nursing Process  58  Results of the P a t i e n t Records Audited Using C r i t e r i a E s t a b l i s h e d f o r the E v a l u a t i o n Phase of the Nursing Process  60  Pre and Post T e s t Results from the Q u e s t i o n n a i r e on A t t i t u d e Toward the Nursing Process f o r the Study Group and the Control Group  61  .vii i  LIST OF FIGURES Figure 1.  2.  Page Behaving-Learning Cycle Showing D e c i s i o n Making i n F a m i l i a r S i t u a t i o n s a t I n t u i t i v e and V e r b a l i z e d L e v e l s , and Problem S o l v i n g in Unfamiliar Situations  42  Meaning, F e e l i n g , and Concepts . •  43  ix  ACKNOWLEDGEMENTS  I would l i k e t o express my a p p r e c i a t i o n t o the n u r s i n g s t a f f o f a l a r g e general h o s p i t a l i n the lower mainland f o r t h e i r cooperation i n t h i s study. My s p e c i a l thanks t o Nadene Carlson and Ann Oleksiuk f o r t h e i r a s s i s t a n c e i n the c o l l e c t i o n o f data and t o Dr. Margaret Campbell f o r her a s s i s t a n c e i n the development o f the i n s t r u c t i o n a l program on the n u r s i n g process.  I a l s o wish t o thank P r o f e s s o r s  Jack Yensen and Mary C r u i s e f o r t h e i r advice and guidance.  x  1  CHAPTER I INTRODUCTION TO THE STUDY  INTRODUCTION T h i s study focuses on the n u r s i n g process which c o n s i s t s of f o u r phases, assessment, p l a n n i n g , implementing  and e v a l u a t i n g .  In recent years there has been a great deal o f d i s c u s s i o n i n the l i t e r a t u r e concerning the nursing process.  I t has been  s a i d i t s use i s e s s e n t i a l f o r n u r s i n g t o s u r v i v e as a p r o f e s s i o n , 4 t h a t i t i s the very essence o f n u r s i n g , and t h a t nursing care 5  2  planning i s an i n t e g r a l p a r t o f n u r s i n g c a r e . There i s a strong b e l i e f found i n the l i t e r a t u r e t h a t the nursing process i s very important i f not a b s o l u t e l y e s s e n t i a l t o q u a l i t y p a t i e n t care.  However, t h i s same commitment t o i t s use  i s not found i n the c l i n i c a l area.  There i s an attempt i n the  c l i n i c a l area t o use the nursing process, manifested i n p a r t by the use o f the nursing care plan. A d e f i n e d data base, which i s p a r t o f the assessment phase and used i n t e r c h a n g e a b l y i n t h i s paper with the n u r s i n g h i s t o r y , i s e s s e n t i a l t o the subsequent phases o f the p r o c e s s , but very often t h i s data base i s incomplete.  The data base  may only c o n t a i n i n f o r m a t i o n regarding the p a t i e n t s v i t a l s i g n s , age, sex, medical d i a g n o s i s , a l l e r g i e s , medications  2 and p r o s t h e t i c d e v i c e s .  There may be more i n f o r m a t i o n i n c l u d e d  but not c o n s i s t e n t l y e i t h e r i n frequency o f occurrence o r areas covered.  Due to the l i m i t e d data base the p a t i e n t problems  i d e n t i f i e d c e n t e r mainly around the medical d i a g n o s i s . Again there are e x c e p t i o n s but they are dependent on the i n d i v i d u a l nurse r a t h e r than a s y s t e m a t i c approach to p a t i e n t c a r e . The p l a n n i n g phase o f the n u r s i n g process i s o f t e n incomplete f o r two reasons: (1) i n s u f f i c i e n t i n f o r m a t i o n r e g a r d i n g the p a t i e n t upon which to formulate a p l a n ; and (2) an absence o f measurable p a t i e n t g o a l s which are necessary i n g u i d i n g the p l a n n i n g o f c a r e . T h i s i s not to say t h a t nurses never plan c a r e but t h a t the p l a n n i n g i s not c e n t e r e d around predetermined g o a l s , r e l a t i n g to s p e c i f i c p a t i e n t problems t h a t have been i d e n t i f i e d .  T h i s type  o f p l a n n i n g tends to be nurse performance c e n t e r e d r a t h e r than p a t i e n t problem o r i e n t e d . The incompleteness o f the assessment and p l a n n i n g phases o f the n u r s i n g process g r e a t l y a f f e c t the implementation phase. The implementation o f a plan o f c a r e c e n t e r e d around predetermined p a t i e n t goals i s u s u a l l y not p o s s i b l e due to the absence o f such a p l a n . The p a t i e n t i s most d e f i n i t e l y r e c e i v i n g care which i s what the implementation phase i s concerned w i t h , but (as with the p l a n n i n g phase) the care u s u a l l y c e n t e r s around immediate p a t i e n t needs and i n many cases tends to be nurse performance c e n t e r e d r a t h e r than p a t i e n t problem o r i e n t e d . I t becomes immediately apparent t h a t the e v a l u a t i o n phase o f the n u r s i n g process i s extremely d i f f i c u l t , i f not i m p o s s i b l e ,  3 to c a r r y out due to the inadequacies o f the former three phases. E v a l u a t i o n o f care r e c e i v e d by the p a t i e n t depends on the comp l e t e n e s s o f the problem l i s t and predetermined goals i n r e l a t i o n to these problems.  Unless these two c o n d i t i o n s are met there i s  no way o f knowing i f p a t i e n t problems have been missed, o r , what behaviour the p a t i e n t needs to e x h i b i t i n o r d e r to determine success o r f a i l u r e o f the c a r e he r e c e i v e s . Several nurses were asked on an informal b a s i s , to g i v e t h e i r o p i n i o n s concerning the reasons f o r the incompleteness o f the phases o f the n u r s i n g process i n the c l i n i c a l a r e a .  There were  s e v e r a l reasons given and they centered mainly around the f o l l o w i n g : (1) i n s u f f i c i e n t time to c o l l e c t data and subsequently plan p a t i e n t c a r e , i n the c l i n i c a l a r e a ; (2) l a c k o f adequate s k i l l s r e q u i r e d to c a r r y out the n u r s i n g p r o c e s s ; and (3) l a c k o f c o n v i c t i o n o f the n e c e s s i t y o f using the n u r s i n g process i n order to g i v e q u a l i t y patient care.  I t was f e l t t h a t the l a c k o f s k i l l s o f the graduate  nurse might have been the major problem.  THE PURPOSE OF THE STUDY The purpose o f the study i s to determine whether an i n s t r u c t i o n a l program f o r graduate nurses concerning the n u r s i n g process would: (1) i n c r e a s e the frequency with which a n u r s i n g h i s t o r y ( d e f i n e d data base) i s obtained on i n d i v i d u a l p a t i e n t s ; (2) i n c r e a s e the number o f p a t i e n t problems  identified;  4 (3) i n c r e a s e the c o n s i s t e n c y of the i n d i v i d u a l p a t i e n t problems with e s t a b l i s h e d c r i t e r i a ; (4) show subsequent p l a n n i n g , implementing  improvement i n the  and e v a l u a t i o n phases of the n u r s i n g  process; and (5) have a f a v o u r a b l e e f f e c t on how the graduate nurse views the nursing process.  THE PROBLEM Statement of the  Problem  I f the graduate nurse completes an i n s t r u c t i o n a l program concerning the n u r s i n g p r o c e s s , what e f f e c t w i l l i t have on the use o f the n u r s i n g process i n the p r a c t i c e area?  There are three  questions which need to be answered i n order to s o l v e t h i s namely:  problem,  (1) i f the graduate nurse completes an i n s t r u c t i o n a l  program concerning the n u r s i n g p r o c e s s , w i l l there be an i n c r e a s e i n the frequency with which a d e f i n e d data base i s obtained on individual patients?  (2)  I f the graduate nurse completes  an  i n s t r u c t i o n a l program concerning the n u r s i n g p r o c e s s , w i l l there be an improvement i n the p l a n n i n g , implementing phases?  And f i n a l l y , (3)  and e v a l u a t i n g  i f the graduate nurse completes  an  i n s t r u c t i o n a l program concerning the n u r s i n g p r o c e s s , w i l l there be a f a v o u r a b l e e f f e c t on the way the graduate nurse views the n u r s i n g process?  5 S p e c i f i c O b j e c t i v e s o f the Study The s p e c i f i c o b j e c t i v e s o f the study a r e : (1) t o provide the graduate nurse with i n f o r m a t i o n regarding a l l phases o f the n u r s i n g process; and (2) t o provide the graduate nurse with an o p p o r t u n i t y t o p r a c t i s e the r e q u i r e d s k i l l s with a s s i s t a n c e . In a d d i t i o n t o the above o b j e c t i v e s , data w i l l be gathered which w i l l  i n d i c a t e whether p r o v i d i n g the graduate  nurse  with i n f o r m a t i o n on a l l phases o f the n u r s i n g process and an o p p o r t u n i t y t o p r a c t i s e the r e q u i r e d s k i l l s with a s s i s t a n c e w i l l : (1) have an e f f e c t on the frequency with which a d e f i n e d data base i s obtained on i n d i v i d u a l p a t i e n t s ; (2) improve the p l a n n i n g , implementing  and e v a l u a t i n g phases o f the n u r s i n g p r o c e s s ; and  (3) have a f a v o u r a b l e e f f e c t on the way the graduate  nurse  views the n u r s i n g process.  S i g n i f i c a n c e o f the Problem Nursing l e a d e r s , such as Yura and Walsh,  L i t t l e and  C a r n e v a l i / Mayers,^ M a r r i n e r ^ and A l f a n o , ^ hold the b a s i c assumption t h a t i f the n u r s i n g p r o c e s s , i n i t s e n t i r e t y , i s used when c a r i n g f o r a p a t i e n t the q u a l i t y o f care t h a t p a t i e n t r e c e i v e s w i l l be i n c r e a s e d .  However, i t does not appear t h a t  t h i s assumption has been t e s t e d , nor does i t seem t h a t the n u r s i n g process i s used i n p r a c t i c e . There i s a l s o a great deal o f concern today r e g a r d i n g 11 12 13 14 measurement c r i t e r i a f o r a s s e s s i n g q u a l i t y c a r e , ' ' '  6  with p a r t i c u l a r i n t e r e s t i n outcome c r i t e r i a . ' ' ^ 1 5  1 6  7  However,  t h i s task i s l a r g e l y impeded by the absence o f predetermined p a t i e n t g o a l s , plans c a r r i e d out i n an attempt t o meet those goals and e v a l u a t i o n o f the success or f a i l u r e i n meeting the goals.  The use o f the n u r s i n g process together with a permanent  r e c o r d o f the process would provide the necessary ( i f not s u f f i c i e n t ) i n f o r m a t i o n t o e s t a b l i s h outcome c r i t e r i a . Use o f the n u r s i n g process i n p r a c t i c e i s a necessary p r e r e q u i s i t e f o r the measurement o f q u a l i t y p a t i e n t c a r e . The q u a l i t y o f p a t i e n t care c o u l d be measured by a u d i t i n g each phase o f the n u r s i n g process i n r e l a t i o n t o i t s appropriateness and e f f e c t i v e n e s s i n i d e n t i f y i n g and d e a l i n g with p a t i e n t problems. T h i s study, although not d i r e c t l y concerned with measuring the q u a l i t y o f p a t i e n t c a r e , i s an attempt t o t e s t the e f f e c t i v e n e s s o f one approach t o the implementation o f the n u r s i n g process i n p r a c t i c e . ASSUMPTIONS T h i s study i s based on the f o l l o w i n g assumptions: (1) the n u r s i n g process i s not being c a r r i e d out c o n s i s t e n t l y i n the c l i n i c a l area; (2) graduate nurses are f a m i l i a r with the term n u r s i n g process and have f e e l i n g s and a t t i t u d e s concerning i t s use; (3) graduate nurses do not always possess the s k i l l s t o c a r r y out the n u r s i n g process; and (4) t e a c h i n g f a c i l i t a t e s l e a r n i n g .  7 DEFINITIONS Nursing Process The n u r s i n g process i s an o r d e r l y , s y s t e m a t i c manner o f determining p a t i e n t problems, making plans to r e s o l v e them, i n i t i a t i n g the plan or a s s i g n i n g o t h e r s to implement i t , and e v a l u a t i n g the e x t e n t to which the plan was e f f e c t i v e i n r e s o l v 19  ing the problems  identified.  Graduate Nurse A person who has graduated with a diploma from an approved school o f n u r s i n g and i s l i c e n s e d to p r a c t i s e . P a t i e n t Problem A p a t i e n t problem e x i s t s whenever an i n d i v i d u a l p a t i e n t can no longer meet one o r more o f h i s b a s i c needs without a s s i s t a n c e .  Defined Data Base A n u r s i n g h i s t o r y obtained on c l e a r l y s p e c i f i e d (Appendix  B)  parameters.  8 LIMITATIONS The l i m i t a t i o n s of t h i s study are:  (1) the method  of s e l e c t i o n of the study group and c o n t r o l group i s not random, t h e r e f o r e , the r e s u l t s cannot be g e n e r a l i z e d to a l a r g e r popul a t i o n ; (2) f i v e graduate nurses out o f a l l n u r s i n g p e r s o n n e l , on the medical u n i t , i n v o l v e d i n a s s e s s i n g , p l a n n i n g ,  implementing  and e v a l u a t i n g p a t i e n t care w i l l have completed the i n s t r u c t i o n a l program.  T h e r e f o r e , p a t i e n t records which w i l l be a u d i t e d , may  not be completed by a member of the study group; (3) i t w i l l not be p o s s i b l e to compare the graduate nurse's a t t i t u d e , on an i n d i v i d u a l b a s i s , toward the n u r s i n g process on the pre and post t e s t due to the requirements of anonymity i n the completion of the q u e s t i o n n a i r e .  The comparison, t h e r e f o r e , w i l l be on the  average d i f f e r e n c e and any s i g n i f i c a n t d i f f e r e n c e t h a t may  be  found i n i n d i v i d u a l s w i l l be obscured; and (4) p a t i e n t records o n l y , w i l l be used to measure the use of the n u r s i n g process. With t h i s method of measurement the phases o f the nursing process which are c a r r i e d out and not recorded w i l l not be c o n s i d e r e d .  * SUMMARY T h i s study i s an attempt to t e s t one approach to the implementation  of the nursing process i n p r a c t i c e which i s , to  provide the graduate nurse with i n f o r m a t i o n regarding the nursing process and an o p p o r t u n i t y to p r a c t i s e the r e q u i r e d  9 s k i l l s under s u p e r v i s i o n .  The purpose of t h i s study i s t o  determine whether an i n s t r u c t i o n a l program f o r graduate concerning the nursing process would:  nurses  (1) i n c r e a s e the frequency  with which a n u r s i n g h i s t o r y ( d e f i n e d data base) i s obtained on i n d i v i d u a l p a t i e n t s ; (2) i n c r e a s e the number o f p a t i e n t problems i d e n t i f i e d ; (3) i n c r e a s e the c o n s i s t e n c y o f the i n d i v i d u a l p a t i e n t problems, with e s t a b l i s h e d assessment c r i t e r i a ; (4) show subsequent improvement i n the p l a n n i n g , implementing  and e v a l u a t i o n phases o f  the nursing process; and (5) have a f a v o u r a b l e e f f e c t on how the graduate nurse views the nursing process.  10  CHAPTER II REVIEW OF THE LITERATURE  INTRODUCTION In reviewing the l i t e r a t u r e i t became apparent t h a t there i s ambiguity among nursing l e a d e r s concerning a d e f i n i t i o n o f the n u r s i n g process and the terminology used t o d e s c r i b e i t . T h i s ambiguity among n u r s i n g l e a d e r s leads t o c o n f u s i o n i n the p r a c t i c e a r e a , when there i s an attempt to c a r r y o u t the n u r s i n g process. T h i s c o n f u s i o n concerning the n u r s i n g process may c o n t r i b u t e , t o a l a r g e e x t e n t , to the l a c k o f i t s use i n p r a c t i c e .  HISTORICAL DEVELOPMENT OF THE NURSING PROCESS A d i s c u s s i o n o f the h i s t o r y o f "planned i n d i v i d u a l i z e d c a r e " can be found i n H e n d e r s o n J  Henderson p o i n t s o u t t h a t "planned  i n d i v i d u a l i z e d n u r s i n g c a r e " had i t s beginnings i n the case study method, which was d e s c r i b e d i n 1929 by Deborah MacLurg Jensen. Henderson a l s o p o i n t s out t h a t a u n i t e n t i t l e d "Planning I n d i v i d u a l i z e d Care" was i n t r o d u c e d i n t o the f i r s t n u r s i n g course o f the Curriculum Guide f o r Schools o f Nursing, p u b l i s h e d by the National League f o r Nursing Education i n 1937.  n  A c c o r d i n g t o Yura and Walsh the term nursing process was not p r e v a l e n t i n the nursing l i t e r a t u r e u n t i l the m i d - s i x t i e s , although some l i m i t e d evidence o f the term appeared during the 2 fifties. In 1955 L y d i a H a l l d e s c r i b e d n u r s i n g as a process, but Orlando was one o f the e a r l i e s t authors to use t h e term n u r s i n g 3  process. In 1967 Yura and Walsh i d e n t i f i e d the phases o f t h e n u r s i n g process as: a s s e s s i n g ; p l a n n i n g ; implementing; and 4 evaluating.  THE NURSING PROCESS In depth d i s c u s s i o n o f the n u r s i n g process can be found i n Yura and Walsh, M a r r i n e r , 5  6  Mayers,  7  L i t t l e and C a r n e v a l i ^  q  and Becknell and Smith.  These authors l a b e l the v a r i o u s phases  o f the n u r s i n g process d i f f e r e n t l y but a l l agree t h a t i t i s a systematic approach to nursing care and t h a t care planning must i n c l u d e : a n u r s i n g h i s t o r y ; a problem l i s t o r n u r s i n g behavioural o b j e c t i v e s o r g o a l s ; a plan o f c a r e ;  diagnoses;  implementation  o f the plan o f c a r e ; and e v a l u a t i o n o f t h e c a r e provided.  There  i s a l s o agreement t h a t the care must be planned and c a r r i e d out i n c o o p e r a t i o n with the p a t i e n t and/or h i s f a m i l y . -Nursing l i t e r a t u r e concerned with the n u r s i n g process i s almost e x c l u s i v e l y found i n North America.  An exception to t h i s  i s an a r t i c l e by Hargreaves pub!ished i n B r i t a i n .  1 0  He conducted  12 a l i t e r a t u r e search on the nursing process and was s u r p r i s e d at the s c a r c i t y of a r t i c l e s on the n u r s i n g process i n B r i t a i n , because he f e l t t h a t i t i s as a p p l i c a b l e i n B r i t a i n as i t i s i n North America. Several s t u d i e s were c a r r i e d out by an i n t e r d i s c i p l i n a r y group at the U n i v e r s i t y of Colorado, which i n v e s t i g a t e d the c l i n i c a l i n f e r e n c e process as i t r e f e r r e d to n u r s i n g . T h e y  used  the Lens Model i n l o o k i n g at t h i s i n f e r e n t i a l process, which i n c l u d e d : i d e n t i f i c a t i o n of the s t a t e of the p a t i e n t from which cues are read or i n t e r p r e t e d ; i n f e r e n c e s deduced; and the a c t i o n planned 18 implemented according to d e f i n e d g o a l s .  and  A study of a group of p a t i e n t s c a r r i e d out at the Loeb Center i n New York, where the nursing process i s c o n s i s t e n t l y used w i t h i n a well d e f i n e d philosophy, showed no s i g n i f i c a n t d i f f e r e n c e i n p a t i e n t outcomes when compared to a group of p a t i e n t s cared f o r 19 in a conventional general h o s p i t a l environment.  Although  the  r e s u l t s lacked s t a t i s t i c a l s i g n i f i c a n c e , the Loeb Center group d i d f a r e b e t t e r than the c o n t r o l group at a l e s s o v e r a l l c o s t . Several authors b e l i e v e t h a t the use of the n u r s i n g  process  i n p r a c t i c e i s e s s e n t i a l to q u a l i t y care but express concern the d i f f i c u l t y i n p u t t i n g i t i n t o p r a c t i c e . Mauksch and  with  David  p r e d i c t t h a t nursing as a d i s c r e t e occupation w i l l not s u r v i v e unless nurses adopt the nursing process as a way of p r o f e s s i o n a l 20 life.  They d i s c u s s the c h a r a c t e r i s t i c s of a p r o f e s s i o n and  f e e l t h a t the use of the n u r s i n g process would y i e l d these  charac-  13 t e r i s t i c s in nursing.  Lewis b e l i e v e s t h a t the n u r s i n g process can  be the key which opens the door to p a t i e n t problems and to the ways 21 o f s o l v i n g them.  According to C a r l s o n the nursing process i s  set up f o r one purpose, which i s , to encourage the nurse to use a problem-solving approach i n a s s i s t i n g the p a t i e n t to understand his l i f e processes o r s t y l e so t h a t he can b e t t e r c o n t r o l and cope 22 with h i s i l l n e s s .  The reasons C a r l s o n o f f e r s f o r the n u r s i n g  process not being used i n p r a c t i c e are: the o l d e r graduate  never  used i t ; the newer graduate may t h i n k t h a t the process i s to be used o n l y f o r student l e a r n i n g ; and n u r s i n g care plans are thrown away because they are not viewed as important enough to become p a r t o f the permanent r e c o r d . Zimmerman and Gohrke o u t l i n e d the care f o r a p a t i e n t using the n u r s i n g process and they f e l t t h a t the care f o r t h a t p a t i e n t was enhanced by the u t i l i z a t i o n o f a systematic process o f a s s e s s 23 ment, goal s e t t i n g , p l a n n i n g , implementing  and e v a l u a t i o n .  They f e e l t h a t the major s t r e n g t h o f the n u r s i n g process i s the g o a l - d i r e c t e d n e s s o f nursing c a r e , and the f a c t t h a t the nurse can use m e a s u r a b l e c r i t e r i a to demonstrate her c o n t r i b u t i o n to the patients well-being. Yura and Walsh b e l i e v e t h a t the use o f the nursing process i s c e n t r a l to a l l n u r s i n g a c t i o n s , i s the very essence o f n u r s i n g and i s a p p l i c a b l e i n any s e t t i n g , i n any frame of r e f e r e n c e and 24 w i t h i n any philosophy. L i t t l e and C a r n e v a l i see the planning 25 o f care as an i n t e g r a l p a r t o f nursing c a r e . Mayers p o i n t s out  14 t h a t the n u r s i n g care plan has been seen by f e d e r a l and s t a t e governing and review a g e n c i e s , as well as by n u r s i n g i t s e l f , to be a most b a s i c requirement f o r the subsequent e v a l u a t i o n o f n u r s i n g success o r f a i l u r e . implementing  She a l s o d i s c u s s e s the d i f f i c u l t y i n  the planning o f care i n p r a c t i c e and suggests f o u r  b a s i c u n d e r l y i n g reasons: . . . (1) A l a c k o f general understanding among Nursing Educators and Nursing S e r v i c e s t h a t there i s and should be a s i g n i f i c a n t d i f f e r e n c e between a d e t a i l e d , time-consuming e d u c a t i o n a l t o o l f o r l e a r n i n g and a f u n c t i o n a l , e f f i c i e n t s e r v i c e t o o l f o r n u r s i n g care d e l i v e r y ; (2) u n c l e a r d e f i n i t i o n s i n the s e r v i c e s e t t i n g regarding the meaning and purpose o f a Nursing Care P l a n , and ambiguity regarding the agency's d e f i n i t i o n o f p a t i e n t problems and needs o r o b j e c t i v e s and approaches; (3) a l a c k o f c l e a r d e l e g a t i o n o f r e s p o n s i b i l i t y to c e r t a i n n u r s i n g personnel who are to be r e s p o n s i b l e f o r i n i t i a t i n g and updating care p l a n s ; and (4) an absence o f a c l e a r , well d e f i n e d r a t i o n a l e f o r r u l i n g i n and r u l i n g out which problems and items should appear on a Nursing Care Plan.27  ASSESSMENT Nursing H i s t o r y and Assessment C r i t e r i a The assessment phase o f the n u r s i n g process has r e c e i v e d a g r e a t deal o f a t t e n t i o n i n the l i t e r a t u r e . i n t h i s area are Smith and McPhetridge.  Two prominent authors  Smith developed a C l i n i c a l 28  Nursing Tool a t the U n i v e r s i t y o f F l o r i d a i n 1968.  The  t h e o r e t i c a l framework f o r the t o o l was V i r g i n i a Henderson's Philosophy o f Nursing and was centered around the f o u r t e e n b a s i c  15 human needs i d e n t i f i e d by Henderson.  29  The t o o l p r o v i d e d a system-  a t i c way o f o b t a i n i n g a n u r s i n g h i s t o r y and provided g u i d e l i n e s f o r the subsequent phases o f the n u r s i n g process.  A further  refinement o f the t o o l along with a d i s c u s s i o n o f the s k i l l s t h a t are necessary f o r o b t a i n i n g a n u r s i n g h i s t o r y can be found i n Becknell 30 and Smith.  McPhetridge  a l s o developed a Nursing H i s t o r y Form  which i n c l u d e d i n f o r m a t i o n on the p a t i e n t s p e r c e p t i o n s and expect a t i o n s r e l a t e d to i l l n e s s and/or h o s p i t a l i z a t i o n and centered 31 around s p e c i f i c b a s i c needs.  McPhetridge  believes that a nursing  h i s t o r y i s one means to i n d i v i d u a l i z e n u r s i n g care and  developed  the h i s t o r y form to help the nurse make maximum use o f her l i m i t e d time with the p a t i e n t by o b t a i n i n g s y s t e m a t i c a l l y the i n f o r m a t i o n 32 needed to plan h i s n u r s i n g c a r e . Another method o f assessment was developed by McCain and 33 centered around i d e n t i f i e d b o d i l y f u n c t i o n s .  The f u n c t i o n a l  areas a r e ; s o c i a l , mentalj emotional, body temperature, r e s p i r a t o r y , c i r c u l a t o r y , n u t r i t i o n a l , e l i m i n a t i o n and r e p r o d u c t i v e s t a t u s , s t a t e o f r e s t and comfort, s t a t e o f s k i n and appendages, sensory p e r c e p t i o n , and motor a b i l i t y . Hamdi and Hutelmyer developed a Nursing Assessment Tool which c o n s i s t e d o f ten c a t e g o r i e s based on the t h i r t e e n f u n c t i o n a l 34 a b i l i t i e s i d e n t i f i e d by McCain.  T h i s t o o l was t e s t e d by Hamdi  and Hutelmyer and there was no s i g n i f i c a n t d i f f e r e n c e found between the number o f v a l i d p a t i e n t problems, when compared to  16 the t o t a l number o f p a t i e n t problems, i d e n t i f i e d by the group using 35 the t o o l , and the group not using the t o o l . However, the group using the t o o l s t a t e d a s i g n i f i c a n t l y g r e a t e r p r o p o r t i o n o f reasons which s u b s t a n t i a t e d the problems. F u r t h e r work done i n the assessment phase o f the n u r s i n g 36 process was c a r r i e d out by Marshall and Feeny.  They compared  the use o f a s t r u c t u r e d i n t e r v i e w and an i n t u i t i v e i n t e r v i e w and found t h a t the s t r u c t u r e d i n t e r v i e w was found to y i e l d s i g n i f i c a n t l y more i n f o r m a t i o n i n approximately h a l f the time.  McPhetridge  s t u d i e d the r e l a t i o n s h i p o f p a t i e n t s ' responses to n u r s i n g h i s t o r y questions and s e l e c t e d f a c t o r s and found a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n twenty-eight instances between responses 37 variables studied.  and  Two o f the i n t e r e s t i n g d i s c o v e r i e s i n her  study were, the p a t i e n t s a b i l i t y to i d e n t i f y t h e i r own problems and t h e i r a b i l i t y to i d e n t i f y p o s s i b l e s o l u t i o n s , which emphasize the importance o f planning care with the p a t i e n t r a t h e r than f o r 38 him.  H e f f e r i n and Hunter conducted a study on nursing care  plans and found s i g n i f i c a n t i n c r e a s e s i n the number o f p a t i e n t problem statements and n u r s i n g i n t e r v e n t i o n statements  occurred  only f o l l o w i n g the i n t r o d u c t i o n o f the n u r s i n g h i s t o r y , as d i d the numbers o f nursing i n t e r v e n t i o n s r e l a t e d to the i d e n t i f i e d 39 p a t i e n t problems.  T h e i r f i n d i n g s suggested t h a t , s i n c e the  care plans r e f l e c t e d l e s s than h a l f the p a t i e n t problems i d e n t i f i e d on the n u r s i n g h i s t o r i e s , care plan s t u d i e s alone might not be a p p r o p r i a t e f o r e v a l u a t i n g the breadth o f n u r s i n g care p l a n n i n g .  17 Mayers, i n l o o k i n g a t assessment c r i t e r i a , found nine c r i t e r i a used by Community Health Nurses i n a s s e s s i n g p a t i e n t status.^  These c r i t e r i a were:  (1) a b i l i t y to a c t independently;  (2) p h y s i c a l c o n d i t i o n ; (3) congruent f e e l i n g s o r a f f e c t ; (4) i n t e r personal a b i l i t y ; (5) v e r b a l a b i l i t y ; (6) a b i l i t y to meet r o l e e x p e c t a t i o n s ; (7) congruent l i f e s t y l e ; (8) a p p r o p r i a t e n e s s o f f u t u r e p l a n s ; and (9) i n t e l l e c t u a l  ability.  Mayers a l s o found  f o u r f a c t o r s t h a t were c l o s e l y c o r r e l a t e d with n u r s e - p e r c e i v e d coping a b i l i t i e s o f the p a t i e n t .  They were:  (1) the ease or d i f f i c u l t y  with which a p a t i e n t allows e n t r y i n t o h i s home; (2) evidence o f an open or c l o s e d environment;  (3) the a b i l i t y o f a p a t i e n t to focus  his a t t e n t i o n and c o n v e r s a t i o n ; and (4) the p a t i e n t s mood-response pattern.  People coping were foynd to be p o s i t i v e i n most o f these  areas and people c o n s i d e r e d not coping were found to be negative i n most o f these a r e a s .  Problem  List Gebbie and L a v i n i n c l a s s i f y i n g n u r s i n g diagnoses have 41  come up with a t e n t a t i v e l i s t o f t h i r t y - f o u r n u r s i n g diagnoses. Nursing diagnoses and n u r s i n g problems are f r e q u e n t l y used i n t e r changeably and judgement based on knowledge i s i n h e r e n t i n the 42 term n u r s i n g diagnoses.  A c c o r d i n g to Chambers, i n v e s t i g a t i n g  the f a c t s about a n u r s i n g problem, i n t e r p r e t i n g those f a c t s and d e c i d i n g the course o f a c t i o n toward s o l v i n g the problem are 43 part of a nursing diagnosis. I t i s important to w r i t e down  18 the d i a g n o s i s because nurses need t o show the p a t i e n t what they are doing and must be able t o say what nurses can t r e a t 44 independently. There are v a r i o u s views on what c o n s t i t u t e s a p a t i e n t problem o r nursing d i a g n o s i s and how they should be s t a t e d .  Yura  and Walsh b e l i e v e t h a t problems are t o be s t a t e d i n terms o f c l i e n t problems, and r e s u l t when b a s i c human needs are e i t h e r not met o r 45 met inadequately. According t o Smith and Becknell a n u r s i n g problem e x i s t s when the p a t i e n t lacks the necessary s t r e n g t h , w i l l , 46 or knowledge, t o meet h i s needs. Mayers d i f f e r e n t i a t e s the problems i n t o usual problems, unusual problems, a c t u a l problems, 47 p o t e n t i a l problems and p o s s i b l e problems.  PLANNING O b j e c t i v e s f o r p a t i e n t care should be w r i t t e n as expected 48 p a t i e n t behaviours. The o b j e c t i v e s serve as a guide t o nurses to where they are going i n p a t i e n t care and t o l e t them know when 49 and where they have a r r i v e d .  Yura b e l i e v e s that the planning  phase begins with the nursing d i a g n o s i s , and terminates with the development o f the n u r s i n g care plan which i s the b l u e p r i n t f o r a c t i o n , p r o v i d i n g d i r e c t i o n f o r implementing 50 p r o v i d i n g the framework f o r e v a l u a t i o n .  the plan and According t o Smith and  Becknell the i n i t i a l plan r e f e r s to the beginning d e s i g n , method, or scheme o f a c t i o n by which the p a t i e n t s n u r s i n g problems are t o  19 be managed.  51  The plan o f care i s a continuous process and as  such, i s r e v i s e d whenever new data i n d i c a t e the need f o r m o d i f i cation.  Mayers has i d e n t i f i e d nine elements o f a care plan:  p h y s i c i a n ' s e x p e c t a t i o n s o f course o f treatment; n u r s i n g c r i t e r i a f o r d i s c h a r g e or maintenance; p h y s i c i a n ' s o r d e r s ; usual problems; unusual problems; expected outcomes; p r e s c r i b e d nursing a c t i o n s ; 53 p a t i e n t response; and standard c a r e r o u t i n e . The b a s i c components o f a w r i t t e n n u r s i n g care plan i d e n t i f i e d by L i t t l e and C a r n e v a l i are: o b s e r v a t i o n and assessment o f the p a t i e n t to r u l e i n and r u l e out present or p o t e n t i a l n u r s i n g care problems; p a t i e n t goals o r o b j e c t i v e s f o r each problem p e r c e i v e d ; n u r s i n g a c t i o n to be undertaken as a means o f accomplishing the goal and r e l i e v i n g the problem; and p a t i e n t responses f o r each problem t h a t must be assessed i n o r d e r t h a t the n u r s i n g c a r e may be evaluated and 54 readjusted. Ciuca conducted a survey on n u r s i n g care plans and found t h a t the care plan was p r i m a r i l y used to note f u n c t i o n a l d u t i e s such as medicines, treatments, v i t a l s i g n s , i n t a k e and output and 55 diagnostic studies.  Notations i n d i c a t i n g the planning o f nursing  a c t i o n were c o n s p i c u o u s l y absent and the n u r s i n g care plan d i d not r e f l e c t the comprehensive approach to p a t i e n t care t h a t i s so e v i d e n t i n the l i t e r a t u r e .  He deduced t h a t the nursing care plan  cannot be c l a s s i f i e d as a t o o l f o r the d e l i v e r y o f p a t i e n t c a r e , 56 s i n c e i t i s not well u t i l i z e d i n p r a c t i c e .  20 G r o s i c k e_t aJL, audited 1347 n u r s i n g care plans and  found  the f o l l o w i n g : i n few i n s t a n c e s were i d e n t i f y i n g data added to t h a t which was stamped with the p a t i e n t s ' admission p l a t e ; d e f i c i e n c i e s were apparent i n d e f i n i n g p a t i e n t s t o t a l needs and  determining  the approaches a s s o c i a t e d with meeting these needs, however, p s y c h o s o c i a l needs and r e l a t e d approaches were found i n over 50% o f the p l a n s ; and both long term and s h o r t term goals were c o n s p i c u 57 o u s l y absent o r u n r e a l i s t i c on over two-thirds o f the plans.  A  q u e s t i o n n a i r e was administered to graduate nurses as p a r t o f t h i s study, and i t was found t h a t the graduate nurses b e l i e v e d l a c k o f time to be the more s i g n i f i c a n t f a c t o r i n not completing care p l a n s , followed by a l a c k o f knowledge and understanding, and f a i l u r e to see the need, importance or u s e f u l n e s s o f n u r s i n g care p l a n s . ^ Sixty-two percent o f the nurses expressed a need f o r help i n 59  r e f i n i n g t h e i r s k i l l s i n p r e p a r i n g n u r s i n g care plans. K e l l y conducted a study o f n u r s i n g care plans used by s t a f f nurses and found that most o f the i n f o r m a t i o n i n c l u d e d i n the plans had to do with n u r s i n g f u n c t i o n s i n r e l a t i o n to the p h y s i c fin ians t h e r a p e u t i c p l a n .  K e l l y b e l i e v e s t h a t nursing care plans  are not u t i l i z e d because students r e c e i v e l i t t l e e x p l a n a t i o n o f the d i f f e r e n c e between a student n u r s i n g care plan designed to e l i c i t the p r i n c i p l e s b a s i c to nursing a c t i o n , and the nursing care plan which i s a c t u a l l y a n u r s i n g order form, which she i s expected to use i n n u r s i n g p r a c t i c e .  21 A study on n u r s i n g care plans was conducted by Hanson which r e s u l t e d i n the i n c o r p o r a t i o n o f the n u r s i n g care plan i n t o the permanent r e c o r d and demonstrated the r e l e v a n c e o f the plan to the 61  care o f a readmitted p a t i e n t .  T h i s study a l s o r e s u l t e d i n a  copy o f the n u r s i n g h i s t o r y and care plan being sent with i n t e r agency and p u b l i c h e a l t h nurse r e f e r r a l s .  IMPLEMENTATION D i s c u s s i o n s o f a t h e o r e t i c a l framework f o r implementing 62 nursing care can be found i n Yura and Walsh and L i t t l e and CO  Carnevali.  The a c t u a l g i v i n g o f n u r s i n g care i n v o l v e s c a r r y i n g  out the p h y s i c i a n s orders and f o l l o w i n g h o s p i t a l p o l i c i e s as well as implementing  nursing orders.  Planned a c t i o n s may be accom-  p l i s h e d by the c l i e n t , some by the nurse and others by n u r s i n g team 65 members. The implementation phase o f the n u r s i n g process draws h e a v i l y upon the i n t e l l e c t u a l , i n t e r p e r s o n a l and t e c h n i c a l s k i l l s 6fi  o f the nurse. and independent  Nursing i n t e r v e n t i o n s i n c l u d e both the dependent f u n c t i o n s o f n u r s i n g , which are: the g i v i n g o f  s t r e n g t h and comfort to a s s i s t f a m i l i e s i n coping with problems; s a f e and e f f i c i e n t performance o f n u r s i n g techniques; c r e a t i o n o f an environment conducive to m a i n t a i n i n g f a m i l y i n t e g r i t y and u n i t y ; p r o t e c t i o n o f the p a t i e n t from danger, i n j u r y , o r r i s k ; teaching to provide knowledge, understanding, and s k i l l s ; and  22 c o u n s e l l i n g and s o c i a l i z i n g to develop a t r u s t i n g , g o a l - d i r e c t e d r e l a t i o n s h i p with the family.*'  7  EVALUATION General d i s c u s s i o n s of e v a l u a t i o n of n u r s i n g care can be found i n P h a n e u f , ^ Wandelt and A g e r , ^ Wandelt and S t e w a r t , Carter, et a l .  70  and  E v a l u a t i o n i s always i n terms of how the c l i e n t 72 i s expected t o respond to the planned a c t i o n . Judgement about 7 1  73  how problems are being r e s o l v e d should o r i g i n a t e with the c l i e n t . Based on the behavioural e x p e c t a t i o n s of the c l i e n t r e l a t i v e t o the mutually agreed upon immediate, i n t e r m e d i a t e and long-range g o a l s , data are c o l l e c t e d so t h a t e v a l u a t i v e judgements can be 74 made.  M a r r i n e r views e v a l u a t i o n as the comparison  of the  p a t i e n t s behaviour with the terminal behavior d e s c r i b e d i n the o b j e c t i v e o f the n u r s i n g care plan and with the b a s e l i n e data i n 75 the n u r s i n g h i s t o r y to determine the p a t i e n t s p r o g r e s s . In p a t i e n t c a r e , the standards f o r c o n t r o l are i n the n u r s i n g care p l, a n . 76 E v a l u a t i o n of n u r s i n g care c o n s i s t s of three frameworks: (1) s t r u c t u r e ; (2) process; and (3) o u t c o m e . cerned with the environment  77  S t r u c t u r e i s con-  or s e t t i n g i n which the care i s g i v e n ,  process r e f e r s to the n u r s i n g p r o c e s s , and outcome i s r e l a t e d to the p a t i e n t ' s responses to the n u r s i n g c a r e .  Bloch f e e l s t h a t  process should be s t u d i e d along with outcome i n order to determine  the cause(s) of a p a r t i c u l a r o u t c o m e /  0  In order to do t h i s she 79  f e e l s t h a t the f o l l o w i n g tasks must be achieved: 1.  development of a s e t of measurable outcome c r i t e r i a s p e c i f i c to n u r s i n g ;  2.  development of r e l i a b l e and v a l i d methods f o r measuring these outcomes;  3.  development of a s e t of measurable process c r i t e r i a ;  4.  development o f r e l i a b l e and v a l i d methods f o r measuring the process of n u r s i n g care i n a l l i t s v a r i o u s forms i n c l u d i n g both the p h y s i c a l aspects o f the process as w e l l as the p s y c h o s o c i a l and c o g n i t i v e a s p e c t s ;  5.  t e s t i n g o f the v a r i o u s aspects of n u r s i n g p r a c t i c e i n r e l a t i o n to p a t i e n t outcomes, by a p p l y i n g process as w e l l as outcome measurement. C r i t e r i a to measure process has been developed by 80  Wandelt and Ager.  The measurement tool i s c a l l e d Q u a l i t y  P a t i e n t Care S c a l e and c o n s i s t s o f 68 items which d e l i n e a t e a c t i o n s by n u r s i n g personnel addressed t o p r o v i d i n g care f o r an 81 individual patient. C r i t e r i a concerned with s t r u c t u r e have been developed by Wandelt and Stewart and the measurement tool i s 82 c a l l e d the S l a t e r Nursing Compentencies Rating S c a l e .  This  s c a l e i s very s i m i l a r to the Q u a l i t y P a t i e n t Care S c a l e but focuses i n on n u r s i n g performance  r a t h e r than care r e c e i v e d by  the p a t i e n t . Another method o f e v a l u a t i n g n u r s i n g care has been 83 developed by Phaneuf.  The method c o n s i s t s of a 50 item  instrument designed to measure the q u a l i t y of care r e c e i v e d by  24 a p a t i e n t during a p a r t i c u l a r c y c l e of care.  Records are audited  a f t e r the p a t i e n t i s discharged using components i d e n t i f i e d i n 84 the f o l l o w i n g areas: 1. a p p l i c a t i o n and execution of p h y s i c i a n ' s l e g a l o r d e r s ; 2.  o b s e r v a t i o n o f symptoms;  3.  s u p e r v i s i o n of the p a t i e n t ;  4.  s u p e r v i s i o n o f those p a r t i c i p a t i n g i n c a r e ;  5.  r e p o r t i n g and r e c o r d i n g ;  6.  a p p l i c a t i o n o f n u r s i n g proceedures  7.  promotion o f h e a l t h by d i r e c t i o n and t e a c h i n g .  and techniques;  and  There have been s e v e r a l attempts to develop outcome c r i t e r i a 85 86 87 for s p e c i f i c patient populations. ' ' H i l g e r f e e l s t h a t outcome c r i t e r i a are always r e l a t e d t o an e s t a b l i s h e d o b j e c t i v e or goal and 88 t h a t c r i t e r i a should be w r i t t e n f o r a s p e c i f i c p o p u l a t i o n . C o r n e l l developed a two dimensional  Q instrument to measure the  q u a l i t y of care given to s p i n a l cord i n j u r e d p a t i e n t s and T a y l o r 89 90 developed outcome c r i t e r i a r e l a t e d to neurology. ' Taylor f e l t that because n u r s i n g i s a group a c t i v i t y no one takes the r e s p o n s i 91 b i 1 i t y f o r planning care. Therefore a d e f i n e d data base i s l a c k i n g that would e s t a b l i s h norms f o r present p r a c t i c e and form a b a s i s f o r comparing the e f f e c t i v e n e s s of one method of care over 92 another. Although there has been i n d i v i d u a l attempts at e v a l u a t i n g q u a l i t y p a t i e n t care an o v e r a l l agreement on what c o n s t i t u t e s q u a l i t y p a t i e n t care i s not apparent i n the l i t e r a t u r e . f e e l s t h a t n u r s i n g does not have r e l i a b l e i n f o r m a t i o n  Schlotfeldt concerning  25 p r e d i c t a b l e responses o f p a t i e n t s , or agreement except i n a general way, about p h y s i o l o g i c a l and p s y c h o l o g i c a l responses which can be 93 judged good or bad.  Information on and agreement o f , p r e d i c t a b l e  responses o f p a t i e n t s , a r e necessary i n developing outcome c r i t e r i a .  METHOD OF RECORDING THE NURSING PROCESS The present method o f r e c o r d i n g i n the c l i n i c a l area does 95 96 97 not r e f l e c t the use o f the n u r s i n g p r o c e s s . ' ' Mitchell points out three purposes o f nurses' notes and suggests t h a t due t o the present method o f r e c o r d i n g , these purposes are n o t being 98 fulfilled.  The purposes are:  a l e g a l document o f p a t i e n t c a r e ;  communication o f the p a t i e n t ' s responses t o medical and n u r s i n g c a r e ; r e f e r e n c e f o r the p h y s i c i a n i n h i s d i a g n o s i s and treatment. McCloskey b e l i e v e s t h a t the w r i t t e n n u r s i n g care p l a n i s no l o n g e r a s u c c e s s f u l tool f o r planning and communicating p a t i e n t c a r e , and 99 t h a t i t must be r e p l a c e d by problem-oriented r e c o r d s .  Discussion  of problem-oriented records as they r e l a t e t o the p r a c t i c e o f medicine, can be found i n W e e d . ^  The p a r t s o f the problem-  o r i e n t e d medical records advocated by Weed are the d e f i n e d data base, problem l i s t , i n i t i a l plan and progress notes.  General d i s c u s s i o n s  of problem-oriented records as they r e l a t e t o the n u r s i n g process use Weed's approach as a b a s i c guide, and can be found i n Becknell and S m i t h , ^  Woolley e_t a]_.  and Hurst and W a l k e r . ^  The  s i g n i f i c a n c e o f problem-oriented records i s p o i n t e d out by Woody and  26  Mai 1ison who b e l i e v e t h a t i f no one w r i t e s down c o n s i s t e n t l y what i s done f o r p a t i e n t s and what i s thought should be done, i t i s 104 d i f f i c u l t to a u d i t performance and understanding. of the a p p l i c a b i l i t y of problem-oriented  As evidence  records to the n u r s i n g  process, Vaughan-Wrobel and Henderson have j u s t p u b l i s h e d a workbook f o r student nurses on the problem-oriented  system i n n u r s i n g .  SUMMARY In summary, the l i t e r a t u r e on the n u r s i n g process  has  been reviewed to d i s c o v e r how n u r s i n g leaders view the n u r s i n g process, the s i g n i f i c a n c e of the nursing process i n p a t i e n t c a r e , the present use of the n u r s i n g process i n p r a c t i c e and the r e c o r d i n g of the n u r s i n g process.  I t would seem t h a t although the nursing  process i s valued by n u r s i n g leaders t h i s same commitment i s not found i n p r a c t i c e . Several authors have put f o r t h reasons f o r t h i s d i f f e r e n c e and have proposed v a r i o u s s o l u t i o n s . T e s t i n g o f the v a r i o u s s o l u t i o n s i n r e l a t i o n t o a l l phases of the nursing process i n the p r a c t i c e area were not found. A f t e r reviewing the various d e f i n i t i o n s of the n u r s i n g process, the one from Yura and Walsh was chosen f o r the study. Yura and Walsh have i d e n t i f i e d f o u r phases of the n u r s i n g process; a s s e s s i n g , p l a n n i n g , implementing  and e v a l u a t i n g .  1 0 7  The theor-  e t i c a l framework used f o r the nursing process i n the i n s t r u c t i o n a l 108 program was V i r g i n i a Henderson's Philosophy of Nursing.  27 An e x t e n s i v e l i t e r a t u r e review has been  conducted.  However, i t does not i n c l u d e a l l t h a t has been w r i t t e n on the n u r s i n process.  An attempt has been made to present the views o f the  n u r s i n g l e a d e r s who have w r i t t e n e x t e n s i v e l y on the s u b j e c t . L i t e r a t u r e was a l s o s e l e c t e d , that r e f l e c t e d the present s t a t e o f the use of the n u r s i n g process i n the c l i n i c a l area and the research t h a t has been conducted i n r e l a t i o n to the n u r s i n g p r o c e s s . In reviewing the l i t e r a t u r e i n t h i s manner i t became apparent, t h a t although n u r s i n g l e a d e r s were committed to the use o f the n u r s i n g process i n the care o f p a t i e n t s , they d i d not agree on what i t was or how i t should be c a r r i e d out.  I t a l s o became  obvious t h a t the n u r s i n g process i s not being used as a p r a c t i c e t o o l i n the c l i n i c a l  area.  28  CHAPTER I I I METHODOLOGY  OVERVIEW The f o l l o w i n g procedure was used t o t e s t the seven n u l l hypotheses o f t h i s study:  (1) data were gathered on a l l  dependent v a r i a b l e s i n the study group and the c o n t r o l group; (2) the study group completed an i n s t r u c t i o n a l program on the n u r s i n g p r o c e s s ; and (3) f o l l o w i n g completion o f the i n s t r u c t i o n a l program on the n u r s i n g p r o c e s s , data was gathered on a l l dependent v a r i a b l e s i n the study group and the c o n t r o l group.  I t was  thought, i f graduate nurses were t o complete an i n s t r u c t i o n a l program on the n u r s i n g process (independent v a r i a b l e ) there would be a d i f f e r e n c e , compared t o graduate nurses who d i d not complete the program, both, i n t h e i r a t t i t u d e toward the n u r s i n g process and the u t i l i z a t i o n o f i t i n p r a c t i c e (dependent v a r i a b l e s ) . T h i s chapter f o l l o w s the sequence o f the study. The research design i s e x p l a i n e d , f o l l o w e d by an e x p l a n a t i o n o f the p r e - t e s t , the i n s t r u c t i o n a l program and the p o s t - t e s t .  29 RESEARCH DESIGN A  quasi experimental design was used which i n c l u d e d a non-  e q u i v a l e n t c o n t r o l group and a pre and post t e s t .  Due t o the  d i f f i c u l t y i n l o c a t i n g a study group which was w i l l i n g t o p a r t i c i pate i n an i n s t r u c t i o n a l program i n a d d i t i o n t o t h e i r r e g u l a r d u t i e s , the study group was not randomly chosen.  The study group,  which was l o c a t e d on a t h i r t y - s i x bed general medical u n i t i n an a c t i v e treatment h o s p i t a l , expressed a w i l l i n g n e s s t o p a r t i c i p a t e i n the study.  T h i s method o f r e c r u i t m e n t does weaken the design  but i s not thought t o be a s e r i o u s t h r e a t t o i n t e r n a l v a l i d i t y . ^ The c o n t r o l group, l o c a t e d on a f o r t y bed general s u r g i c a l u n i t i n the same h o s p i t a l , resembled the study group i n r e l a t i o n t o the type o f p a t i e n t problems d e a l t w i t h , more c l o s e l y than any other unit i n that p a r t i c u l a r h o s p i t a l .  A t o t a l sample o f  f i f t e e n graduate nurses agreed t o p a r t i c i p a t e i n the study out o f a p o s s i b l e twenty-seven.  T h i s arrangement i s r e a c t i v e and  needs t o be c o n s i d e r e d i n r e l a t i o n t o e x t e r n a l v a l i d i t y . Sample A t o t a l sample o f f i f t e e n graduate nurses was i n c l u d e d i n the study, f i v e i n the study group and ten i n the c o n t r o l group.  Informed consent was obtained from each member i n the study  group.  (Appendix A)  The p r o p o r t i o n o f the graduate nurses who  p a r t i c i p a t e d i n the study, i n r e l a t i o n t o those who d i d n o t , i s d i s p l a y e d i n Table 1 and Table 2.  30  TABLE I P a r t i c i p a n t s and Non P a r t i c i p a n t s i n the C l i n i c a l Area from Which the Study Group was S e l e c t e d Number o f Graduates  Position  Participant  Non Participant  1  Head Nurse  1  0  4  General Duty  3  1  2  General Duty ( p a r t time)  1  !  1  General Duty (evenings)  0  1  1  General Duty ( p a r t time evenings)  0  !  1  General Duty ( p a r t time 5-9 pm)  0  !  1  General Duty (nights)  0  1  1  General Duty (part time nights)  0  !  5  7  12  31  TABLE II P a r t i c i p a n t s and Pton P a r t i c i p a n t s i n the C l i n i c a l Area From Which the Control Group was S e l e c t e d  Number o f Graduates  Position  Participant  Non Participant  1  Head Nurse  1  0  11  General Duty  9  2  1  General Duty (evenings)  0  1  1  General Duty ( p a r t time evenings)  0  1  1  General Duty ( p a r t time days)  0  1  10  5  15  32  In o r d e r to i d e n t i f y a d i f f e r e n c e i n the use o f the nursing process by the graduate nurses and t h e i r a t t i t u d e i t f o l l o w i n g the i n s t r u c t i o n a l program, seven n u l l were developed.  toward  hypotheses  These hypotheses are l i s t e d below.  Hypotheses 1.  There i s no measurable d i f f e r e n c e i n the frequency with which a d e f i n e d data base i s obtained on i n d i v i d u a l p a t i e n t s before and a f t e r completion of the i n s t r u c t i o n a l program by graduate nurses.  2.  There i s no measurable d i f f e r e n c e i n the number o f p a t i e n t problems i d e n t i f i e d before and a f t e r completion of the i n s t r u c t i o n a l program by the graduate nurses.  3.  There i s no measurable d i f f e r e n c e i n the c o n s i s t e n c y of the problems i d e n t i f i e d with e s t a b l i s h e d c r i t e r i a  (q.v.) before  and a f t e r completion of the i n s t r u c t i o n a l program by the graduate nurses. 4.  There i s no measurable d i f f e r e n c e i n the c o n s i s t e n c y of the planning phase of the n u r s i n g process with e s t a b l i s h e d criteria  (q.v.) before and a f t e r completion of the i n s t r u c t i o n a l  program by the graduate nurses. 5.  There i s no measurable d i f f e r e n c e i n the c o n s i s t e n c y of the implementing phase of the n u r s i n g process with e s t a b l i s h e d c r i t e r i a (q.v.) before and a f t e r completion of the i n s t r u c t i o n a l program by the graduate nurses.  33  6.  There i s no measurable d i f f e r e n c e i n the c o n s i s t e n c y of the e v a l u a t i n g phase of the n u r s i n g process with e s t a b l i s h e d c r i t e r i a (q.v.) before and a f t e r completion o f the i n s t r u c t i o n a l program by the graduate nurses.  7.  There i s no measurable d i f f e r e n c e i n the way the graduate nurse views the n u r s i n g process before and a f t e r completion of the i n s t r u c t i o n a l program by the graduate nurse. The v a r i a b l e s i d e n t i f i e d i n the study are l i s t e d below.  Independent V a r i a b l e 1.  Program of i n s t r u c t i o n concerning the n u r s i n g p r o c e s s . (Appendix E)  Dependent V a r i a b l e s 1.  Frequency with which a d e f i n e d data base i s obtained on i n d i v i d u a l p a t i e n t s before and a f t e r completion of the i n s t r u c t i o n a l program.  2.  Number of p a t i e n t problems i d e n t i f i e d on i n d i v i d u a l p a t i e n t s before and a f t e r completion o f the i n s t r u c t i o n a l program.  3.  C o n s i s t e n c y o f the i d e n t i f i e d problems with e s t a b l i s h e d c r i t e r i a before and a f t e r completion of the i n s t r u c t i o n a l program.  4.  C o n s i s t e n c y of the planning phase o f the n u r s i n g process with e s t a b l i s h e d c r i t e r i a before and a f t e r completion of the i n s t r u c t i o n a l program.  34  5.  C o n s i s t e n c y of the implementing phase o f the n u r s i n g process with e s t a b l i s h e d c r i t e r i a before and a f t e r completion of the i n s t r u c t i o n a l program.  6.  Consistency of the e v a l u a t i n g phase o f the n u r s i n g process with e s t a b l i s h e d c r i t e r i a before and a f t e r completion o f the i n s t r u c t i o n a l program.  7.  The way i n which the graduate nurse views the n u r s i n g process before and a f t e r completion of the i n s t r u c t i o n a l program.  PRETEST Data were gathered on a l l dependent v a r i a b l e s i n both groups p r i o r to the i n t r o d u c t i o n of the i n s t r u c t i o n a l program on the n u r s i n g p r o c e s s .  Data on a l l phases o f the n u r s i n g process  were obtained by a u d i t i n g the n u r s i n g care p l a n , n u r s i n g h i s t o r y and nurses notes, f o r each p a t i e n t i n both n u r s i n g u n i t s .  (Appendix  Measurement o f the a t t i t u d e of each graduate nurse toward the n u r s i n g process was c a r r i e d out by the a d m i n i s t r a t i o n of a questionnaire. The c r i t e r i a used i n a u d i t i n g the above p a r t s of the p a t i e n t r e c o r d were d e v i s e d from the d e f i n i t i o n s of each phase of the n u r s i n g process found i n the l i t e r a t u r e .  The major source of 3 i n f o r m a t i o n r e g a r d i n g the d e f i n i t i o n s was Yura and Walsh.  C r i t e r i a Used i n A u d i t i n g P a t i e n t Records 1.  The frequency with which a d e f i n e d data base was  obtained  on i n d i v i d u a l p a t i e n t s by the graduate nurse, was  determined  by counting the number of p a t i e n t records which contained a d e f i n e d data base. 2.  The number of p a t i e n t problems i d e n t i f i e d by the graduate nurse . was determined by counting the p a t i e n t problems t h a t appear on the nursing care plan.  3.  The c o n s i s t e n c y of p a t i e n t problems are c h a r a c t e r i z e d by the following c r i t e r i a : (a)  p a t i e n t problems i d e n t i f i e d are based on data  obtained  on the i n d i v i d u a l p a t i e n t ; (b)  p a t i e n t problems i d e n t i f i e d are reviewed with the p a t i e n t and/or h i s f a m i l y f o r v e r i f i c a t i o n ;  s e l e c t e d p a t i e n t records were audited i n r e l a t i o n to t h e i r c o n s i s t e n c y with the above c r i t e r i a . 4.  The planning phase of the nursing process i s c h a r a c t e r i z e d by the f o l l o w i n g c r i t e r i a : (a)  p a t i e n t problems are arranged i n order of p r i o r i t y ;  (b)  expected behavioural  outcomes f o r the p a t i e n t are  established; (c)  the expected behavioural  outcomes are r e a l i s t i c ;  (d)  the expected behavioural  outcomes are r e l a t e d to  p a t i e n t problems i d e n t i f i e d i n the assessment phase;  36  (e)  the expected behavioural outcomes f o r the p a t i e n t are reviewed with the p a t i e n t , and/or h i s f a m i l y f o r verification;  (f)  nursing a c t i o n i s planned i n r e l a t i o n to the problems i d e n t i f i e d i n the assessment phase;  (g)  nursing a c t i o n i s planned i n order to achieve expected behavioural  the  outcomes e s t a b l i s h e d f o r the  patient; (h)  nursing a c t i o n s planned to achieve the expected behavioural  outcomes by the p a t i e n t are reviewed  with the p a t i e n t and/or h i s f a m i l y f o r v e r i f i c a t i o n ; s e l e c t e d p a t i e n t records were audited i n r e l a t i o n to t h e i r c o n s i s t e n c y with the above c r i t e r i a . 5.  The implementation phase i s c h a r a c t e r i z e d by the f o l l o w i n g criteria: (a)  nursing a c t i o n c a r r i e d out i s based on the i d e n t i f i e d p a t i e n t problems;  (b)  nursing a c t i o n c a r r i e d out i s d i r e c t e d toward the expected behavioural  (c)  producing  outcomes i n the p a t i e n t ;  nursing a c t i o n c a r r i e d out i s i n cooperation with the p a t i e n t and/or h i s f a m i l y ;  s e l e c t e d p a t i e n t records were audited i n r e l a t i o n to t h e i r c o n s i s t e n c y with the above c r i t e r i a .  37  6.  The e v a l u a t i o n phase of the n u r s i n g process i s c h a r a c t e r i z e d by the f o l l o w i n g c r i t e r i o n : (a)  n u r s i n g a c t i o n c a r r i e d out i s e v a l u a t e d i n terms o f i t s i n f l u e n c e on the attainment of the expected behavioural outcomes by the p a t i e n t ;  s e l e c t e d p a t i e n t records were a u d i t e d i n r e l a t i o n to t h e i r c o n s i s t e n c y with the above c r i t e r i o n .  Judges Used i n A u d i t i n g P a t i e n t Records The a u d i t i n g of the p a t i e n t records was c a r r i e d out by three p r o f e s s i o n a l nurses, which i n c l u d e d the i n v e s t i g a t o r . P r i o r to the c o l l e c t i o n of data the c r i t e r i a were reviewed by the three judges and a t r i a l run was conducted.  The records f o r three  p a t i e n t s were used and a u d i t e d independently by each of the judges. The r e s u l t s are d i s p l a y e d i n Table I I I . The l e v e l o f s i g n i f i c a n c e f o r c r i t i c a l value determin a t i o n was p=0.5.  Kendall's C o e f f i c i e n t of Concordance W was  computed, and an i n t e r r a t e r r e l i a b i l i t y c o e f f i c i e n t of 0.95 obtained.^  was  (p=0.0001)  Since the number of observations was 2 5 g r e a t e r than seven the X t r a n s f o r m a t i o n was a p p l i e d . A t t i t u d e Scale A q u e s t i o n n a i r e developed to measure a t t i t u d e s toward the n u r s i n g p r o c e s s , was administered to the graduate nurses i n the study group and the c o n t r o l group p r i o r t o the i n t r o d u c t i o n of the i n s t r u c t i o n a l program.  (Appendix  C)  38  The q u e s t i o n n a i r e was developed by Fewster at the U n i v e r s i t y of B r i t i s h Columbia.^  A L i k e r t s c a l e was used to  develop the q u e s t i o n n a i r e , h a l f of the b e l i e f statements were worded p o s i t i v e l y and h a l f n e g a t i v e l y towards the n u r s i n g process. 7 The items were then ordered on a random b a s i s . 8 The items were s e t to a f i v e p o i n t agree-disagree s c a l e so 9 t h a t the h i g h e r the score the more p o s i t i v e the a t t i t u d e . A t e s t - r e t e s t using seven respondents was c a r r i e d out by the i n v e s t i g a t o r and a r e l i a b i l i t y c o e f f i c i e n t of 0.49 obtained.  was  The scores obtained on the t e s t - r e t e s t are l i s t e d  i n Table IV. The low r e l i a b i l i t y c o e f f i c i e n t was due p r i m a r i l y to the scores o f p a r t i c i p a n t s f o u r and f i v e .  The v a l i d i t y of the  t o o l cannot exceed the square root of the r e l i a b i l i t y c o e f f i c i e n t , t h e r e f o r e more t e s t i n g needs t o be done to e s t a b l i s h i t s r e l i a b i l i t y . The q u e s t i o n n a i r e was sent to t w e n t y - f i v e experts  who  were obtained from a p a r t i c i p a n t l i s t of the Eighth Communicating Nursing Research Conference h e l d at Phoenix, A r i z o n a i n 1975.  The  q u e s t i o n n a i r e was sent i n r e l a t i o n to i t s v a l i d i t y , with an explanatory l e t t e r .  (Appendix D)  Of the q u e s t i o n n a i r e s , s i x t e e n were  r e t u r n e d , with s i x having been r a t e d by the o u t l i n e d procedure. Of these s i x there was a range of e i g h t out of twenty items cons i d e r e d v a l i d to seventeen out o f twenty.  Work i s being continued  on t h i s a t t i t u d e s c a l e i n an attempt to produce a v a l i d and r e l i a b l e measure of nurse's a t t i t u d e s toward the nursing p r o c e s s .  1 0  39  TABLE I I I Results Obtained by a Panel o f Three Judges A u d i t i n g P a t i e n t Records Using the E s t a b l i s h e d C r i t e r i a *  Criterion  J  l  J  2  J  3  R  l  R  2  R  3  1  3  3  3  13  14.5  13  2  5  5  5  15.5  16  14.5  3a  4  3  5  14  14.5  14.4  b  0  0  2  6  6  4a  0  0  0  6  6  5.5  b  0  0  0  6  6  5.5  c  0  0  0  6  6  5.5  d  0  0  0  6  6  5.5.  e  0  0  0  6  6  5.5  f  5  2  6  15.5  12.5  g  0  0  0  6  6  5.5  h  0  0  0  6  6  5.5  5a  1  2  1  12  12.5  b  0  0  0  6  6  5.5  c  0  0  0  6  6  5.5  6a  0  0  0  6  6  5.5  12  16  11  J = Judge, R = Rank. S i x t e e n c r i t e r i a were ranked a c c o r d i n g t o v a l u e . The number o f t i e s determine the number o f equal ranks. * See page 35.  40  TABLE IV Scores Obtained From Seven Respondents on the T e s t - R e t e s t of the Q u e s t i o n n a i r e Measuring A t t i t u d e Toward the Nursing Process  Participant  Test  Retest  1  86  82  2  89  91  3  92  98  4'  85  76  5  78  90  6  85 .  84  7  78  80  INSTRUCTIONAL PROGRAM The i n s t r u c t i o n a l program concerning the nursing process was i n t r o d u c e d t o the study group f o l l o w i n g the c o l l e c t i o n o f data on a l l dependent v a r i a b l e s .  The program centered around  the f o u r phases o f the nursing p r o c e s s :  a s s e s s i n g ; p l a n n i n g ; imple-  menting; and e v a l u a t i n g . The t h e o r e t i c a l framework w i t h i n which the  41 nursing process was presented was V i r g i n i a Henderson's Philosophy Nursing.  The program was developed  11  of  to a s s i s t the graduate nurse  t o a t t a i n the behavioural o b j e c t i v e s of the program.  The o b j e c t i v e s  centered around the nursing process which i s e s s e n t i a l l y a problem-solving  approach to p a t i e n t care, t h e r e f o r e , the approach 12  chosen was based on work by Woodruff on l e a r n i n g and i n s t r u c t i o n . (Figure 1) I t was thought t h a t graduate nurses were often problems o l v i n g at an i n t u i t i v e l e v e l . subjective.  T h i s type of d e c i s i o n making i s h i g h l y  Woodruff's model points out that these i n t u i t i v e  d e c i s i o n s can be r a i s e d to v e r b a l i z e d d e c i s i o n s where the l e a r n e r i s brought t o a l e v e l of r e c o g n i t i o n and f i n a l l y to the of a g e n e r a l i z e d concept.  formation  The teaching methods were chosen t o  a s s i s t the graduate nurse to c o n s c i o u s l y examine i n f o r m a t i o n on which she based her d e c i s i o n s .  These methods were:  method; (2) q u e s t i o n i n g ; and (3) d i s c u s s i o n .  (1) the case  Once the graduate nurse  reaches the l e v e l of v e r b a l i z e d concept formation i t becomes necessary f o r her to p r a c t i s e the concepts i n order to reach the l e v e l of g e n e r a l i z e d concept formation.  T h e r e f o r e , the graduate nurse  was given the o p p o r t u n i t y to p r a c t i s e the various phases of the nursing process with s u p e r v i s i o n . The a t t i t u d i n a l component of the i n s t r u c t i o n a l program was based on the r e l a t i o n s h i p between experience, meaning, and f e e l i n g d e s c r i b e d by Woodruff.  (Figure 2)  Woodruff points out that  CONCEPT-USING PROCESSES  CONCEPT-FORMING PROCESSES  Matching Transfer or y  G e n e r a l i zed Concepts  Problem Solving (Conscious and Verbalized)  Verbalized Concepts  Verbalized  Intui tive Concepts  Perception o f Concrete Objects and Events  r  Decision Making Subliminal Decision Making  to  c Generalized o •r+-> Process ra Z3 +-> Concepts to oo sGeneral ra Characteristics of Unfamiliar Situation  Conscious and Examined Decisions I n t u i t i v e and  T  I n t u i t i v e and Unrecognized Decisions  A  Perception o f S i t u a t i o n Requiring A d j u s t i v e Response  Sensory Intake  Figure 1  42  R I  L  F e e d b a c k  Processes  Behaving-Learning Cycle Showing D e c i s i o n Making i n F a m i l i a r S i t u a t i o n s a t I n t u i t i v e and V e r b a l i z e d L e v e l s , and Problem S o l v i n g i n U n f a m i l i a r S i t u a t i o n s . 1 3  43  •MEANING-  Concept  Concept with Positive Value  EXPERIENCE —  I—SATISFYING"  Positive Value  -FEELING — •—ANNOYING  Figure 2  Negative Value  Meaning, F e e l i n g and Concepts 15  Concept with Negative Value  44  concepts formed with p o s i t i v e value are more l a s t i n g than 16 concepts formed with negative v a l u e . The i n s t r u c t i o n a l program was s t r u c t u r e d : (1) to provide the graduate nurse with support; (2) to recognize the i n d i v i d u a l ' s e x p e r t i s e ; and (3) t o f o s t e r an atmosphere o f shared information.  I t was hoped t h a t t h i s would be a s a t i s f y i n g  l e a r n i n g experience and t h a t concept formation would be coupled with a p o s i t i v e value. In an attempt to meet the three o b j e c t i v e s l i s t e d above the f o l l o w i n g approaches were used: 1.  each graduate nurse was encouraged by the i n v e s t i g a t o r to d i s c u s s her a t t i t u d e s toward the use of the n u r s i n g process as a p r a c t i c e t o o l .  Negative a t t i t u d e s were e x p l o r e d and  care was taken by the i n v e s t i g a t o r to r e f r a i n from p l a c i n g value judgements on the opinions o f the graduate nurses; 2.  each graduate nurse was encouraged to i d e n t i f y her a r e a ( s ) of e x p e r t i s e and to draw on t h a t e x p e r t i s e i n her use of the n u r s i n g process;  3.  the i n v e s t i g a t o r was viewed by the graduate nurses as a nursing c o l l e a g u e with e x p e r t i s e i n a p a r t i c u l a r area.  No  a u t h o r i t a t i v e h i e r a r c h y was i n v o l v e d , only mutual r e s p e c t f o r each others knowledge and a b i l i t i e s . The n u r s i n g h i s t o r y form used by the study group, which was the form used by the i n s t i t u t i o n , was not adequate f o r use i n  45  the program.  Smith's h i s t o r y t o o l was used as a guide to p r o v i d e  a d d i t i o n a l areas on which i n f o r m a t i o n was to be gathered, from the p a t i e n t and/or h i s f a m i l y . ^  Smith's t o o l was chosen because i t  i s based on Henderson's Philosophy of Nursing. In a d d i t i o n to the h i s t o r y t o o l used by i n s t i t u t i o n s , the f o l l o w i n g i n f o r m a t i o n was  gathered:  . appearance on f i r s t s i g h t . events l e a d i n g up to i l l n e s s . some i n d i c a t i o n o f the p a t i e n t ' s e x p e c t a t i o n s . b r i e f s o c i a l and c u l t u r a l h i s t o r y i n c l u d i n g work, e d u c a t i o n , and s i g n i f i c a n t others i n p a t i e n t ' s l i f e . skin i n t e g r i t y . a c t i v i t y and r e c r e a t i o n preferences . i n t e r p e r s o n a l and communicative p a t t e r n s . temperament . dependency and independency patterns . senses . what i s important to t h i s p a t i e n t ?  e.g. What makes him  f e e l secure, comfortable, p r o t e c t e d , s a f e , and cared f o r ? The i n s t r u c t i o n a l program c o n s i s t e d of f o u r phases: (1)  assessment o f each graduate nurse i n r e l a t i o n to her knowledge  and s k i l l i n the use o f the nursing process; ( 2 ) p r o v i s i o n of i n f o r m a t i o n concerning the n u r s i n g process; ( 3 ) the o p p o r t u n i t y to u t i l i z e the n u r s i n g process under s u p e r v i s i o n ; and ( 4 ) assessment of each graduate nurse i n r e l a t i o n to her attainment of the  46  p r e - e s t a b l i s h e d o b j e c t i v e s of the program.  Completion of the  program by each graduate nurse was determined by the attainment of p r e - e s t a b l i s h e d o b j e c t i v e s . The i n s t r u c t i o n a l program was c a r r i e d out by the i n v e s t i gator two days per week f o r t h r e e months. T h i s time was spent i n the c l i n i c a l area with the study group.  Due to s h i f t work, days  o f f , and h o l i d a y s , a c t u a l exposure time ( t o the i n v e s t i g a t o r ) , f o r each graduate nurse averaged f i v e hours.  T h i s d i d not i n c l u d e  the time each graduate nurse spent p r e p a r i n g the necessary a s s i g n ments.  I t was not p o s s i b l e to have access to the e n t i r e group  at once due to the c o n s t r a i n t s o f t h e i r work. A block of time was not a l l o t t e d to the graduate nurses f o r completion o f the i n s t r u c t i o n a l program, t h e r e f o r e , i t had to be completed s i m u l t a n e o u s l y with t h e i r r e g u l a r d u t i e s .  P r e - e s t a b l i s h e d O b j e c t i v e s f o r the Graduate Nurse Overall Objective The graduate nurse uses the n u r s i n g p r o c e s s , based on a t h e o r e t i c a l framework, i n c a r i n g f o r an i n d i v i d u a l p a t i e n t .  Specific Objectives The graduate nurse i n c a r i n g f o r an i n d i v i d u a l p a t i e n t : 1.  uses the p r e s c r i b e d h i s t o r y t o o l to c o l l e c t d a t a ;  2.  i d e n t i f i e s p a t i e n t problems from the data base;  47 3.  v a l i d a t e s the problem l i s t with the p a t i e n t and/or h i s family;  4.  e s t a b l i s h e s r e a l i s t i c expected behavioural outcomes f o r the p a t i e n t i n cooperation with the p a t i e n t and/or his family;  5.  plans nursing a c t i o n with the p a t i e n t and/or h i s f a m i l y , d i r e c t e d toward the attainment o f expected b e h a v i o u r a l outcomes by the p a t i e n t ;  6.  c a r r i e s out or assigns to others the planned n u r s i n g a c t i o n i n cooperation with the p a t i e n t and/or h i s f a m i l y ;  7.  evaluates n u r s i n g a c t i o n , i n cooperation with the p a t i e n t and/or h i s f a m i l y i n terms of the degree of attainment of the expected behavioural outcomes by the p a t i e n t ;  8.  demonstrates  commitment to the use o f the nursing process.  Phases o f the I n s t r u c t i o n a l Program Phase I Each graduate nurse completed an assignment which c o n s i s t e d of a w r i t t e n r e c o r d of her care o f a p a t i e n t , using the n u r s i n g p r o c e s s , p r i o r to the i n t r o d u c t i o n of any i n f o r m a t i o n on the n u r s i n g process.  T h i s assignment was assessed i n r e l a t i o n to the pre-  e s t a b l i s h e d o b j e c t i v e s to determine her knowledge and s k i l l i n the use of the n u r s i n g process.  48  Phase I I The  p r e - e s t a b l i s h e d o b j e c t i v e s were reviewed w i t h each  graduate nurse and i t was e x p l a i n e d t h a t the a t t a i n m e n t o f these o b j e c t i v e s was n e c e s s a r y f o r c o m p l e t i o n o f the program. W r i t t e n i n f o r m a t i o n on the n u r s i n g p r o c e s s was g i v e n t o each graduate n u r s e .  (Appendix  D)  T h i s m a t e r i a l was reviewed  with the i n v e s t i g a t o r f o r e x p l a n a t i o n and t o answer q u e s t i o n s posed by the graduate n u r s e .  T h i s m a t e r i a l was made a v a i l a b l e  so t h a t a l l graduate nurses i n t h e program would have common information to refer t o . Phase I I I Each all  phases  graduate nurse i n c a r i n g  o f the n u r s i n g p r o c e s s .  f o r a p a t i e n t ( s ) c a r r i e d out  A written  and/or v e r b a l  account  o f t h e care p r o v i d e d was c o n c u r r e n t l y reviewed w i t h the i n v e s t i gator • Phase IV Each graduate nurse completed o f the n u r s i n g p r o c e s s which  an assignment  consisted of verbal  on each  and/or  phase  written  accounts o f t h e i r care o f a p a t i e n t u s i n g the n u r s i n g p r o c e s s . When the i n v e s t i g a t o r and the graduate nurse were s a t i s f i e d the p r e - e s t a b l i s h e d  that  o b j e c t i v e s had been met, the program was  complete. All  o f t h e graduate nurses completed  t h r e e months.  the program w i t h i n  49  POST-TEST Data were gathered on a l l dependent v a r i a b l e s i n both groups f o l l o w i n g the completion of the i n s t r u c t i o n a l program by the study group.  Data on a l l phases of the nursing process were  obtained i n the same manner as i n the p r e t e s t .  The questionnaire  to determine a t t i t u d e toward the nursing process was again administered to both groups.  SUMMARY In an attempt to t e s t the seven n u l l hypotheses i n t h i s study three steps were c a r r i e d out.  (1) Data were gathered on  a l l dependent v a r i a b l e s i n the study group and the control group. (2) The study group completed an i n s t r u c t i o n a l program on the nursing process.  (3) Following completion of the i n s t r u c t i o n a l  program on the nursing process, data were gathered on a l l dependent v a r i a b l e s i n the study group and the control group. The research design was quasi experimental with a non-equivalent control group and a pre and post t e s t .  The sample consisted of  f i f t e e n graduate nurses, f i v e i n the study group and ten i n the control group. This procedure was c a r r i e d out i n an attempt to determine what e f f e c t providing the graduate nurse with information on the nursing process, and an opportunity to u t i l i z e the nursing process under s u p e r v i s i o n , would have on the use of the nursing process i n the p r a c t i c e a r e a , and the a t t i t u d e of the graduate nurse toward i t .  50  CHAPTER IV ANALYSIS OF THE DATA  INTRODUCTION Data gathered on the dependent v a r i a b l e s w i l l be d i s c u s s e d under f i v e headings: ASSESSMENT; PLANNING; IMPLEMENTATION; EVALUATION; and ATTITUDE TOWARD THE NURSING PROCESS.  In order t o  determine whether d i f f e r e n c e s e x i s t between the two groups the Student's t - t e s t was computed on s i x t e e n data sets and the Chi Square on one. The s i g n i f i c a n c e l e v e l f o r c r i t i c a l value determination was p=0.5.  ASSESSMENT The dependent v a r i a b l e s i n c l u d e d i n the assessment phase of the n u r s i n g process a r e : (1) the frequency with which a d e f i n e d data base i s obtained on i n d i v i d u a l p a t i e n t s before and a f t e r comp l e t i o n o f the i n s t r u c t i o n a l program; (2) the number o f p a t i e n t problems i d e n t i f i e d on i n d i v i d u a l p a t i e n t s before and a f t e r completion o f the i n s t r u c t i o n a l program; and (3) the c o n s i s t e n c y o f the i d e n t i f i e d problems with e s t a b l i s h e d c r i t e r i a before and a f t e r completion o f the i n s t r u c t i o n a l program.  See Table V f o r r e s u l t s .  51  TABLE V Results o f the P a t i e n t Records Audited using the C r i t e r i a E s t a b l i s h e d f o r the Assessment Phase o f the Nursing Process  Audited Records  Dependent V a r i a b l e  Study Group Posttest Pretest (N = 35) (N = 32)  Control Group Pretest Posttest (N = 36) (N = 36)  30  26  30  24  65  58  58  38  (a) P a t i e n t Problems Bases on Data  45  36  34  24  (b) P a t i e n t Problems V a l i d a t e d with Patient  0  9  2  9  Data Base  (present)  P a t i e n t Problems Identi f i e d Consistency with Criteria  N =  Number o f records  audited.  Hypothesis I There i s no measurable d i f f e r e n c e i n the frequency with which a d e f i n e d data base i s obtained on i n d i v i d u a l p a t i e n t s before and a f t e r completion  o f the i n s t r u c t i o n a l program by graduate nurses.  Results The frequency with which a d e f i n e d data base was  obtained  d i d not i n c r e a s e i n e i t h e r the study group or the c o n t r o l group.  52  (See Table V)  There was, however, a s l i g h t decrease.  The Student's  t - t e s t was computed and the t - v a l u e o b t a i n e d was not s i g n i f i c a n t . T h e r e f o r e the n u l l hypothesis was r e t a i n e d ,  ( t = approximately 0 with  68df) Hypothesis 2 There i s no measurable d i f f e r e n c e i n the number of p a t i e n t problems i d e n t i f i e d before and a f t e r completion o f the i n s t r u c t i o n a l program by the graduate nurses. Results There was a decrease i n the number of p a t i e n t problems i n both groups, (see Table V) which would seem t o i n d i c a t e t h a t the drop i n the number o f p a t i e n t problems i d e n t i f i e d was not due t o the i n s t r u c t i o n a l program.  The Student's t - t e s t was computed on the  average d i f f e r e n c e , (which i n t h i s case was n e g a t i v e ) , and a t - v a l u e of 0.808 with 68df was o b t a i n e d J  T h i s was not s i g n i f i c a n t , t h e r e -  f o r e , the n u l l hypothesis was r e t a i n e d .  Hypothesis 3 There i s no measurable d i f f e r e n c e i n the c o n s i s t e n c y o f the problems i d e n t i f i e d with e s t a b l i s h e d c r i t e r i a before and a f t e r completion of the i n s t r u c t i o n a l program by the graduate nurses. Results The r e s u l t s have been t a b u l a t e d f o r each c r i t e r i o n . (Table V) C r i t e r i o n a:  p a t i e n t problems i d e n t i f i e d are based on data o b t a i n e d  on the i n d i v i d u a l p a t i e n t .  53  The r e s u l t s showed a decrease i n both the study group and the c o n t r o l group.  A t - t e s t was computed on the average d i f f e r e n c e ,  (which was negative) and the t - v a l u e obtained was 0.257 with 68 d f . The t - v a l u e d i d not reach s t a t i s t i c a l  significance.  C r i t e r i o n b: p a t i e n t problems are reviewed with the p a t i e n t and/or his f a m i l y f o r v e r i f i c a t i o n . There was an i n c r e a s e i n both groups, but the i n c r e a s e was small and the t - v a l u e obtained was approximately 0 with 68df. These r e s u l t s l a c k e d s t a t i s t i c a l s i g n i f i c a n c e , t h e r e f o r e , the n u l l hypothesis was r e t a i n e d .  PLANNING The dependent v a r i a b l e o f concern here i s c o n s i s t e n c y o f the planning phase o f the n u r s i n g process with e s t a b l i s h e d c r i t e r i a before and a f t e r completion o f the i n s t r u c t i o n a l program.  Hypothesis 4 There i s no measurable d i f f e r e n c e i n the planning phase o f the n u r s i n g process before and a f t e r completion o f the i n s t r u c t i o n a l program by the graduate nurses. Results The r e s u l t s o f the planning phase o f the n u r s i n g process have been t a b u l a t e d f o r each c r i t e r i o n .  (Table VI)  54  C r i t e r i o n a:  p a t i e n t problems are arranged i n order of p r i o r i t y .  There was an i n c r e a s e i n the number of p a t i e n t problems t h a t were arranged i n order of p r i o r i t y i n the study group. A Chi Square (X  was computed but was not s t a t i s t i c a l l y s i g n i f i c a n t .  =3.29 with 1 df)  There was, however, a s i g n i f i c a n t decrease  in the number of p a t i e n t problems p r i o r i z e d i n the c o n t r o l group. ( X = 8.425 with 1 d f , p = 0.005) 2  The reason f o r the drop i s  not c l e a r but i t would seem t h a t i t may be due to v a r i a b l e s other than the study, because there was no c o n t a c t made with the c o n t r o l group by the i n v e s t i g a t o r other than the a d m i n i s t r a t i o n o f the questionnaire. C r i t e r i o n b:  expected behavioural outcomes f o r the p a t i e n t are  established. There was an i n c r e a s e i n the number of behavioural outcomes e s t a b l i s h e d i n the study group and a s l i g h t decrease i n the c o n t r o l group.  A t - t e s t was computed on the average d i f f e r e n c e and  was found to be s t a t i s t i c a l l y s i g n i f i c a n t ,  ( t = 5.029 with 68df,  p = 0.001).  (Table VI)  C r i t e r i o n c:  the expected behavioural outcomes are r e a l i s t i c .  The number of r e a l i s t i c behavioural outcomes i n c r e a s e d in the study group and decreased i n the c o n t r o l group. was computed on the average d i f f e r e n c e and was  A t-test  statistically  significant,  ( t = 2.201 with 68df, p = 0.005)  C r i t e r i o n d:  the expected behavioural outcomes are r e l a t e d to  p a t i e n t problems i d e n t i f i e d i n the assessment  (Table VI)  phase.  TABLE VI Results o f the P a t i e n t Records Audited Using C r i t e r i a E s t a b l i s h e d f o r the Planning Phase o f the Nursing Process Criterion  Audited Records Study Group Pretest (N = 35)  a. b. c. d. e. f. g. h.  P r i o r i z e d P a t i e n t Problems Expected Behavioural Outcomes R e a l i s t i c Behavioural Outcomes Behavioural Outcomes Related to I d e n t i f i e d P a t i e n t Problems Behavioural Outcomes V a l i d a t e d with P a t i e n t and/or Family Planned Nursing A c t i o n Related to I d e n t i f i e d P a t i e n t Problems Nursing A c t i o n Planned to Achieve Expected Behavioural Outcomes Nursing A c t i o n Planned i s V a l i d a t e d with the P a t i e n t and/or Family  3 7 5  Control Group  Posttest (N = 32) 8 38* g**  Pretest (N = 36)  Posttest (N = 36)  17 43 18  5 36 8  3  7***  8  3  0  0  1  0  74  49  57  32  4  11  18  14  0  0  1  2  N = Number o f records a u d i t e d * t = 5.029 with 68df s i g n i f i c a n t >0.001 ( o n e - t a i l e d t e s t f o r the t-value) * t = 2.201 with 68df s i g n i f i c a n t >0.005 (one t a i l e d t e s t f o r the t - v a l u e ) * t = 1.85 with 68df s i g n i f i c a n t >0.05 (one t a i l e d t e s t f o r the t - v a l u e )  56  C r i t e r i o n d i n c r e a s e d i n the study group and decreased i n the c o n t r o l group.  A t - t e s t was computed on the average  d i f f e r e n c e and was found t o be s t a t i s t i c a l l y (t = 1.85 with 68df, p = 0.05) C r i t e r i o n e:  significant,  (Table VI)  the expected behavioural outcomes f o r the p a t i e n t  are reviewed with the p a t i e n t and/or h i s f a m i l y f o r v e r i f i c a t i o n . There was no d i f f e r e n c e i n the number o f behavioural outcomes reviewed with the p a t i e n t and/or h i s f a m i l y i n e i t h e r the  study group or the c o n t r o l group,  ( t = approximately 0)  C r i t e r i o n f: n u r s i n g a c t i o n i s planned i n r e l a t i o n t o the problems i d e n t i f i e d i n the assessment  phase.  There was a decrease i n the number o f planned n u r s i n g a c t i o n s r e l a t e d t o i d e n t i f i e d p a t i e n t problems, i n both groups. C r i t e r i o n g: n u r s i n g a c t i o n i s planned i n order t o achieve the expected behavioural outcomes e s t a b l i s h e d f o r the p a t i e n t . The number o f n u r s i n g a c t i o n s planned t o achieve the expected behavioural outcomes i n c r e a s e d i n the study group and decreased i n the c o n t r o l group.  A t - t e s t was computed on the  average d i f f e r e n c e and the t - v a l u e obtained was 1.133 with 68df. This t - v a l u e was not s i g n i f i c a n t . C r i t e r i o n h: n u r s i n g a c t i o n planned t o achieve the expected behavioural outcomes by the p a t i e n t are reviewed with the p a t i e n t and/or h i s f a m i l y f o r v e r i f i c a t i o n . There was no change i n c r i t e r i o n h i n the study group and only a s l i g h t change i n the c o n t r o l group. approximately 0.  The t - v a l u e obtained was  57 S t a t i s t i c a l s i g n i f i c a n c e was reached i n c r i t e r i a b, c, and d, however, i n order t o r e j e c t the n u l l hypothesis  statistical  s i g n i f i c a n c e would have been necessary i n a l l c r i t e r i a .  Therefore,  the n u l l hypothesis i s r e t a i n e d .  IMPLEMENTATION The dependent v a r i a b l e i n v o l v e d i n t h i s phase i s c o n s i s t e n c y of the implementing phase o f the n u r s i n g process with e s t a b l i s h e d c r i t e r i a before and a f t e r completion o f the i n s t r u c t i o n a l program.  Hypothesis 5 There i s no measurable d i f f e r e n c e i n the c o n s i s t e n c y o f the implementing phase o f the n u r s i n g process with e s t a b l i s h e d c r i t e r i a before and a f t e r completion o f the i n s t r u c t i o n a l program by the graduate nurses. Results The r e s u l t s o f the implementation phase a r e d i s p l a y e d i n Table V I I .  The r e s u l t s are t a b u l a t e d f o r each c r i t e r i o n .  C r i t e r i o n a: n u r s i n g a c t i o n c a r r i e d out i s based on the i d e n t i f i e d p a t i e n t problems. There was a decrease i n c r i t e r i o n a i n both the study group and the c o n t r o l group.  A t - t e s t was computed on the average  d i f f e r e n c e ( l o s s ) and the t - v a l u e obtained was approximately 0, which o f course was not s i g n i f i c a n t .  58 TABLE VII R e s u l t s of the P a t i e n t Records Audited Using C r i t e r i a E s t a b l i s h e d f o r the Implementation Phase of the Nursing Process Audited  Criterion  Study Group  Records  -  Control Group  Posttest Pretest Posttest Pretest (N = 35) (N = 32) (N = 36) (N = 36) Nursing A c t i o n Based on Identified Patient Problems  47  36  54  38  Nursing A c t i o n D i r e c t e d Toward Expected Beh a v i o u r a l Outcomes  2  8  16  11  Nursing A c t i o n i s i n Cooperation with the P a t i e n t and/or Family  0  0  0  0  N  =  number o f records a u d i t e d  C r i t e r i o n b:  n u r s i n g a c t i o n c a r r i e d out i s d i r e c t e d toward  produc-  ing the expected behavioural outcomes i n the p a t i e n t . There was a s l i g h t decrease i n c r i t e r i o n b i n the study group and a s l i g h t i n c r e a s e i n the c o n t r o l group.  A t - t e s t was computed f o r  the "mean d i f f e r e n c e " and a t - v a l u e o f 1.307 with 68 df was o b t a i n e d . This t - v a l u e d i d not reach s t a t i s t i c a l s i g n i f i c a n c e . C r i t e r i o n c:  n u r s i n g a c t i o n c a r r i e d out i s i n c o o p e r a t i o n with  the p a t i e n t and/or h i s f a m i l y .  59  There was no change i n c r i t e r i o n c i n e i t h e r the study group o r the c o n t r o l group. The t - v a l u e obtained was approximately 0. The n u l l hypothesis was r e t a i n e d due t o the f a c t t h a t there was no s i g n i f i c a n t d i f f e r e n c e i n c r i t e r i a a, b, and c, a f t e r the completion o f the i n s t r u c t i o n a l program.  EVALUATION The dependent v a r i a b l e i s c o n s i s t e n c y o f the e v a l u a t i n g phase o f the n u r s i n g process with e s t a b l i s h e d c r i t e r i a b e f o r e and a f t e r completion o f the i n s t r u c t i o n a l program.  Hypothesis 6 There i s no measurable d i f f e r e n c e i n the c o n s i s t e n c y o f the e v a l u a t i n g phase o f the n u r s i n g process with e s t a b l i s h e d c r i t e r i a before and a f t e r completion o f the i n s t r u c t i o n a l program by the graduate nurses. Results There was a very s l i g h t d i f f e r e n c e i n the study group and the c o n t r o l group i n r e l a t i o n t o the number o f times n u r s i n g a c t i o n was e v a l u a t e d i n terms o f the expected behavioural outcomes. (Table V I I I )  The t - v a l u e obtained was approximately 0, t h e r e f o r e  the n u l l hypothesis was r e t a i n e d .  60 TABLE VIII Results of the P a t i e n t Records Audited Using C r i t e r i a E s t a b l i s h e d f o r the E v a l u a t i o n Phase of the Nursing Process Criterion  Audited  Records  Study Group Pretest (N = 35)  Posttest (N = 32)  Control Group Pretest (N = 36)  Posttest (N = 36)  Nursing A c t i o n i s Evaluated i n R e l a t i o n to the Expected Behavi o u r a l Outcomes  N = number o f r e c o r d s a u d i t e d  ATTITUDE TOWARD THE NURSING PROCESS The dependent v a r i a b l e i s the way i n which the graduate nurse views the nursing process before and a f t e r completion o f the i n s t r u c t i o n a l program.  Hypothesis 7 There i s no measurable d i f f e r e n c e i n the way the graduate nurse views the n u r s i n g process before and a f t e r completion of the i n s t r u c t i o n a l program by the graduate nurses.  61  Results There was an i n c r e a s e i n the mean score obtained on the q u e s t i o n n a i r e by the study group and a decrease i n the c o n t r o l group.  (Table IX)  was 3.48 with 68df.  A t - t e s t was computed and the t - v a l u e obtained T h i s value i s s i g n i f i c a n t (p = 0.01, one  t a i l e d t e s t ) , however, s i n c e the gain i n the study group c o n s i d e r e d a g a i n s t a (supposed) no change i n the c o n t r o l group, would r e s u l t i n an i n s i g n i f i c a n t d i f f e r e n c e , i t i s dubious t h a t the t - v a l u e r e f l e c t s a t r u e d i f f e r e n c e . To r e j e c t the n u l l hypothesis would probably be a type I e r r o r .  TABLE IX Pre and Post T e s t Results from the Q u e s t i o n n a i r e on A t t i t u d e Toward the Nursing Process f o r the Study Group and the Control Group  Group  Pretest  Difference Between • Pre and Post Tests Deviation  Posttest  Mean  Deviation  Mean  Study  74.5  6.31  79.75  4.27  +5.25  Control  65.8  12.84  60.66  9.22  -5.14  L i m i t a t i o n s o f the study, i n a d d i t i o n t o those d i s c u s s e d i n Chapter One, were i d e n t i f i e d f o l l o w i n g the study.  The l i m i t a t i o n s  and an e v a l u a t i o n o f the e f f e c t i v e n e s s o f the i n s t r u c t i o n a l program  62 i t s e l f , w i l l be d i s c u s s e d under the f o l l o w i n g headings: (1) DISCUSSION OF LIMITATIONS; and (2) EFFECTIVENESS OF THE INSTRUCTIONAL PROGRAM.  DISCUSSION OF LIMITATIONS In a d d i t i o n t o the l i m i t a t i o n s d i s c u s s e d i n Chapter One, others were i d e n t i f i e d .  The major l i m i t a t i o n centered around the  i n a b i l i t y t o compare each graduate nurse's performance, i n the study group, i n the use o f the n u r s i n g process before and a f t e r completion o f the i n s t r u c t i o n a l program.  T h e r e f o r e a small e f f e c t  of the i n s t r u c t i o n a l program would have been obscured by the number of n u r s i n g personnel not completing the program.  Furthermore,  any d i f f e r e n c e i n the study group may have been spurious due t o the p r o p o r t i o n o f records completed by n u r s i n g personnel who completed the i n s t r u c t i o n a l program and those who d i d n o t . Many v a r i a b l e s other than the knowledge and s k i l l o f the graduate nurse were i d e n t i f i e d i n terms o f t h e i r e f f e c t on the u t i l i z a t i o n o f the n u r s i n g process by the graduate nurse i n practice.  These v a r i a b l e s were i d e n t i f i e d by the graduate nurses  in the study group as reasons f o r t h e i r i n a b i l i t y t o use the n u r s i n g process i n p r a c t i c e . When the graduate nurses i n the study group were assessed i n i t i a l l y , i n terms o f the p r e - e s t a b l i s h e d o b j e c t i v e s o f  63 the program, i t was found t h a t they a l l had some idea o f what the n u r s i n g process was but none were able to meet the o b j e c t i v e s . Once the graduate nurses i n the study group were able t o use the nursing process,  i t became apparent t h a t other i n h i b i t i n g f a c t o r s  were i n v o l v e d i n t h e i r use of the n u r s i n g process i n p r a c t i c e . These i n h i b i t i n g f a c t o r s a r e : (1) a method o f r e c o r d i n g the v a r i o u s phases of the n u r s i n g process; (2) absence o f a u n i f i e d f r o n t i n the u t i l i z a t i o n of the n u r s i n g process i n the c l i n i c a l area; (3) i n s u f f i c i e n t time i n the c l i n i c a l area t o o b t a i n  a  n u r s i n g h i s t o r y , develop a problem l i s t and develop a w r i t t e n plan o f care; and (4) inadequate numbers o f r o l e models i n the use o f the n u r s i n g process.  Method o f Recording the Nursing  Process  . The graduate nurses i n the study group expressed  great  d i f f i c u l t y i n r e c o r d i n g the v a r i o u s phases o f the nursing process. The p a t i e n t records d i d not lend themselves l i s t , or progress notes.  t o r e c o r d i n g a problem  The n u r s i n g care plan form was too small  to i n c l u d e the problem l i s t , o b j e c t i v e s o f c a r e , and subsequent plan of care.  The nurses' notes were not used to record the  n u r s i n g process because they were used by n u r s i n g personnel  other  than those i n the study, who, were not using the nursing process. An attempt was made t o use the nurses' notes t o record the problem l i s t and subsequent plan o f care but nursing personnel not i n the study d i d not understand t h a t method o f r e c o r d i n g .  64 Without a proper method of r e c o r d i n g the n u r s i n g p r o c e s s , t h e r e i s l i t t l e hope of the c o n t i n u i t y of p a t i e n t care a t t a i n e d through the use of the n u r s i n g process.  U n i f i e d Front Nursing h i s t o r i e s were p r i m a r i l y obtained by L i c e n s e d P r a c t i c a l Nurses, who, were not i n c l u d e d i n the study.  Not only  were the L i c e n s e d P r a c t i c a l Nurses not i n c l u d e d i n the study, but seven of the graduates on the u n i t d i d not consent t o p a r t i c i p a t e in the study.  The study group f e l t they c o u l d not u t i l i z e the  n u r s i n g process i n t h e i r p r a c t i c e , without the support of the n u r s i n g personnel who d i d not take p a r t i n the study.  They f e l t  t h a t a l l n u r s i n g personnel on the u n i t needed t o be i n v o l v e d i n the i n s t r u c t i o n a l program before the n u r s i n g process c o u l d be u t i l i z e d i n the p r a c t i c e area.  Time i n the C l i n i c a l Area The study group expressed a d i f f i c u l t y i n f i n d i n g the time to o b t a i n a n u r s i n g h i s t o r y , analyze the data to form a problem l i s t , and c a r r y through the subsequent planning of the n u r s i n g care. duties  They f e l t t h a t most of t h e i r time was taken up i n such as, m e d i c a t i o n s , checking I.V.'s, and t a k i n g care of the  immediate needs of each p a t i e n t . I t was suggested t h a t i f u t i l i z a t i o n of the n u r s i n g process was expected behaviour, time would be found t o c a r r y i t through.  T h i s i s s u e was not r e s o l v e d .  65  Number of Role Models The study group expressed a need f o r the support and guidance of r o l e models i n the use of the n u r s i n g process.  I t was  f e l t t h a t the r o l e models needed to have the a u t h o r i t y which would allow them to i n i t i a t e the use of the n u r s i n g process i n p r a c t i c e .  EFFECTIVENESS OF THE INSTRUCTIONAL PROGRAM The e f f e c t i v e n e s s of the i n s t r u c t i o n a l program needs to be c o n s i d e r e d i n r e l a t i o n to the r e s u l t s o f the study. model on concept formation  Woodruff's  was used i n planning the program and  was d i s c u s s e d i n Chapter Three.  The program was s t r u c t u r e d t o  provide the graduate nurse with an overview of the n u r s i n g process f o l l o w e d by a more d e t a i l e d look at each phase.  The major weakness  of the program was the i n a b i l i t y to s t r u c t u r e a p o r t i o n of time in the c l i n i c a l area where the graduate nurse c o u l d concentrate on developing concepts concerning the  n u r s i n g process and c o n s c i o u s l y  t r y i n g out these concepts i n planned c l i n i c a l s i t u a t i o n s .  This  meant t h a t the t r i a l phase of concept formation (Figure 1) was inadequately d e a l t w i t h . T h i s lack of s t r u c t u r e d time i n the c l i n i c a l area was thought to be a s i g n i f i c a n t f a c t o r i n the o v e r a l l e f f e c t i v e n e s s of the i n s t r u c t i o n a l program.  66  SUMMARY A l l seven n u l l hypotheses were r e t a i n e d , although there was a s i g n i f i c a n t i n c r e a s e i n three o f the c r i t e r i a i n the p l a n n i n g phase.  The s t a t i s t i c a l s i g n i f i c a n c e o b t a i n e d i n c r i t e r i a c, and  d o f the planning phase must be viewed with c a u t i o n s i n c e a l a r g e p a r t o f the t - r a t i o i s c o n t r i b u t e d by the decrease present i n the c o n t r o l group.  The i n a b i l i t y to r e j e c t any o f the n u l l  hypotheses  may be due i n p a r t to the l i m i t a t i o n s o f t h i s study.  The major  l i m i t a t i o n was the i n a b i l i t y to compare each nurses  performance,  i n the study group, on an i n d i v i d u a l b a s i s before and a f t e r comp l e t i o n o f the i n s t r u c t i o n a l program.  The e f f e c t s o f the  i n s t r u c t i o n a l program needed to be very l a r g e to o b t a i n a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n the use o f the n u r s i n g process before and a f t e r completion o f the i n s t r u c t i o n a l program, due to the number o f n u r s i n g personnel not i n c l u d e d i n the study.  67  CHAPTER V SUMMARY, CONCLUSIONS AND IMPLICATIONS FOR RESEARCH AND PRACTICE SUMMARY The purpose o f t h i s study was to determine whether an i n s t r u c t i o n a l program f o r graduate nurses concerning the n u r s i n g process would:  (1) i n c r e a s e the frequency with which a n u r s i n g  h i s t o r y ( d e f i n e d data base) i s o b t a i n e d ; (2) i n c r e a s e the number o f p a t i e n t problems i d e n t i f i e d ; (3) i n c r e a s e the c o n s i s t e n c y o f the i n d i v i d u a l p a t i e n t problems, with e s t a b l i s h e d c r i t e r i a ; (4) show subsequent improvement i n the p l a n n i n g , implementing  and  e v a l u a t i o n phases o f the n u r s i n g process; and (5) have a f a v o u r a b l e e f f e c t on how the graduate nurse views the n u r s i n g process. A quasi experimental design was used with a non-equivalent c o n t r o l group and a pre and post t e s t .  Data were gathered on a l l  dependent v a r i a b l e s before and a f t e r the completion o f an i n s t r u c t i o n a l program by the study group on the n u r s i n g process.  A  panel o f three judges was used to a u d i t p a t i e n t records ( n u r s i n g h i s t o r y , n u r s i n g care p l a n , and nurses' n o t e s ) , i n o r d e r to o b t a i n data on a l l phases of the n u r s i n g process f o r both groups. A q u e s t i o n n a i r e was a d m i n i s t e r e d to the study group and the c o n t r o l group to o b t a i n data on the a t t i t u d e o f the graduate nurse toward the n u r s i n g process.  The a u d i t o f the p a t i e n t records  68  and  the a d m i n i s t r a t i o n of the q u e s t i o n n a i r e were c a r r i e d out before  and a f t e r completion of the i n s t r u c t i o n a l program by the graduate nurses i n the study group. The i n s t r u c t i o n a l program on the n u r s i n g process was completed by the study group f o l l o w i n g the p r e t e s t . The  program  was c a r r i e d out on an i n d i v i d u a l b a s i s with the i n v e s t i g a t o r and c o n c u r r e n t l y with the r e g u l a r d u t i e s o f the graduate nurse.  Com-  p l e t i o n o f the program was determined by the attainment o f pree s t a b l i s h e d o b j e c t i v e s by the graduate nurse. A l l of the n u l l hypotheses i n t h i s study were r e t a i n e d . There was, however, a s i g n i f i c a n t i n c r e a s e i n three c r i t e r i a i n the planning phase of the n u r s i n g process  i n the study group, f o l l o w i n g  the completion o f the i n s t r u c t i o n a l program. (1) expected  These c r i t e r i a were:  b e h a v i o u r a l outcomes f o r the p a t i e n t are e s t a b l i s h e d ;  (2) the expected b e h a v i o u r a l outcomes are r e a l i s t i c ; and (3) the expected b e h a v i o u r a l outcomes are r e l a t e d to p a t i e n t problems i d e n t i f i e d i n the assessment phase.  I t must be p o i n t e d out t h a t  a l a r g e c o n t r i b u t i o n to the t - v a l u e i n c r i t e r i a 2 and 3 was cont r i b u t e d by the decrease present i n the c o n t r o l group. I t was thought t h a t the:  (1) method of r e c o r d i n g the n u r s i n g  p r o c e s s ; (2) u n i f i e d f r o n t ; (3) time i n the c l i n i c a l a r e a ; (4) number of r o l e models; (5) i n a b i l i t y to compare each graduate nurse, i n the study, i n r e l a t i o n to her use o f the n u r s i n g process before and a f t e r completing the i n s t r u c t i o n a l program; and (6) absence o f s t r u c t u r e d time i n the c l i n i c a l area f o r  the  69  graduate nurse to p r a c t i s e the s k i l l s r e q u i r e d i n the use o f the nursing process were i n f l u e n c i n g f a c t o r s i n the r e t e n t i o n of the null  hypotheses.  CONCLUSIONS The r e t e n t i o n of a l l seven n u l l hypotheses leads to the c o n c l u s i o n t h a t the completion o f an i n s t r u c t i o n a l program by graduate nurses d i d not have an e f f e c t on the use of the n u r s i n g process i n the c l i n i c a l area or on t h e i r a t t i t u d e toward i t .  The  r e t e n t i o n of the n u l l hypotheses may have been due i n p a r t to the l i m i t a t i o n s of the study and i n p a r t to the absence of s t r u c tured time i n the c l i n i c a l area f o r the graduate nurses to p r a c t i s e the s k i l l s r e q u i r e d i n u s i n g the n u r s i n g p r o c e s s .  IMPLICATIONS FOR RESEARCH From  t h i s study there stems a need to i d e n t i f y other  v a r i a b l e s t h a t i n h i b i t the use of the n u r s i n g process i n the p r a c t i c e area.  I t became e v i d e n t during the study t h a t many  v a r i a b l e s besides inadequate knowledge and s k i l l by the graduate nurse i n using the n u r s i n g p r o c e s s , were i n v o l v e d i n determining the use o f the n u r s i n g process i n the p r a c t i c e area.  70  The e f f e c t of r o l e models, an adequate method of r e c o r d i n g the n u r s i n g process and the i n c l u s i o n of a l l n u r s i n g personnel ( i n a p a r t i c u l a r area) i n an i n s t r u c t i o n a l program on the n u r s i n g p r o c e s s , need to be looked at i n r e l a t i o n to the use of the n u r s i n g process i n the p r a c t i c e s e t t i n g .  Recommendations 1.  R e p l i c a t i o n of t h i s study with the i n c l u s i o n of a l l n u r s i n g personnel i n a p a r t i c u l a r area and the comparison of each s u b j e c t s performance i n the use of the n u r s i n g process before and a f t e r the completion of the i n s t r u c t i o n a l program.  2.  Comparison  of the use of the n u r s i n g process as a p r a c t i c e  tool between areas where s u f f i c i e n t r o l e models e x i s t and areas where they do not. 3.  Comparison  of the use of the n u r s i n g process as a p r a c t i c e  t o o l between areas where there i s a h i g h l y p o s i t i v e a t t i t u d e toward the use o f the n u r s i n g process as a p r a c t i c e tool and areas where the a t t i t u d e i s l e s s p o s i t i v e . 4.  Comparison  of the e f f e c t i v e n e s s of v a r i o u s i n s t r u c t i o n a l  methods i n i n c r e a s i n g the use of the n u r s i n g process i n the p r a c t i c e area.  e.g. programmed l e a r n i n g , independent  study  with an a v a i l a b l e c o n s u l t a n t , and s t r u c t u r e d group i n s t r u c t i o n . 5.  E x p l o r a t i o n of the r e l a t i o n s h i p between q u a l i t y of care and the use of the n u r s i n g process.  The t o o l s f o r measuring  quality  71  care t h a t were mentioned i n Chapter Two could be used i n a s s e s s i n g whether a p o s i t i v e c o r r e l a t i o n e x i s t e d between the measurements of q u a l i t y care and the use of the n u r s i n g process i n the p r a c t i c e area.  These t o o l s were the Q u a l i t y P a t i e n t Care S c a l e , the  S l a t e r Nursing Competencies Rating S c a l e , and The Nursing A u d i t .  IMPLICATIONS FOR PRACTICE I m p l i c a t i o n s f o r p r a c t i c e i n r e l a t i o n to t h i s study o r i g i n a t e from the request of the graduate nurses, who completed  the i n s t r u c -  t i o n a l program, f o r r o l e models, a u n i f i e d f r o n t and an improved method o f r e c o r d i n g the n u r s i n g process.  Although time  was  considered an important v a r i a b l e i t was thought t h a t i t s s i g n i f i c a n c e could not be p r o p e r l y assessed u n t i l the other v a r i a b l e s were d e a l t w i t h .  Recommendati ons 1.  The a v a i l a b i l i t y of a s u f f i c i e n t number o f r o l e models i n the use of the n u r s i n g process i n the p r a c t i c e area.  2.  The i n t r o d u c t i o n , i n t o the c l i n i c a l area, of an adequate method of r e c o r d i n g the n u r s i n g process such as problem oriented records.  3.  P r i o r agreement from a l l n u r s i n g personnel i n v o l v e d , conc e r n i n g i n i t i a t i o n of the use of the nursing process as a practice tool.  72  SUMMARY T h i s study has been an attempt to look at the n u r s i n g process as a p r a c t i c e tool r a t h e r than i t s r e l a t i o n s h i p to q u a l i t y p a t i e n t care.  However, the r e l a t i o n s h i p between the n u r s i n g process  and q u a l i t y care i s an important area.  Does the q u a l i t y of care  improve with the use of the n u r s i n g process?  T h i s , o f course, v  i s the most important question t h a t needs to be answered, but u n t i l more c l i n i c a l areas are using the n u r s i n g process as a p r a c t i c e t o o l , t h i s question w i l l remain unanswerable.  73  \  FOOTNOTES  74  FOOTNOTES CHAPTER I  Helen Yura and Mary Walsh, The Nursing Process: a s s e s s i n g , p l a n n i n g , implementing, e v a l u a t i n g , New York: Appleton-CenturyC r o f t s , 1973, 15. G.I. A l f a n o , "Healing or Caretaking Which W i l l I t Be?", Nursing C l i n i c s of North America, June, 1971, 6:2, 273-280.  2  3  Ingeborg G. Mauksch and Miriam L. David, " P r e s c r i p t i o n f o r S u r v i v a l , " American Journal of Nursing, December, 1972, 72:12, 4 Yura and Walsh, 1. 5 Dolores E. L i t t l e and Doris L. C a r n e v a l i , Nursing Care P l a n n i n g , P h i l a d e l p h i a : J.B L i p p i n c o t t Company, 1969, 9. Yura and Walsh.  6  ^ L i t t l e and C a r n e v a l i . Marlene G. Mayers, A Systematic Approach to the Nursing Care Plan, New York: A p p l e t o n - C e n t u r y - C r o f t s , 1972. g  Ann M a r r i n e r , The Nursing Process: A S c i e n t i f i c Approach t o Nursing Care, S a i n t L o u i s : C.V. Mosby Company, 1975. 10  Alfano.  ^ Doris B l o c h , " E v a l u a t i o n o f Nursing Care i n Terms of Process and Outcome: Issues i n Research and Q u a l i t y Assurance," Nursing Research, July-August, 1975, 24:4, 256-263. 12  Marlene G. Mayers, "A Search f o r Assessment Outlook, May, 1972, 20:5, 323-326.  C r i t e r i a , " Nursing  E i l e e n G. Hasselmeyer, D i s c u s s a n t : "Problems i n the Development of Adequate C r i t e r i a , " Nursing Research, F a l l , 1962, 11:4, 208-211.  75  R o z e l l a M. S c h l o t f e l d t , D i s c u s s a n t : "Problems i n the Development of Adequate C r i t e r i a , " Nursing Research, F a l l , 1962, 11:4, 211-213. 15  E i l e e n E. H i l g e r , "Developing Nursing Outcome C r i t e r i a , " Nursing C l i n i c s of North America, June, 1974, 9:2, 323-330. Helen V. Berg, "Nursing A u d i t and Outcome C r i t e r i a , " Nursing C l i n i c s of North America, June, 1974, 9:2, 331-335. " T a y l o r , 337-348. I  Q  Marion E. N i c h o l l s , " Q u a l i t y Control i n P a t i e n t Care," American Journal of N u r s i n g , March, 1974, 74:3, 456-459. 19  Yura and Walsh, 15.  76  FOOTNOTES CHAPTER I I  ' V i r g i n i a Henderson, "On Nursing Care Plans and T h e i r H i s t o r y , " Nursing Outlook, June, 1973, 21:8, 378-379. Helen Yura and Mary Walsh, The Nursing Process: a s s e s s i n g , p l a n n i n g , implementing, e v a l u a t i n g , New York: Appleton-CenturyC r o f t s , 1973, 19. 2  3  I b i d . , 20  4  I b i d . , 21.  5  I b i d . , 68-137.  Ann M a r r i n e r , The Nursing Process: A S c i e n t i f i c Approach to Nursing Care, S a i n t L o u i s : C.V. Mosby Company, 1975. Marlene G. Mayers, A Systematic Approach to the Nursing Care P l a n , New York: A p p l e t o n - C e n t u r y - C r o f t s , 1972. 7  Q  Dolores E. L i t t l e and D o r i s L. C a r n e v a l i , Nursing Care P l a n n i n g , P h i l a d e l p h i a : J.B. L i p p i n c o t t Co., 1969. g E i l e e n P. B e c k n e l l and Dorothy M. Smith, System o f Nursing P r a c t i c e : a c l i n i c a l n u r s i n g assessment t o o l , P h i l a d e l p h i a : F.A. Davis Company, 1975. Ian Hargreaves, "The Nursing Process: the Key to I n d i v i d u a l i z e d Care," Nursing Times, August 28, 1975, 71:35, 89-91. 0  K.J. K e l l y and K. Hammond, "An Approach to Study o f C l i n i c a l Inference i n Nursing," Nursing Research, F a l l , 1964, 13:4, 314322. 1  K. K e l l y , " C l i n i c a l Inference i n Nursing - A Nurse's Nursing Research, Winter, 1966, 15:1, 23-26.  Viewpoint,"  77 13 K.R. Hammond, " C l i n i c a l Inference i n Nursing - A P s y c h o l o g i s t ' s Viewpoint," Nursing Research, Winter, 1966, 15:1, 27-38. 14  K.R. Hammond, K.J. K e l l y , N.J. C a s t e l l a n J r . and R.J. Schneider, " C l i n i c a l I n f e r e n c e i n Nursing - A n a l y z i n g C o g n i t i v e Tasks R e p r e s e n t a t i v e o f Nursing Problems," Nursing Research, S p r i n g , 1966, 15:2, 134-138. 15 K.R. Hammond, K.J. K e l l y , N.J. C a s t e l l a n J r . and R.J. S c h n e i d e r , " C l i n i c a l Inference i n Nursing - Information U n i t s Used," Nursing Research, Summer, 1966, 15:3, 236-243. K.R. Hammond, K.J. K e l l y , N.J. C a s t e l l a n J r . R.J. Schneider, and M. V a n c i n i , " C l i n i c a l Inference i n Nursing - Use o f Information Seeking S t r a t e g i e s , " Nursing Research, F a l l , 1966, 15:4, 330336. 1 6  ^ K.R. Hammond, K.J. K e l l y and R.J. Schneider, " C l i n i c a l I n f e r ence i n Nursing - R e v i s i n g Judgements," Nursing Research, Winter, 1967, 16:1, 38-45. 1  Yura and Walsh, 22.  19  Research Grant D i v i s i o n o f N u r s i n g , U.S. Department o f H e a l t h , Education and Welfare, Long-Term E f f e c t s o f an Experimental Nursing Process, L. Hall and G.J. A l f a n o , p r i n c i p a l i n v e s t i g a t o r s , NU-00308, 1968-1974, Unpublished. 20 I.G. Mauksch and M.L. David, " P r e s c r i p t i o n f o r S u r v i v a l , " American Journal o f Nursing, December, 1972, 72:12, 2189-2193. 21 L.Lewis, "This I B e l i e v e . . . About t h e Nursing Process-Key to Care," Nursing Outlook, 1968, 16:5, 26-29. 22 S. C a r l s o n , "A P r a c t i c a l Approach t o the Nursing Process," American J o u r n a l o f Nursing, September, 1972, 75:9, 1589-1591. 23 D.S. Zimmerman and C. Gohrke, "The G o a l - D i r e c t e d Nursing Approach: I t Does Work," American Journal o f Nursing, February, 1970, 70:2 , 306-310. 2 4  25  Yura and Walsh, 1. L i t t l e and C a r n e v a l i , 1.  78 26  27  Mayers, 12. Ibid.  28  Dorothy M. Smith, "A C l i n i c a l Nursing T o o l , " American J o u r n a l of Nursing, November, 1968, 68:11, 2384-2388. 29 V i r g i n i a Henderson, The Nature o f N u r s i n g , New York: MacMillan Company, 1966, 16-17. 30 Becknell and Smith, 3-35. 31 L. M. McPhetridge, "Nursing H i s t o r y : One Means to P e r s o n a l i z e Care," American J o u r n a l o f Nursing, January, 1968, 68:1, 68-75. 3 2  I b i d . , 68.  33  R. Faye McCain, "Nursing by Assessment - Not I n t u i t i o n , " American J o u r n a l o f Nursing, A p r i l , 1965, 65:4, 82-84. 34  M.E. Hamdi and C M . Hutelmyer, "A Study o f the E f f e c t i v e n e s s o f an Assessment Tool i n the I d e n t i f i c a t i o n o f Nursing Care Problems," Nursing Research, J u l y - A u g u s t , 1970, 19:4, 354-359. 35  Ibid.  J.C. M a r s h a l l and S. Feeney, " S t r u c t u r e d Versus I n t u i t i v e Intake I n t e r v i e w , " Nursing Research, May-June, 1972, 21:3, 269272. 37  L.M. McPhetridge, " R e l a t i o n s h i p o f P a t i e n t s ' Responses to Nursing H i s t o r y Questions and S e l e c t e d F a c t o r s : P r e l i m i n a r y Study," Nursing Research, J u l y - A u g u s t , 1973, 22:4, 310-320. 3 8  39  I b i d . , 320.  E.A. H e f f e r i n and R.E. Hunter, "Nursing Assessment and Care Plan Statements," Nursing Research, September-October, 1975, 24:5, 360-366.  79 40 Marlene G. Mayers, "A Search f o r Assessment C r i t e r i a , " Nursing Outlook, May, 1972, 20:5, 323-326. 41  K. Gebbie and M.A. L a v i n , " C l a s s i f y i n g Nursing Diagnoses," American Journal o f Nursing, February, 1974, 74:2, 250-253. 42 N.I. Komorita, "Nursing Diagnoses," American Journal o f Nursing, December, 1963, 63:12, 83-86. 43 W. Chambers, "Nursing D i a g n o s i s , " American Journal o f Nursing, November, 1962, 62:11, 102-104. 44 M.0. Mundinger and G.D. Jauron, "Developing a Nursing D i a g n o s i s , " Nursing Outlook, February, 1975, 23:2, 94-98. 45  Yura and Walsh, 92.  46 B e c k n e l l and Smith, 68. 4 7  Mayers, 28-33.  48  Dorothy M. Smith, " W r i t i n g O b j e c t i v e s as a Nursing P r a c t i c e S k i l l , " American Journal o f Nursing, February, 1971, 71:2, 319320. 4 9  Ibid. .  50  Yura and Walsh, 93.  51 Becknell and Smith, 85. Ibid. 53  Mayers, 15.  54  55  L i t t l e and C a r n e v a l i , 63-64.  R.L. C i u c a , "Over the Years with the Nursing Care P l a n , " Nursing Outlook, November, 1972, 20:11, 706-711. Ibid. 5 6  80 J.P. G r o s i c k , M. Hagey and I. Johnson, "Nursing Care P l a n s : Survey o f Status and Opinions About C u r r e n t Usage," Journal o f P s y c h i a t r i c Nursing, November-December, 1967, 5:6, 567-585. 58  Ibid.  59  Ibid.  N.C. K e l l y , "Nursing Care P l a n s , " Nursing Outlook, May, 14:5, 61-64.  6 0  1966,  R.L. Hanson, "The Nursing H i s t o r y and Care P l a n : A Throw Away?" Washington S t a t e Journal o f Nursing, S p r i n g , 1972, 44: 2 , 2123. 62  Yura and Walsh, 35-67.  63  L i t t l e and C a r n e v a l i , 19-45.  64 M a r r i n e r , 109. 65  66  67  Yura and Walsh, 108. Ibid. Lewis, 28.  68 M.C. Phanuef, The Nursing A u d i t : P r o f i l e f o r E x c e l l e n c e , New York: A p p l e t o n - C e n t u r y - C r o f t s , 1962. 69 M.A. Wandelt and J.W. Ager, Q u a l i t y P a t i e n t Care S c a l e , New York: A p p l e t o n - C e n t u r y - C r o f t s , 1974. ^ M.A. Wandelt and D.S., Stewart, S l a t e r Nursing Competencies Rating S c a l e , New York: A p p l e t o n - C e n t u r y - C r o f t s , 1975. 7  J.H. C a r t e r , M. H i l l i a r d , M.R. C a s t l e s , L.D. S t o l l and A. Cowan, Standards o f Nursing Care, New York: S p r i n g e r P u b l i s h i n g Company Inc., 1972. 71  72  Yura and Walsh, 120-121.  81  73  Ibid.  74  Ibid.  75 M a r r i n e r , 195. M.E. N i c h o l l s , " Q u a l i t y Control i n P a t i e n t Care," American Journal of Nursing, March, 1974, 74:3, 456-459. 76  Howard B a i l i t , Judy Lewis, Louis Hochheiser, and Nancy Bush, "Assessing the Q u a l i t y of Care", Nursing Outlook, March, 1975, 23:3, 153-159. 77  78  Doris B l o c h , " E v a l u a t i o n o f Nursing Care i n Terms o f Process and Outcome: Issues i n Research and Q u a l i t y Assurance," Nursing Research, J u l y - A u g u s t , 1975, 24:4, 256-263. 79  80  81  I b i d . , 258 Wandelt and Ager. Ibid.  82  Wandelt and Stewart. 8 3  Phanuef.  8 4  I b i d . , 15-16.  85  E i l e e n E. H i l g e r , "Developing Nursing Outcome C r i t e r i a , " Nursing C l i n i c s of North America, June, 1974, 9:2, 323-330. ^ Sudie A. C o r n e l l , "Development of an Instrument f o r Measuring the Q u a l i t y o f Nursing Care," Nursing Research, M a r c h - A p r i l , 1974, 23:2, 108-117 8  87  Joyce Waterman T a y l o r , "Measuring the Outcomes of Nursing Care," Nursing C l i n i c s of North America, June, 1974, 9:2, 337-348. 8 8  Hilger.  8 9  Cornell.  82  9 0  Taylor.  91  Ibid.  9 2  Ibid.  93  R o z e l l a M. S c h l o t f e l d t , D i s c u s s a n t : "Problems i n the Development o f Adequate C r i t e r i a , " Nursing Research, F a l l , 1962, 11:4, 211-213. 94 y 4  Ibid.  95  J.C. McCloskey, "The Problem-Oriented Records vs the Nursing Care P l a n : A P r o p o s a l , " Nursing Outlook, August, 1975, 23:8, 492-495. 96 P.H. M i t c h e l l , "A Systematic Nursing Progress Record: The Problem-Oriented Approach," Nursing Forum, 1973, 12:2, 187-209. 97 S.R. Y a r n a l l and J . Atwood, "Problem-Oriented P r a c t i c e f o r Nurses and P h y s i c i a n s , " Nursing C l i n i c s o f North America, June, 1974, 9:2, 215-228. M i t c h e l l , 187. 9 8  9 9  McCloskey, 493.  ^ L. Weed, "Medical Records t h a t Guide and Teach," New England Journal o f M e d i c i n e , March 14, 1968, 278:11, 593-600. 101  102  B e c k n e l l and Smith, 15-17.  F. Woolley, N.W. Warnick, R.L. Kane and E.D. Dyer, ProblemO r i e n t e d N u r s i n g , New York: S p r i n g e r P u b l i s h i n g Company, 1974. 103 W. J . Hurst and K.H. Walker, Eds., The Problem-Oriented System, New York: Medcom P r e s s , 1972. 104 M. Woody and M. M a l l i s o n , "The Problem-Oriented System f o r P a t i e n t - C e n t e r e d Care," American J o u r n a l o f N u r s i n g , J u l y , 1973, 73:7, 1168-1175.  83  B.C. Vaughan-Wrobel and B. Henderson, The Problem-Oriented System i n N u r s i n g , A Workbook, Toronto: C.V. Mosby Company, 1976. lV0  106  Yura and Walsh, 23.  1 0 7  Yura and Walsh, 26-31.  1 0 8  Henderson, 6-23.  84  FOOTNOTES CHAPTER I I I  Donald T. Campbell and J u l i a n C. S t a n l e y , Experimental and Quasi Experimental Designs f o r Research, Chicago: Rand McNally C o l l e g e P u b l i s h i n g Company, 1966, 50. 2 3  Campbell and S t a n l e y , 50.  Helen Yura and Mary Walsh, The Nursing Process: a s s e s s i n g , p l a n n i n g , implementing, e v a l u a t i n g , New York: A p p l e t o n - C e n t u r y - C r o f t s , 1973, 15. 4 George A. Ferguson, S t a t i s t i c a l A n a l y s i s i n Psychology and E d u c a t i o n, Fourth e d i t i o n , New York: McGraw-Hill Book Company, 1976, 373-376. 5  I b i d . , 375-376.  g  M. Fewster, "The Development o f a S c a l e to Measure Nurses' A t t i t u d e Toward the Nursing Process," Unpublished, U n i v e r s i t y o f B r i t i s h Columbia, 1975. 7  I b i d . , 8.  8  Ibid.  9  Ibid.  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"On Nursing Care Plans and T h e i r H i s t o r y , " Nursing Outlook, June, 1973, 21:8, 378-379. H i l g e r , E i l e e n E. "Developing Nursing Outcome C r i t e r i a , " Nursing C l i n i c s o f North America, June, 1974, 9:2, 323-330. K e l l y , K.J. " C l i n i c a l Inference i n Nursing - A Nurse's Viewpoint," Nursing Research, Winter, 1966, 15:1, 23-26. K e l l y , K.J. and Hammond, K. "An Approach to Study of C l i n i c a l Inference i n Nursing," Nursing Research, F a l l , 1964, 13:4, 314-322. K e l l y , N.C. "Nursing Care P l a n s , " Nursing Outlook, May, 14:5, 61-64.  1966,  Komorita, N.I. "Nursing Diagnoses," American J o u r n a l o f N u r s i n g , December, 1963, 63:12, 83-86. Lewis, L. " T h i s . I B e l i e v e ... . . About the Nursing Process-Key to Care:, Nursing Outlook., May, 1963, 16;5, 26-29.. McCain, R. Faye. "Nursing by Assessment - Not I n t u i t i o n , " American Journal of N u r s i n g , A p r i l , 1965, 65:4, 82-84. McCloskey, J.C. "The Problem-Oriented Records vs the Nursing Care P l a n : A P r o p o s a l , " Nursing Outlook, August, 1975, 23:8, 492-495. McPhetridge, L.M. "Nursing H i s t o r y : One Means to P e r s o n a l i z e Care," American J o u r n a l of N u r s i n g , January, 1968, 68:1, 68-75. McPhetridge, L.M. " R e l a t i o n s h i p of P a t i e n t s ' Responses to Nursing H i s t o r y Questions and S e l e c t e d F a c t o r s : P r e l i m i n a r y Study," Nursing Research, J u l y - A u g u s t , 1973, 22:4, 310-320. M a r s h a l l , J.C. and Feeney, S. " S t r u c t u r e d Versus I n t u i t i v e Intake Interview," Nursing Research, May-June, 1972, 21:3, 269-272.  91 Mauksch, I.G. and David, M.L. " P r e s c r i p t i o n f o r S u r v i v a l , " American Journal of N u r s i n g , December, 1972, 72:12, 2189-2193. Mayers, Marlene G. "A Search f o r Assessment C r i t e r i a , " Nursing Outlook, May, 1972, 20:5, 323-326. M i t c h e l l , P.H. "A Systematic Nursing Progress Records: The ProblemOriented Approach," Nursing Forum, 1973, 12:2, 187-209. Mundinger, M.O. and Jauron, G.D. "Developing a Nursing D i a g n o s i s , " Nursing Outlook, February, 1975, 23:2, 94-98. N i c h o l l s , M.E. " Q u a l i t y C o n t r o l i n P a t i e n t Care," American J o u r n a l of N u r s i n g , March, 1974, 74:3, 456-459. S c h l o t f e l d t , R o z e l l a M. D i s c u s s a n t : "Problems i n the Development of Adequate C r i t e r i a , " Nursing Research, F a l l , 1962, 11:4, 211-213. Smith, Dorothy M. " C l i n i c a l Nursing T o o l , " American J o u r n a l of N u r s i n g , November, 1968, 68:11, 2384-2388. Smith, Dorothy M. " W r i t i n g O b j e c t i v e s as a Nursing P r a c t i c e S k i l l , " American J o u r n a l of N u r s i n g , February, 1971, 71:2, 319-320. T a y l o r , Joyce Waterman. "Measuring the Outcomes of Nursing Care," Nursing C l i n i c s of North America, June, 1974, 9:2,"337-348. Tyzenhouse, P h y l l i s . "Care Plans f o r Nursing Home P a t i e n t s , " Nursing Outlook, March, 1972, 20:3, 169-172. Wandlet, Mable A. and Phaneuf, Maria C. "Three Instruments f o r Measuring the Q u a l i t y of Nursing Care," H o s p i t a l T o p i c s , August, 1972, 50, 20-29. Weed, L.  "Medical Records t h a t Guide and Teach," New England Journal of M e d i c i n e , March 14, 1968, 278:11, 593-600.  Woody, M. and M a l l i s o n , M. "The Problem-Oriented System f o r P a t i e n t Centered Care," American J o u r n a l of N u r s i n g , J u l y , 1973, 73:7, 1168-1175. Y a r n a l l , S.R. and Atwood, J . "Problem-Oriented P r a c t i c e f o r Nurses and P h y s i c i a n s , " Nursing C l i n i c s of North America, June, 1974, 9:2, 215-228. Zimmerman, D.S. and Gohrke, C. "The G o a l - D i r e c t e d Nursing Approach: I t Does Work," American J o u r n a l of N u r s i n g , February, 1970, 70:2, 306-310.  92  UNPUBLISHED REPORTS Fewster, Mary. "The Development o f a S c a l e t o Measure Nurses A t t i t u d e Toward the Nursing P r o c e s s , " Unpublished, U n i v e r s i t y o f B r i t i s h Columbia, 1975. Research Grants D i v i s i o n o f N u r s i n g , U.S. Department o f H e a l t h , Education and W e l f a r e . Long-Term E f f e c t s o f an Experimental Nursing Process, L. H a l l and G.J. A l f a n o , p r i n c i p a l i n v e s t i g a t o r s , NU-00308, 1968-1974, unpublished. PERSONAL  COMMUNICATION  Fewster, Mary. Telephone Interview, I n s t r u c t o r , Douglas C o l l e g e School o f Nursing, Surrey Campus, B.C., A p r i l 12, 1976.  APPENDIX A FORM OF CONSENT  94  FORM OF CONSENT  I consent to p a r t i c i p a t e as a s u b j e c t i n the study conducted by B. Boyle on 4 South a t Surrey Memorial H o s p i t a l .  I have been  informed o f the procedures i n v o l v e d i n t h i s study, which r e q u i r e s the completion o f a q u e s t i o n n a i r e before and a f t e r the study i s completed.  The time r e q u i r e d f o r completing the q u e s t i o n n a i r e  has been s t a t e d t o be 1 0 - 1 5 minutes.  I may withdraw  the study a t any time.  Signature Date  from  FORM OF CONSENT  I consent t o p a r t i c i p a t e as a s u b j e c t i n the study conducted by B. Boyle on 4 East a t Surrey Memorial H o s p i t a l .  I have  been informed by B. Boyle o f the procedures i n v o l v e d i n t h i s study.  I am aware o f the c o n t e n t o f the i n s t r u c t i o n a l program  and have been informed t h a t the time r e q u i r e d f o r t h i s procedure i s unknown a t p r e s e n t .  I have a l s o been informed  t h a t the study i n v o l v e s f i l l i n g o u t a q u e s t i o n n a i r e and the time r e q u i r e d f o r t h i s i s 1 0 - 1 5 minutes. from the study a t any time.  Signature Date  I may withdraw  APPENDIX B PATIENT RECORDS  SURREY MEMORIAL HOSPITAL NURSES' NOTES & HISTORY  97  Date NURSING CARE AND OBSERVATIONS Time  Admission Interview by  Admitted walking, w h e e l c h a i r , s t r e t c h e r , ( C i r c l e ) T  P  R  Apex  BP  Weight i n K i l o s  Allergies Contact Lenses S o f t o r hard  Dentures  Upper Lower  Diet  Normal  Special  Sleep  Well  Fair  Glasses Prosthesis Hearing A i d  Poor  Urinary I r r e g u l a r i t i e s Bowel  Irregularities  M e d i c a t i o n Taken a t Home:  O b s e r v a t i o n r e : P a t i e n t ' s P h y s i c a l C o n d i t i o n and Apparent S t a t e o f Mind:  P a t i e n t ' s Understanding o f I l l n e s s and Reason f o r Admission:  A d d i t i o n a l Information: (Include past i l l n e s s and hospitalization)  98  Surrey Memorial H o s p i t a l Form (continued)  DATE  HOUR  MEDICATION AND TREATMENT  NOTES  99 Form #22 - 2/74 MEDICATION  ORDERED  INTRAVENOUS  ORDERED  ALLERGIES Form # 22 - 2/74 (other s i d e the same)  Form 30 - 1/74  NURSING OBJECTIVE  DATE  TREATMENTS  DATE  LABORATORY  X-RAY MISCELLANEOUS/SPECIAL  100 Form #30 - 1/74 (continued) DIET NPO CLEAR FLUIDS FULL FLUIDS SOFT FULL SPECIAL ( S p e c i f y )  ACTIVITY BED REST BRP DANGLE CHAIR WHEELCHAIR WALKER UP AD LIB CRUTCHES  FLUIDS  HYGIENE  NPO I/V INTAKE & OUTPUT FORCE RESTRICT TO  BED BATH PARTIAL BATH SELF BATH SHOWER TUB DENTURES ORAL CARE  FEEDING  SIDE RAILS  SELF ASSIST FEED  CONSTANT NIGHT ONLY  BOWEL/BLADDER BRP CATHETER INCONTINENT COMMODE COLOSTOMY CLINITEST B.M.  PHYSICAL TRAITS HEMIPLEGIC L R PARAPLEGIC QUADRAPLEGIC BLIND L R DEAF L R SPEECH IMPEDIMENT OTHER ( S p e c i f y )  P a t i e n t P r o f i l e - Prev. Admis. P e r t i n e n t Events Occupation  GOAL UPDATED PATIENT NEED/PROBLEM AND OBJECTIVES  — . ADM DATE DIAGNOSIS NAME  BP  AGE  PC  NURSING APPROACHES/SOLUTION/ ACTION  WT  RELIGION  PO PP  SURGERY DELIVERY DOCTOR  CONSULTANT  APPENDIX C QUESTIONNAIRE  UNIVERSITY OF BRITISH COLUMBIA SCHOOL OF NURSING Some Opinion Items Concerning the Nursing  Process  The n u r s i n g process i s a s y s t e m a t i c approach t o n u r s i n g care which i n v o l v e s t a k i n g a n u r s i n g h i s t o r y , a n a l y z i n g the data, p l a n n i n g , and e v a l u a t i n g p a t i e n t c a r e .  implementing  The aim o f t h i s  s e t o f items i s to determine how nurses view the n u r s i n g process.  For each item place a check (/) i n the column which best i n d i c a t e s your views.  PLEASE CHECK  ONLY ONE COLUMN FOR EACH ITEM AND TRY TO ANSWER EACH ITEM.  Strongly Agree  Agree  Undecided  Disagree  Strongly Disagree  1. The time consuming nature o f the nursing process negates i t s value as a systematic approach to p a t i e n t c a r e . 2. The n u r s i n g process i s the best system to use when i d e n t i f y i n g p a t i e n t problems. 3. The n u r s i n g process i s too i d e a l i s t i c and thus not f u n c t i o n a l .  -  4. The q u a l i t y o f i n d i v i d u a l i z e d p a t i e n t care would improve i f most nurses used the process. 5. The nursing process i n v o l v e s too much w r i t i n g and t h i n k i n g . 6. The nursing process i s more e f f e c t i v e i n meeting the i n d i v i d u a l needs o f the p a t i e n t than nursing based on i n t u i t i o n . 7. The nursing process i s slow, l a b o r i o u s and a waste o f time. 8.. The use o f the nursing process communication between nurses.  improves  9. The nursing process should be used because the p a t i e n t has more i n p u t i n t o h i s c a r e . o  CO  Strongly Agree 10. Using the nursing process makes the nurse more aware o f the p a t i e n t as a person. 11. The n u r s i n g process should be used only f o r long term p a t i e n t s . 12. Use o f the nursing process helps most nurses t o c l a r i f y goals o f p a t i e n t care. 13. Having to f o l l o w the nursing process does not a l l o w the nurse to use her own judgement. 14. The nursing process i s a v a l u a b l e means o f providing continuity i n patient care. 15. The problem with the nursing process i s that i t i s too complicated to be p r a c t i c a l . 16. The n u r s i n g process i s i m p r a c t i c a l when p a t i e n t care i s a l s o planned by other members o f the h e a l t h team. 17. The nursing process i s a good means o f evalua t i n g the q u a l i t y o f p a t i e n t care. 18. Use o f the nursing process improves the planning and o r g a n i z a t i o n o f p a t i e n t care. 19. The nursing h i s t o r y i s an unnecessary o f the p a t i e n t s p r i v a c y .  invasion  20. A l l nurses should be encouraged to use the nursing process.  Agree  Undecided  Disagree  Strongly Disagree  APPENDIX D COMMUNICATION TO PANEL OF EXPERTS  106 THE UNIVERSITY OF BRITISH COLUMBIA VANCOUVER 8, CANADA School o f Nursing  February 16th,  1976  Dear Please excuse the v e r s i o n o f t h i s l e t t e r , but we are t r y i n g to reach as l a r g e an audience as p o s s i b l e c o n s t r a i n e d as we are by time and budget. One o f the r e s e a r c h p r o j e c t s being c a r r i e d out a t the School of Nursing here a t U.B.C. i n v o l v e s the use o f a t t i t u d i n a l s c a l e r e : use o f the n u r s i n g p r o c e s s . We have e n c l o s e d the s c a l e f o r your perusal and would a p p r e c i a t e some small amount o f your time f o r t h i s task. We are attempting to v a l i d a t e t h i s s c a l e u s i n g a consensus approach through a panel of e x p e r t s . We b e l i e v e you are such a person and, t h e r e f o r e , hope t h a t you w i l l f e e l motivated to help us. P l e a s e look through the items and then respond f o r each item how you e s t i m a t e or f e e l about the v a l i d i t y . Please i n t e r p r e t the s c a l e o f - - s t r o n g l y agree through s t r o n g l y d i s a g r e e — a s you i n t e r p r e t or estimate the e x t e n t to which v a l i d i t y i s r e a l i z e d i n the q u e s t i o n . When we r e c e i v e your completed s c a l e , we w i l l , by u s i n g the c o e f f i c i e n t o f concordance, s u c c e s s i v e l y d i s c a r d items u n t i l we reach an established significance level. As a 'quid pro quo', we w i l l be happy to send you the f i n a l s c a l e with d e t a i l s o f i t s r e l i a b i l i t y and v a l i d i t y . The graduate student c a r r y i n g out t h i s work i s Barbara Boyle, and her t o p i c i s The E f f e c t s o f An I n s t r u c t i o n a l Program Regarding the Nursing Process on the U t i l i z a t i o n o f the Nursing Process i n Practice. She and I, both, look forward to s e e i n g you a t the W.S.R.N, meeting i n S e a t t l e i n May. Yours c o r d i a l l y ,  JY:mbo  Jack Yensen  APPENDIX E WRITTEN INFORMATION ON THE NURSING PROCESS  THE NURSING PROCESS AN INSTRUCTIONAL PROGRAM  by BARBARA BOYLE  109  COURSE OUTLINE I.  II.  III.  Overview o f the Nursing Process A.  Definition  B.  Reasons f o r Using the Nursing Process  T h e o r e t i c a l Framework Within Which the Nursing Process W i l l Be Used A.  D e f i n i t i o n o f a T h e o r e t i c a l Framework  B.  V i r g i n i a Henderson's Philosophy o f Nursing  The Nursing Process Within the T h e o r e t i c a l Framework A.  Assessing  B.  Planning  C.  Intervening  D. E v a l u a t i n g IV.  Clinical Practice  Methods o f E v a l u a t i o n  C l i n i c a l P r a c t i c e - each graduate nurse w i l l care f o r a p a t i e n t ( s ) using the n u r s i n g process w i t h i n a t h e o r e t i c a l framework. W r i t t e n Assignment - the assignment w i l l c o n s i s t o f the n u r s i n g care o f an i n d i v i d u a l p a t i e n t , o u t l i n i n g each phase o f the n u r s i n g p r o c e s s . Each graduate nurse w i l l have completed the program when he/she has met the course o b j e c t i v e s .  no I.  Overview o f the Nursing A.  Process  Definition The n u r s i n g process i s an o r d e r l y , s y s t e m a t i c manner o f d e t e r m i n i n g the p a t i e n t s problems, making plans t o s o l v e them, i n i t i a t i n g the p l a n o r a s s i g n i n g o t h e r s t o implement i t , and e v a l u a t i n g the e x t e n t t o which the p l a n was effective.!  In r e c e n t y e a r s the n u r s i n g p r o c e s s has been d i s c u s s e d q u i t e extensively i n nursing l i t e r a t u r e . I t i s viewed as a h i g h l y d e s i r a b l e , i f n o t e s s e n t i a l , method o f g i v i n g c a r e . V a r i a t i o n i n the number and names o f the d i f f e r e n t phases o f the n u r s i n g process a r e found i n t h e l i t e r a t u r e , b u t t h e r e i s agreement t h a t the n u r s i n g p r o c e s s i s a s y s t e m a t i c approach to n u r s i n g c a r e , which r e l i e s h e a v i l y on the nurses a b i l i t y t o p r o b l e m - s o l v e and make d e c i s i o n s . The n u r s i n g p r o c e s s i s a c o n t i n u o u s p r o c e s s , which i n r e a l i t y cannot be c l e a r l y s e p a r a t e d i n t o d i f f e r e n t phases. However, i n o r d e r to study the n u r s i n g process i t must be s e p a r a t e d , keeping i n mind t h a t i t i s an a r t i f i c i a l s e p a r a t i o n and c o n s t a n t o v e r l a p p i n g o f each phase o c c u r s . T h i s d i f f i c u l t y i n s e p a r a t i n g the n u r s i n g process i n t o v a r i o u s phases p r o b a b l y a c c o u n t s f o r t h e v a r i a t i o n i n t h e number and names o f t h e phases found i n the l i t e r a t u r e . F o r the purpose o f t h i s program the n u r s i n g p r o c e s s w i l l be d i v i d e d i n t o f o u r phases: assessment; p l a n n i n g ; i n t e r v e n t i o n ; a n d e v a l u a t i o n . B.  Reasons f o r Using  the N u r s i n g  Process  Why i s the n u r s i n g process c o n s i d e r e d t o be e s s e n t i a l f o r q u a l i t y c a r e t o be a s s u r e d ? P r o b a b l y one o f t h e most s i g n i f i c a n t r e a s o n s , i s t h a t n u r s i n g c a r e i s planned around i n d i v i d u a l p a t i e n t problems r a t h e r than t a s k s t h a t must be done. When the problem s o l v i n g approach i s not used i n g i v i n g c a r e , t a s k s a r e completed as needed and i n d i v i d u a l p a t i e n t problems a r e l o s t i n a sea o f r o u t i n e s . Other s i g n i f i c a n t reasons f o r u s i n g the n u r s i n g p r o c e s s a r e : (1) e v a l u a t i o n o f n u r s i n g c a r e by comparing p a t i e n t outcomes w i t h predetermined p a t i e n t g o a l s ; (2) a c t i v e p a r t i c i p a t i o n by the p a t i e n t and/or h i s f a m i l y i n h i s c a r e ; (3) accumulation o f a body o f knowledge c o n c e r n i n g p a t i e n t problems and e f f e c t i v e n u r s i n g i n t e r v e n t i o n - , and (4) i n c r e a s e d o p p o r t u n i t y f o r the nurse t o make d e c i s i o n s r e g a r d i n g p a t i e n t c a r e . The reasons g i v e n a r e o n l y a few o f the many f o r u s i n g the n u r s i n g p r o c e s s , and they presuppose t h a t a permanent r e c o r d i s kept o f the n u r s i n g p r o c e s s on each p a t i e n t . Without the use o f the n u r s i n g process t h e r e i s no s a t i s f a c t o r y method o f a s s e s s i n g the b e n e f i t the p a t i e n t r e c e i v e s from the n u r s i n g c a r e .  Yura Helen, Walsh Mary B., The Nursing P r o c e s s : a s s e s s i n g , p l a n n i n g , implementing, e v a l u a t i n g . A p p l e t o n - C e n t u r y - C r o f t , New York, 1973, p. 23.  Ill II.  T h e o r e t i c a l Framework A.  Definition  The guidance we need i n using the nursing process comes from the t h e o r e t i c a l framework. A t h e o r e t i c a l framework i s a way o f l o o k i n g a t and o r g a n i z i n g phenomena, and can be e i t h e r a philosophy o r a model. The t h e o r e t i c a l framework used w i l l make a d i f f e r e n c e on how p a t i e n t problems a r e viewed, the p r i o r i t y o f one problem over another, and the i n t e r v e n t i o n s c a r r i e d o u t i n r e l a t i o n to the p a t i e n t problems. I f man i s viewed as being unique, with d i g n i t y and worth, he w i l l be approached much d i f f e r e n t l y than i f he i s n o t viewed i n t h i s manner. The nursing process c o u l d be used whether o r not man was viewed as unique, with d i g n i t y and worth, b u t with very d i f f e r e n t r e s u l t s . B.  V i r g i n i a Henderson's Philosophy o f Nursing  The t h e o r e t i c a l framework chosen f o r t h i s program i s V i r g i n i a Henderson's Philosophy o f Nursing. She b e l i e v e s t h a t : The unique f u n c t i o n o f nursing i s to a s s i s t the i n d i v i d u a l , s i c k o r w e l l , i n the performance o f those a c t i v i t i e s c o n t r i b u t i n g to h e a l t h o r i t s recovery ( o r to a peaceful death) t h a t he would perform unaided i f he had the necessary s t r e n g t h , w i l l o r knowledge. And to do t h i s i n such a way as to help him gain independence as r a p i d l y as possible.2 she goes on to s a y : T h i s aspect o f h e r work, t h i s p a r t o f her f u n c t i o n she i n i t i a t e s and c o n t r o l s ; o f t h i s she i s master. In a d d i t i o n she helps the p a t i e n t to c a r r y o u t the t h e r a p e u t i c plan as i n i t i a t e d by the p h y s i c i a n . She a l s o , as a member o f a medical team, helps other members, as they i n turn help her, to plan and c a r r y out the t o t a l program whether i t be f o r the improvement o f h e a l t h , or the recovery from i l l n e s s o r support i n death. No one o f the team should make such heavy demands on another member t h a t any one o f them i s unable to perform h i s o r her unique f u n c t i o n . 3 V i r g i n i a Henderson b e l i e v e s t h a t one o f man's goals i s good h e a l t h . She equates good h e a l t h with wholeness o f mind and body, and she sees the mind and body as being i n s e p a r a b l e . She b e l i e v e s t h a t man d e s i r e s a s t a t e o f independence and f e e l s t h a t nursing should be p  Henderson V i r g i n i a . The Nature o f Nursing. MacMillan Company, New York, 1967, p. T5. 3  Ibid.  112 c o n s t a n t l y s t r i v i n g t o a s s i s t the p a t i e n t to achieve t h a t independence. She sees man as a b i o p s y c h o s o c i a l being with d i g n i t y and worth, and with fundamental needs which a r e common to a l l men. Each man i n t e r p r e t s h i s needs i n such a way t h a t i s unique to him, and s a t i s f i e s those needs i n h i s own unique way. Each man i n t e r prets f o r h i m s e l f what h e a l t h means to him. T h e r e f o r e , i t i s not man's needs t h a t make him unique but the way i n which he i n t e r p r e t s and s a t i s f i e s them. The needs common t o a l l men have been i d e n t i f i e d by V i r g i n i a Henderson as f o l l o w s : 1. 2. 3. 4. 5. 6. 7.  Breathe normally. Eat and d r i n k adequately. E l i m i n a t e body wastes. Move and maintain d e s i r a b l e posture. Sleep and r e s t . S e l e c t s u i t a b l e c l o t h e s - dress and undress. Maintain body temperature w i t h i n normal range by a d j u s t i n g c l o t h i n g and modifying the environment. 8. Keep the body c l e a n and well groomed and p r o t e c t the integument. 9. Avoid dangers i n the environment and a v o i d injuring others. 10. Communicate with others i n expressing emotions, needs, f e a r s , o r o p i n i o n s . 11. Worship a c c o r d i n g to one's f a i t h . 12. Work i n such a way t h a t there i s a sense o f accomplishment. 13. Play o r p a r t i c i p a t e i n various forms o f recreation. 14. Learn, d i s c o v e r , o r s a t i s f y the c u r i o s i t y t h a t leads t o normal development and h e a l t h and use a v a i l a b l e h e a l t h f a c i l i t i e s . 4 V i r g i n i a Henderson b e l i e v e s t h a t there a r e three phases o f nursing: (1) emotional; (2) t e c h n i c a l ; and (3) c r e a t i v e . Many nurses stop a t the t e c h n i c a l l e v e l and do not progress to the c r e a t i v e phase. She f e e l s t h a t the environment i n which the nurse f i n d s h e r s e l f must f o s t e r c r e a t i v i t y . The p r o g r e s s i o n to the c r e a t i v e phase can be accomplished through the use o f the nursing process. The nurse, while u s i n g the n u r s i n g process, can be c r e a t i v e i n planning n u r s i n g i n t e r ventions t h a t w i l l be necessary to a s s i s t the p a t i e n t to achieve the predetermined g o a l s . Ill.  D e t a i l e d Look a t the Nursing Process w i t h i n the T h e o r e t i c a l Framework A.  Assessing  There a r e r e a l l y two p a r t s to the assessment phase.; the nursing h i s t o r y o r data base, and the i d e n t i f i c a t i o n o f p a t i e n t problems. 4  I b i d . , pp. 16-17.  113 What often happens i s that there i s an i n s u f f i c i e n t data base from which to i d e n t i f y problems. There i s very often no prescribed h i s t o r y tool to insure that there i s information gathered i n a l l necessary areas. Usually the amount of information obtained depends on what a p a r t i c u l a r nurse decides to ask the p a t i e n t , and how busy she i s at the time. A doctor i s often judged on his a b i l i t y to take a thorough and accurate medical h i s t o r y . You may say; how w i l l he know what medical problems the p a t i e n t has unless he takes a medical h i s t o r y which i s thorough and accurate? The same thing a p p l i e s to nursing, f o r i f the nurse does not c o l l e c t a thorough and accurate h i s t o r y i n a systematic way, how can she p o s s i b l y assess the p a t i e n t ' s nursing needs. The answer then i s i n the use of prescribed h i s t o r y tool based on a t h e o r e t i c a l framework, when gathering data from the p a t i e n t . This data base contains the information necessary from which p a t i e n t problems are i d e n t i f i e d . The t h e o r e t i c a l framework provides the d i r e c t i o n f o r the s e l e c t i o n of areas on which information i s gathered from the p a t i e n t . The h i s t o r y tool used f o r t h i s program, i s based on V i r g i n i a Henderson's Philosophy of Nursing and draws from the h i s t o r y tool developed by Dorothy Smith at the U n i v e r s i t y of F l o r i d a , and the h i s t o r y tool that i s i n use a t the Surrey Memorial Hospital at the present time. When taking a nursing h i s t o r y inform the p a t i e n t that the nursing h i s t o r y w i l l enable the nursing personnel to be of greater s e r v i c e to him and obtain his permission. Once the h i s t o r y has been taken the problem l i s t can be compiled. This seems to imply that no f u r t h e r information w i l l be gathered once the i n i t i a l h i s t o r y has been taken, which of course i s not true as new information i s c o n s t a n t l y being obtained and the problem l i s t a l t e r e d as necessary. The i d e n t i f i c a t i o n of problems w i l l be based on whether or not the p a t i e n t i s able to meet a l l his basic human needs. I f he cannot meet one or more needs without a s s i s t a n c e , that c o n s t i t u t e s a p a t i e n t problem. The i d e n t i f i c a t i o n of p a t i e n t problems i s something that nurses do a l l the time, but'do not always have s u f f i c i e n t information to j u s t i f y the i d e n t i f i e d problems and may miss problem areas. It would be an i m p o s s i b i l i t y to think that a nurse could i d e n t i f y a l l problems a p a t i e n t may have or be able to solve a l l of them, however, with a systematic approach of data c o l l e c t i o n there i s much less l i k e l i h o o d of missing major problem areas. Another problem that often occurs, when a systematic method of data c o l l e c t i o n i s not used, i s that problems i d e n t i f i e d are based s o l e l y on i n t u i t i o n and are not always communicated to the r e s t of the s t a f f , thereby severely r e s t r i c t i n g the assistance the p a t i e n t may need to solve that problem. Once the l i s t i s completed i t i s v e r i f i e d with the p a t i e n t and/or his f a m i l y to insure that the problems i d e n t i f i e d by the nurse are i n agreement with the problems i d e n t i f i e d by the patient.  114 B.  Planning  Once t h e problems a r e i d e n t i f i e d and v e r i f i e d w i t h t h e p a t i e n t and/or h i s f a m i l y , they must be l i s t e d i n o r d e r o f p r i o r i t y . R e a l i s t i c goals a r e s e t with the p a t i e n t and/or h i s f a m i l y , i n r e l a t i o n to the problems i d e n t i f i e d . These goals may be s h o r t term and/or long term g o a l s . The goals must be planned with the p a t i e n t and/or h i s f a m i l y as i t i s the p a t i e n t who w i l l be expected t o achieve those g o a l s . V i r g i n i a Henderson's philosophy a l s o g i v e s guidance f o r the i n c l u s i o n o f the p a t i e n t and/or h i s f a m i l y as she b e l i e v e s the p a t i e n t should have as much c o n t r o l over h i s s i t u a t i o n as p o s s i b l e . Once the goals have been e s t a b l i s h e d a plan o f a c t i o n i s devised. T h i s plan o f a c t i o n provides d i r e c t i o n f o r implementing the plan and provides the framework f o r e v a l u a t i o n . I f goals a r e not s e t , n e i t h e r the p a t i e n t nor the nurse w i l l know what behaviour i s expected from the p a t i e n t , o r w i l l there be any way o f d e c i d i n g to what extent the p a t i e n t has b e n e f i t e d from the nursing a c t i o n . C.  Implementing  The plan o f a c t i o n i s then implemented by t h e nurse and p a t i e n t , nurse alone, p a t i e n t and/or h i s f a m i l y o r nursing team members. V i r g i n i a Henderson sees the p a t i e n t as having as much c o n t r o l over his care as p o s s i b l e . T h i s d e f i n i t e l y gives the nurse guidance i n t h a t t h e r o l e played by the nurse w i l l be t h a t o f a s s i s t a n c e and support r a t h e r than c o n t r o l . V i r g i n i a Henderson a l s o gives guidance f o r having the f a m i l y p l a y a s i g n i f i c a n t r o l e i n the implementing phase, as she sees them as p a r t o f the h e a l t h team. While implementing the plan the nurse continues t o c o l l e c t data o,n the i n d i v i d u a l p a t i e n t s r e a c t i o n s , f e e l i n g s , progress, e t c . The implementation phase i s f i n i s h e d when nursing a c t i o n s a r e completed, the r e s u l t s and the p a t i e n t ' s r e a c t i o n to them a r e recorded. D.  Evaluating  The e v a l u a t i o n phase i s c a r r i e d o u t i n r e l a t i o n to the predetermined goals t h a t were s e t by the nurse and the p a t i e n t i n the planning phase. During the e v a l u a t i o n phase i t i s determined whether or not ( o r to what extent) the needs o f the p a t i e n t a r e being met by the p a t i e n t , by the nurse alone, o r by the nurse, p a t i e n t and/or his f a m i l y . The plan o f a c t i o n i s assessed according to the extent to which the goals have been a t t a i n e d . The i n f o r m a t i o n gathered i n t h i s phase w i l l i n d i c a t e t h a t e i t h e r the problem i s s o l v e d o r r e assessed i f not s o l v e d . I f unsolved an a l t e r n a t e plan o f a c t i o n w i l l be r e q u i r e d .  115 Conclusion The n u r s i n g process has been a r t i f i c i a l l y separated i n order to have a c l o s e look a t each phase. In r e a l i t y they are not sepa r a b l e , but flow together and c o n s t a n t l y o v e r l a p each o t h e r . You w i l l be provided with the o p p o r t u n i t y to use the n u r s i n g process and w i l l r e c e i v e i n f o r m a t i o n and guidance t h a t w i l l enable you to meet the o b j e c t i v e s o f the program.  

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