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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 of Alb e r t a , 1969 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING IN THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA June 1976 (cT) Barbara^ Boyle 1976 In presenting th i s thesis in pa r t i a l f u l f i l l m e n t of the requirements for an advanced degree at the Univers i ty of B r i t i s h Columbia, I agree that the L ibrary shal l make i t f ree l y ava i lab le for reference and study. I further agree that permission for extensive copying of th i s thesis for scholar ly purposes may be granted by the Head of my Department or by his representatives. I t i s understood that copying or publ icat ion of th i s thesis for f i nanc ia l gain sha l l not be allowed without my wr i t ten permission. BARBARA ANN JOYCE BOYLE School of Nursing The Univers i ty of B r i t i s h Columbia Vancouver, B r i t i s h Columbia V6T 1W5 Date September 4th., 19,76 ABSTRACT The purpose of t h i s study was to examine the e f f e c t of 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 of the nursing process by graduate nurses i n the p r a c t i c e area, and on the a t t i t u d e of the graduate nurse toward the nursing process. P a t i e n t records were audited before and a f t e r completion of an i n s t r u c t i o n a l program to determine the extent to which the nursing process was being used. A q u e s t i o n n a i r e to determine a t t i t u d e toward the nursing process that was held by the graduate nurse, was administered to the study and c o n t r o l groups before and a f t e r completion of the i n s t r u c t i o n a l program. I t was hypothesized that there would be no measurable d i f f e r e n c e i n : 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 ; 2. the number of p a t i e n t problems i d e n t i f i e d ; 3. the number of p a t i e n t problems which are c o n s i s t e n t with e s t a b l i s h e d c r i t e r i a ; 4. the planning phase of the nursing process; 5. the implementing phase of the nursing process; 6. the e v a l u a t i n g phase of the nursing process; or 7. the way i n which the graduate nurse views the nursing process, before and a f t e r completion of an i n s t r u c t i o n a l program by such graduate nurses. i i 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 of 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 con-c e r n i n g the use of the nursing 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 of 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 nursing 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 . . . . . . . . . i v LIST OF TABLES . v i i i LIST OF FIGURES i x ACKNOWLEDGEMENTS . . . . . . . x Chapter I. INTRODUCTION TO THE STUDY . . . . . . . . . . . . 1 INTRODUCTION 1 THE PURPOSE OF THE STUDY . 3 THE PROBLEM 4 Statement of the Problem 4 S p e c i f i c O bjectives of the Study . . . . . . . 5 S i g n i f i c a n c e of the Problem . . . . . . . . . 5 ASSUMPTIONS 6 DEFINITIONS . . . . . 6 Nursing Process 7 Graduate Nurse 7 Pa t i e n t Problem . . . . 7 Defined Data Base 7 LIMITATIONS . . . . . 8 SUMMARY 8 I I . REVIEW OF THE LITERATURE 10 INTRODUCTION '. . 10 HISTORICAL DEVELOPMENT OF THE NURSING PROCESS. . . 10 i v 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 . . . . 14 Problem L i s t . . 17 PLANNING .' • 18 IMPLEMENTATION 21 EVALUATION 22 METHOD OF RECORDING THE NURSING PROCESS . . . . . . 23 SUMMARY 26 I I I . METHODOLOGY 28 OVERVIEW 28 RESEARCH DESIGN 29 Sample 29 Hypotheses . . . . . 32 Independent V a r i a b l e 33 Dependent V a r i a b l e 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 ... 35 Judges Used i n A u d i t i n g P a t i e n t Records . . . . 37 A t t i t u d e Scale 37 INSTRUCTIONAL PROGRAM ... 40 Pr 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 46 Phases of the I n s t r u c t i o n a l Program 47 POST-TEST 49 SUMMARY . . . . . . 49 v Chapter Page IV. ANALYSIS OF THE DATA . . 50 INTRODUCTION 50 ASSESSMENT 50 Hypothesis 1 51 Results 51 Hypothesis 2 52 Results 52 Hypothesis 3 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 60 Results . . . . . 61 DISCUSSION OF LIMITATIONS 62 Method of Recording the Nursing Process . . . . 63 U n i f i e d Front . . . . . 64 Time i n the C l i n i c a l Area 64 Number of Role Models 65 EFFECTIVENESS OF THE INSTRUCTIONAL PROGRAM . . . . . 65 SUMMARY 66 vi Chapter Page V. 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 72 FOOTNOTES « a e * . a « a o o o « 0 o o o a a e e « o « o « » 73 BIBLIOGRAPHY 86 APPENDIX A - FORM OF CONSENT . 93 APPENDIX B - PATIENT RECORDS . . . . . . 96 APPENDIX C - QUESTIONNAIRE . . . . . . . . . . . . . . . . 101 APPENDIX D - COMMUNICATION TO PANEL OF EXPERTS . . . . . . 105 APPENDIX E - WRITTEN INFORMATION ON THE NURSING PROCESS . . 107 v i i LIST OF TABLES Table Page 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 30 I 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 Control Group was S e l e c t e d . . , 31 I I I . Results Obtained by a Panel of 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 . . . . . 39 IV. Scores Obtained From Respondents on the T e s t -Retest of the Questionnaire Measuring A t t i t u d e Toward the Nursing Process 40 V. 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 Assessment Phase of the Nursing Process . , . . 51 VI. 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 VII. 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 V I I I . 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 IX. Pre and Post Test Results from the Questionnaire on A t t i t u d e Toward the Nursing Process f o r the Study Group and the Control Group 61 . v i i i LIST OF FIGURES Figure Page 1. Behaving-Learning Cycle Showing Decision 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 42 2. Meaning, F e e l i n g , and Concepts . • 43 i x ACKNOWLEDGEMENTS I would l i k e to express my a p p r e c i a t i o n to the nursing s t a f f o f a la 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 to 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 of data and to Dr. Margaret Campbell f o r her a s s i s t a n c e i n the development of the i n s t r u c t i o n a l program on the nursing process. I a l s o wish to thank Pr o f e s s o r s Jack Yensen and Mary Cruis e f o r t h e i r advice and guidance. x 1 CHAPTER I INTRODUCTION TO THE STUDY INTRODUCTION This study focuses on the nursing process which c o n s i s t s of f o u r phases, assessment, pl 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 of 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 2 s a i d i t s use i s e s s e n t i a l f o r nursing to s u r v i v e as a p r o f e s s i o n , 4 th a t i t i s the very essence of n u r s i n g , and t h a t nursing care 5 planning i s an i n t e g r a l part of nursing 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 to q u a l i t y p a t i e n t care. However, t h i s same commitment to 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 to use the nursing process, manifested i n pa r t by the use of the nursing care plan. A d e f i n e d data base, which i s part of the assessment phase and used interchangeably i n t h i s paper with the nursing h i s t o r y , i s e s s e n t i a l to the subsequent phases of the process, but very often t h i s data base i s incomplete. The data base may only contain information 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 information 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 or 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 exceptions 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 systematic approach to p a t i e n t c a r e . The planning phase of the nursing 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 regarding the p a t i e n t upon which to formulate a plan; and (2) an absence of measurable p a t i e n t goals which are necessary i n guiding the planning o f c a r e . This i s not to say t h a t nurses never plan care but t h a t the planning i s not centered 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 of planning tends to be nurse performance centered 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 planning phases o f the nursing process g r e a t l y a f f e c t the implementation phase. The implementation of a plan o f care centered 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 of 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 with, but (as with the planning phase) the care u s u a l l y centers around immediate p a t i e n t needs and i n many cases tends to be nurse performance centered 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 that the e v a l u a t i o n phase of the nursing process i s extremely d i f f i c u l t , i f not impossible, 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 com-pleteness 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 order to determine success or f a i l u r e of the care he r e c e i v e s . Several nurses were asked on an informal b a s i s , to give t h e i r opinions concerning the reasons f o r the incompleteness of the phases o f the nursing process i n the c l i n i c a l a rea. There were several 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 nursing 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 nursing process i n order to give q u a l i t y p a t i e n t c a r e . 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 nursing process would: (1) i n c r e a s e the frequency with which a nursing 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 ; 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 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 of the nursing process; and (5) have a favourable 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 nursing process, what e f f e c t w i l l i t have on the use of the nursing 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 problem, namely: (1) i f the graduate nurse completes an i n s t r u c t i o n a l program concerning the nursing process, 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 i n d i v i d u a l p a t i e n t s ? (2) I f the graduate nurse completes an i n s t r u c t i o n a l program concerning the nursing process, w i l l there be an improvement i n the p l a n n i n g , implementing and e v a l u a t i n g phases? And f i n a l l y , (3) i f the graduate nurse completes an i n s t r u c t i o n a l program concerning the nursing process, w i l l there be a favourable e f f e c t on the way the graduate nurse views the nursing process? 5 S p e c i f i c O b j e c t i v e s of the Study The s p e c i f i c o b j e c t i v e s of the study are: (1) to provide the graduate nurse with information regarding a l l phases o f the nursing process; and (2) to provide the graduate nurse with an opportunity to 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 to 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 of the nursing process and an opp 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 defined 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 of the nursing process; and (3) have a favourable e f f e c t on the way the graduate nurse views the nursing 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 Carnev 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 that i f the nursing process, 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 of care that 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 nursing process i s used i n p r a c t i c e . There i s a l s o a great deal of concern today regarding 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 of 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 to meet those goals and e v a l u a t i o n of the success or f a i l u r e i n meeting the go a l s . The use of the nursing process together with a permanent record 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 to e s t a b l i s h outcome c r i t e r i a . Use o f the nursing 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 of q u a l i t y p a t i e n t care. The q u a l i t y of p a t i e n t care could be measured by a u d i t i n g each phase of the nursing process i n r e l a t i o n to 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 of p a t i e n t c a r e , i s an attempt to t e s t the e f f e c t i v e n e s s o f one approach to the implementation o f the nursing process i n p r a c t i c e . ASSUMPTIONS This study i s based on the f o l l o w i n g assumptions: (1) the nursing 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 nursing 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 to c a r r y out the nursing process; and (4) teaching f a c i l i t a t e s l e a r n i n g . 7 DEFINITIONS Nursing Process The nursing process i s an o r d e r l y , systematic manner of 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 others to implement i t , and e v a l u a t i n g the extent 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 i d e n t i f i e d . Graduate Nurse A person who has graduated with a diploma from an approved school o f nursing 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 nursing 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 parameters. (Appendix B) 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 popu-l a t i o n ; (2) f i v e graduate nurses out of a l l nursing personnel, 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 nursing 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 that 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 only, w i l l be used to measure the use of the nursing process. With t h i s method of measurement the phases of the nursing process which are c a r r i e d out and not recorded w i l l not be considered. * SUMMARY This 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 information regarding the nursing process and an opportunity 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 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 nursing process would: (1 ) i n c r e a s e the frequency with which a nursing h i s t o r y (defined 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 of 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 co 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 assessment c r i t e r i a ; (4) show subsequent improvement i n the pla n n i n g , implementing and e v a l u a t i o n phases of the nursing process; and (5) have a favourable 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 that there i s ambiguity among nursing leaders concerning a d e f i n i t i o n o f the nursing process and the terminology used to d e s c r i b e i t . T h i s ambiguity among nursing leaders leads to confusion i n the p r a c t i c e area, when there i s an attempt to c a r r y out the nursing process. T h i s c o n f u s i o n concerning the nursing process may c o n t r i b u t e , to a l a r g e extent, to the lack 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 care" can be found i n HendersonJ Henderson poin t s out t h a t "planned i n d i v i d u a l i z e d nursing c a r e " had i t s beginnings i n the case study method, which was described i n 1929 by Deborah MacLurg Jensen. Henderson a l s o p o i n t s out that 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 introduced 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 According to 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 f i f t i e s . In 1955 Lydia H a l l d e s c r i b e d nursing as a process, but Orlando was one of the e a r l i e s t authors to use the term nursing 3 process. In 1967 Yura and Walsh i d e n t i f i e d the phases o f the nursing process as: a s s e s s i n g ; p l a n n i n g ; implementing; and 4 e v a l u a t i n g . THE NURSING PROCESS In depth d i s c u s s i o n o f the nursing process can be found i n Yura and Walsh, 5 M a r r i n e r , 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 various phases o f the nursing 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 that care planning must i n c l u d e : a nursing h i s t o r y ; a problem l i s t o r nursing diagnoses; behavioural o b j e c t i v e s or g o a l s ; a plan o f c a r e ; implementation o f the plan o f c a r e ; and e v a l u a t i o n o f the care provided. There i s a l s o agreement that the care must be planned and c a r r i e d out i n cooperation 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 nursing 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 nursing process i n B r i t a i n , because he f e l t t h at 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 and 18 implemented according to d e f i n e d g o a l s . 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 i n 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 nursing 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 with 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 David p r e d i c t that 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 l i f e . They di 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 nursing process would y i e l d these charac-13 t e r i s t i c s i n n u r s i n g . Lewis b e l i e v e s that the nursing 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 s e t 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 h i s l i f e processes or 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 Carlson o f f e r s f o r the nursing 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 only f o r student l e a r n i n g ; and nursing care plans are thrown away because they are not viewed as important enough to become part 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 , planning, 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 of the nursing process i s the g o a l - d i r e c t e d n e s s o f nursing care, and the f a c t t hat 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 p a t i e n t s w e l l - b e i n g . Yura and Walsh b e l i e v e that the use o f the nursing process i s c e n t r a l to a l l nursing a c t i o n s , i s the very essence o f nursing 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 reference 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 care. Mayers poin t s out 14 t h a t the nursing care plan has been seen by f e d e r a l and s t a t e governing and review agencies, as well as by nursing 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 nursing success or f a i l u r e . 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 implementing 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 lack o f general understanding among Nursing Educators and Nursing S e r v i c e s that 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 educational 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 nursing 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 Plan, 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 or o b j e c t i v e s and approaches; (3) a lack of 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 nursing 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 plans; and (4) an absence of 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 nursing process has r e c e i v e d a great 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 . Two prominent authors i n t h i s area are Smith and McPhetridge. 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 fo u r t e e n b a s i c 15 29 human needs i d e n t i f i e d by Henderson. The t o o l provided a system-a t i c way o f o b t a i n i n g a nursing 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 f u r t h e r refinement of the tool 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 nursing 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 perceptions and expec-t 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 b e l i e v e s t h a t a n u r s i n g 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 nursing 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 nursing 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. Further work done i n the assessment phase o f the nursing 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 that 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 info 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 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 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 and 37 v a r i a b l e s s t u d i e d . 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 nursing 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 nursing 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 nursing 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 nursing care planning. 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 s t a t u s . ^ 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) verbal 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) appropriateness 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 a b i l i t y . Mayers a l s o found four 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 nurse-perceived 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 of an open or c l o s e d environment; (3) the a b i l i t y of 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 p a t t e r n . People coping were foynd to be p o s i t i v e i n most of these areas and people considered not coping were found to be negative i n most of these areas. Problem L i s t Gebbie and Lavin i n c l a s s i f y i n g nursing 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 nursing diagnoses. Nursing diagnoses and nursing 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 nursing diagnoses. According to Chambers, i n v e s t i g a t i n g the f a c t s about a nursing 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 p a r t o f a nursing d i a g n o s i s . 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 to show the p a t i e n t what they are doing and must be able to say what nurses can t r e a t 44 independently. There are various views on what c o n s t i t u t e s a p a t i e n t problem or 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 that problems are to be s t a t e d i n terms of 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 or 45 met inadequately. According to Smith and Becknell a nursing 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, to 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, actual problems, 47 p o t e n t i a l problems and p o s s i b l e problems. PLANNING Ob 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 to nurses to where they are going i n p a t i e n t care and to 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 of the nurs 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 the plan and 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 . According to Smith and Becknell the i n i t i a l plan r e f e r s to the beginning design, method, or scheme of a c t i o n by which the p a t i e n t s nursing problems are to 19 51 be managed. 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 -c a t i o n . Mayers has i d e n t i f i e d nine elements of a care plan: p h y s i c i a n ' s expectations o f course of treatment; nursing c r i t e r i a f o r discharge or maintenance; p h y s i c i a n ' s orders; 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 care r o u t i n e . The basic components o f a w r i t t e n nursing 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 nursing 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 ; nursing 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 that must be assessed i n order t h a t the nursing care may be evaluated and 54 r e a d j u s t e d . Ciuca conducted a survey on nursing 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 , intake and output and 55 d i a g n o s t i c s t u d i e s . Notations i n d i c a t i n g the planning o f nursing a c t i o n were conspicuously absent and the nursing 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 that 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 nursing care plans and found the f o l l o w i n g : i n few instances were i d e n t i f y i n g data added to that 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, psychosocial needs and r e l a t e d approaches were found i n over 50% o f the plans; and both long term and s h o r t term goals were con s p i c u -57 o u s l y absent or 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 part 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 nursing 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 preparing nursing care plans. K e l l y conducted a study o f nursing 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 nursing 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 that 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 nursing 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 nursing order form, which she i s expected to use i n nursing p r a c t i c e . 21 A study on nursing 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 nursing care plan i n t o the permanent r e c o r d and demonstrated the relevance of the plan to the 61 care of a readmitted p a t i e n t . This study a l s o r e s u l t e d i n a copy of the nursing 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 Discussions 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 C O C a r n e v a l i . The a c t u a l g i v i n g o f nursing 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 o r d e r s . 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 nursing team 65 members. The implementation phase o f the nursing 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. Nursing i n t e r v e n t i o n s i n c l u d e both the dependent and independent 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 of 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; safe and e f f i c i e n t performance o f nursing 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 , or 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 nursing 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 , 7 0 and C a r t e r , e t a l . 7 1 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 to respond to the planned a c t i o n . Judgement about 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 expectations of the c l i e n t r e l a t i v e to the mutually agreed upon immediate, intermediate and long-range g o a l s , data are c o l l e c t e d so that e v a l u a t i v e judgements can be 74 made. Marriner 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 of the nursing care plan and with the b a s e l i n e data i n 75 the nursing h i s t o r y to determine the p a t i e n t s progress. 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 nursing care , 76 plan. E v a l u a t i o n of nursing 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) outcome. 7 7 S t r u c t u r e i s con-cerned with the environment 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 nursing process, and outcome i s r e l a t e d to the p a t i e n t ' s responses to the nursing care. Bloch f e e l s t hat 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 that the f o l l o w i n g tasks must be achieved: 1. development of a set 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 set of measurable process c r i t e r i a ; 4. development of r e l i a b l e and v a l i d methods f o r measuring the process of nursing care i n a l l i t s various forms i n c l u d i n g both the p h y s i c a l aspects of the process as well as the psychosocial and c o g n i t i v e aspects; 5. t e s t i n g of the various aspects of nursing 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 applying 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 t o o l i s c a l l e d Q u a l i t y P a t i e n t Care Scale and c o n s i s t s of 68 items which d e l i n e a t e a c t i o n s by nursing personnel addressed to p r o v i d i n g care f o r an 81 i n d i v i d u a l p a t i e n t . 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 t o o l 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 Scale but focuses i n on nursing 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 of e v a l u a t i n g nursing 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 orders; 2. observation of 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 of those p a r t i c i p a t i n g i n care; 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 of nursing proceedures and techniques; and 7. promotion o f health by d i r e c t i o n and teaching. There have been several attempts to develop outcome c r i t e r i a 85 86 87 f o r s p e c i f i c p a t i e n t p o p u l a t i o n s . ' ' H i l g e r f e e l s that outcome c r i t e r i a are always r e l a t e d to 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. ' T a y l o r f e l t that because nursing 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 defined 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 . S c h l o t f e l d t f e e l s t h a t nursing does not have r e l i a b l e i nformation 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 of p a t i e n t s , are necessary i n developing outcome c r i t e r i a . METHOD OF RECORDING THE NURSING PROCESS The present method of rec 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 of the nursing process. ' ' M i t c h e l l points out three purposes of nurses' notes and suggests that due to the present method of r e c o r d i n g , these purposes are not being 98 f u l f i l l e d . The purposes are: a l e g a l document of p a t i e n t care; communication of the p a t i e n t ' s responses t o medical and nursing care; reference f o r the p h y s i c i a n i n h i s diagnosis 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 plan i s no longer a s u c c e s s f u l t o o l 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 replaced by problem-oriented records. D i s c u s s i o n of problem-oriented records as they r e l a t e to the p r a c t i c e o f medicine, can be found i n W e e d . ^ The parts of the problem-o r i e n t e d medical records advocated by Weed are the de 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 to the nursing 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 pointed out by Woody and 26 Mai 1ison who b e l i e v e that 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. As evidence of the a p p l i c a b i l i t y of problem-oriented records to the nursing process, Vaughan-Wrobel and Henderson have j u s t published a work-book 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 nursing process has been reviewed to d i s c o v e r how nursing leaders view the nursing 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 nursing process i n p r a c t i c e and the r e c o r d i n g of the nursing process. I t would seem that although the nursing process i s valued by nursing 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 various s o l u t i o n s . T e s t i n g o f the various s o l u t i o n s i n r e l a t i o n to 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 nursing 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 four phases of the nursing 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 extensive 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 leaders 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 nursing process i n the c l i n i c a l area and the research that has been conducted i n r e l a t i o n to the nursing process. 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 nursing leaders were committed to the use of the nursing process i n the care of 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 that the nursing 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 III METHODOLOGY OVERVIEW The f o l l o w i n g procedure was used to t e s t the seven n u l l hypotheses of 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 nursing process; and (3) f o l l o w i n g completion of the i n s t r u c t i o n a l program on the nursing process, 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 to complete an i n s t r u c t i o n a l program on the nursing 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 to 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 nursing 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 of the study. The research design i s e x p l a i n e d , followed by an expl a n a t i o n of 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 to 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 to 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 to p a r t i c i p a t e i n the study. This method of recruitment does weaken the design but i s not thought to be a s e r i o u s t h r e a t to 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 of 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 u n i t 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 of f i f t e e n graduate nurses agreed to p a r t i c i p a t e i n the study out of a p o s s i b l e twenty-seven. This arrangement i s r e a c t i v e and needs to be considered i n r e l a t i o n to e x t e r n a l v a l i d i t y . Sample A t o t a l sample of 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 of 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 to those who d i d not, 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 of Non Graduates P o s i t i o n P a r t i c i p a n t P a r t i c i p a n t 1 Head Nurse 1 0 4 General Duty 3 1 2 General Duty 1 ! (pa r t time) 1 General Duty 0 1 (evenings) 1 General Duty 0 ! (pa r t time evenings) 1 General Duty 0 ! ( p a r t time 5-9 pm) 1 General Duty 0 1 ( n i g h t s ) 1 General Duty 0 ! (part time n i g h t s ) 12 5 7 31 TABLE II P a r t i c i p a n t s and P ton 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 of Non Graduates P o s i t i o n P a r t i c i p a n t P a r t i c i p a n t 1 Head Nurse 1 0 11 General Duty 9 2 1 General Duty (evenings) 0 1 1 General Duty (pa r t time evenings) 0 1 1 General Duty (pa r t time days) 0 1 15 10 5 32 In order to i d e n t i f y a d i f f e r e n c e i n the use of the nursing process by the graduate nurses and t h e i r a t t i t u d e toward 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 hypotheses were developed. 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 defined 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 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 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 nursing 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. 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 nursing 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 nursing 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. 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 nursing 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 nursing process. (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 of the i n s t r u c t i o n a l program. 3. Consistency of 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. Consistency of the planning phase of the nursing 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. Consistency of the implementing phase of the nursing 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 of the nursing 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. 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 nursing process. Data on a l l phases of the nursing process were obtained by a u d i t i n g the nursing care p l a n , nursing h i s t o r y and nurses notes, f o r each p a t i e n t i n both nursing u n i t s . (Appendix Measurement of the a t t i t u d e of each graduate nurse toward the nursing 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 ques-t i o n n a i r e . The c r i t e r i a used i n a u d i t i n g the above parts of the p a t i e n t r ecord were devised from the d e f i n i t i o n s of each phase of the nursing process found i n the l i t e r a t u r e . The major source of 3 information regarding 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 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 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 e s t a b l i s h e d ; (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 v e r i f i c a t i o n ; ( f ) n ursing 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 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 ; (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 c r i t e r i a : (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 producing the expected behavioural outcomes i n the p a t i e n t ; (c) 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 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 o n : (a) nursing a c t i o n c a r r i e d out i s evaluated i n terms of 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 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 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 audited 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 of s i g n i f i c a n c e f o r c r i t i c a l value determi-n 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 was obtained.^ (p=0.0001) Since the number of observations was 2 5 g r e a t e r than seven the X transformation 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 nursing process, 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 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. (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 nursing 7 8 process. The items were then ordered on a random b a s i s . 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 that the higher 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 was obtained. 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 of 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 to 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 twenty-five 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 held at Phoenix, Arizona 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 explana-t o r y 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 returned, with s i x having been rated 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 con-s i d e r e d v a l i d to seventeen out of 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 III Results Obtained by a Panel of 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 * C r i t e r i o n J l J 2 J 3 R l R2 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 12 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 16 g 0 0 0 6 6 5.5 h 0 0 0 6 6 5.5 5a 1 2 1 12 12.5 11 b 0 0 0 6 6 5.5 c 0 0 0 6 6 5.5 6a 0 0 0 6 6 5.5 J = Judge, R = Rank. Sixteen c r i t e r i a were ranked according to value. The number of t i e s determine the number of 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 Questionnaire Measuring A t t i t u d e Toward the Nursing Process P a r t i c i p a n t T est 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 introduced to the study group f o l l o w i n g the c o l l e c t i o n of data on a l l dependent v a r i a b l e s . The program centered around the four phases of the nursing process: a s s e s s i n g ; planning; 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 of N u r s i n g . 1 1 The program was developed to a s s i s t the graduate nurse to 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 that graduate nurses were often problem-s o l v i n g at an i n t u i t i v e l e v e l . T h i s type of d e c i s i o n making i s h i g h l y s u b j e c t i v e . 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 to 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 formation of a g e n e r a l i z e d concept. The teaching methods were chosen to a s s i s t the graduate nurse to c o n s c i o u s l y examine information on which she based her d e c i s i o n s . These methods were: (1) the case 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 . 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 nec-essary 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 opportunity 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-FORMING PROCESSES Gene r a l i zed Concepts V e r b a l i z e d Concepts I n t u i t i v e Concepts Perception o f Concrete Objects and Events T r a n s f e r or y Problem S o l v i n g (Conscious and V e r b a l i z e d ) V e r b a l i z e d r D e c i s i o n Making Subliminal D e c i s i o n Making CONCEPT-USING PROCESSES Matching Ge n e r a l i z e d Process Concepts to General C h a r a c t e r i s t i c s o f U n f a m i l i a r S i t u a t i o n to c o •r-+-> ra Z3 +-> oo s-ra Conscious and Examined Decisions I n t u i t i v e and I n t u i t i v e and Unrecognized D e c i s i o n s P e r c e p t i o n o f S i t u a t i o n Requiring A d j u s t i v e Response Sensory Intake Processes 42 T R I A L F e e d b a c k F i g u r e 1 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 EXPERIENCE — •MEANING- Concept I—SATISFYING" -FEELING — P o s i t i v e Value •—ANNOYING Negative Value Concept with P o s i t i v e Value Concept with Negative Value Figure 2 Meaning, F e e l i n g and Concepts 15 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 value. 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) to f o s t e r an atmosphere of shared i n f o r m a t i o n . I t was hoped that 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 that 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 nursing 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 explored 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 of the graduate nurses; 2. each graduate nurse was encouraged to i d e n t i f y her area(s) of e x p e r t i s e and to draw on that e x p e r t i s e in her use of the nursing process; 3. the i n v e s t i g a t o r was viewed by the graduate nurses as a nursing colleague 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 nursing 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 4 5 the program. Smith's h i s t o r y t o o l was used as a guide to provide a d d i t i o n a l areas on which information 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 leading up to i l l n e s s . some i n d i c a t i o n of the p a t i e n t ' s expectations . 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, education, 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 . s k i n 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 patterns . 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 of 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 of the nursing process; ( 2 ) p r o v i s i o n of information concerning the nursing process; ( 3 ) the opportunity to u t i l i z e the nursing process under s u p e r v i s i o n ; and ( 4 ) assess-ment 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 three months. This 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 , ac t u a l exposure time (to 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. This d i d not i n c l u d e the time each graduate nurse spent preparing 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 of 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 of 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 simultaneously 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 O v e r a l l O b j e c t i v e The graduate nurse uses the nursing process, 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 . S p e c i f i c O b j e c t i v e s 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 data; 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 f a m i l y ; 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 h i s f a m i l y ; 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 of expected behavioural 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 nursing 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 nursing 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 of the nursing process. Phases of 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 record of her care of a p a t i e n t , using the nursing process, p r i o r to the i n t r o d u c t i o n of any information on the nursing 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 nursing process. 48 Phase II The pre-established objectives were reviewed with each graduate nurse and i t was explained that the attainment of these objectives was necessary f o r completion of the program. Written information on the nursing process was given to each graduate nurse. (Appendix D) This material was reviewed with the i n v e s t i g a t o r f o r explanation and to answer questions posed by the graduate nurse. This material was made av a i l a b l e so that a l l graduate nurses in the program would have common information to r e f e r to. Phase III Each graduate nurse in caring f o r a patient(s) c a r r i e d out a l l phases of the nursing process. A written and/or verbal account of the care provided was concurrently reviewed with the i n v e s t i -gator • Phase IV Each graduate nurse completed an assignment on each phase of the nursing process which consisted of verbal and/or written accounts of t h e i r care of a patient using the nursing process. 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 that the pre-established objectives had been met, the program was complete. A l l of the graduate nurses completed the program within three months. 49 POST-TEST Data were gathered on a l l dependent variables in both groups fol lowing the completion of the in s t ruct iona l program by the study group. Data on a l l phases of the nursing process were obtained in the same manner as in the pretest. The questionnaire to determine att i tude toward the nursing process was again administered to both groups. SUMMARY In an attempt to test the seven nu l l hypotheses in th i s study three steps were car r ied out. (1) Data were gathered on a l l dependent variables in the study group and the control group. (2) The study group completed an in s t ruct iona l program on the nursing process. (3) Following completion of the in s t ruct iona l program on the nursing process, data were gathered on a l l dependent variables in the study group and the control group. The research design was quasi experimental with a non-equivalent control group and a pre and post te s t . The sample consisted of f i f t een graduate nurses, f i ve in the study group and ten in the control group. This procedure was carr ied out in an attempt to determine what e f fec 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 supervis ion, would have on the use of the nursing process in the pract ice area, and the att i tude 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 di s c u s s e d under f i v e headings: ASSESSMENT; PLANNING; IMPLEMENTATION; EVALUA-TION; 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 nursing process are: (1) the frequency with which a defined 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 com-p 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 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 of the i n s t r u c t i o n a l program; and (3) the co 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. See Table V f o r r e s u l t s . 51 TABLE V 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 Assessment Phase of the Nursing Process Dependent V a r i a b l e Audited Records Study Group Control Group P r e t e s t P o s t t e s t P r e t e s t P o s t t e s t (N = 35) (N = 32) (N = 36) (N = 36) Data Base (present) 30 26 30 24 P a t i e n t Problems Identi f i e d 65 58 58 38 Consistency with C r i t e r i a (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 P a t i e n t 0 9 2 9 N = Number of 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 of the i n s t r u c t i o n a l program by graduate nurses. Results The frequency with which a defined 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-value obtained was not s i g n i f i c a n t . Therefore 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 to i n d i c a t e that 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 to 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-value of 0.808 with 68df was o b t a i n e d J This was not s i g n i f i c a n t , t h ere-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 obtained 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-value obtained was 0.257 with 68 df. The t-value 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 b: p a t i e n t problems 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 an incre a s e i n both groups, but the in c r e a s e was small and the t-value obtained was approximately 0 with 68df. These 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 , 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 of concern here i s co n s i s t e n c y of the planning phase o f the nursing 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. Hypothesis 4 There i s no measurable d i f f e r e n c e i n the planning phase of the nursing 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. Results The r e s u l t s of the planning phase of the nursing 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 that were arranged i n order of p r i o r i t y i n the study group. A Chi Square 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 . (X =3.29 with 1 df) There was, however, a s i g n i f i c a n t decrease i n 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 2 = 8.425 with 1 d f , p = 0.005) 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 contact 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 of the q u e s t i o n n a i r e . 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 e s t a b l i s h e d . There was an i n c r e a s e i n the number of behavioural out-comes 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 increased 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 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 = 2.201 with 68df, p = 0.005) (Table VI) 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 phase. TABLE VI Results of the Pa 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 C r i t e r i o n Audited Records Study Group Control Group Pretest (N = 35) P o s t t e s t (N = 32) Pr e t e s t (N = 36) P o s t t e s t (N = 36) a. P r i o r i z e d P a t i e n t Problems 3 8 17 5 b. Expected Behavioural Outcomes 7 38* 43 36 c. R e a l i s t i c Behavioural Outcomes 5 g** 18 8 d. Behavioural Outcomes Related to I d e n t i f i e d P a t i e n t Problems 3 7*** 8 3 e. Behavioural Outcomes V a l i d a t e d with P a t i e n t and/or Family 0 0 1 0 f. 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 74 49 57 32 g. Nursing A c t i o n Planned to Achieve Expected Behavioural Outcomes 4 11 18 14 h. 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 0 0 1 2 N = Number of records audited * 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-value) * 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-value) 56 C r i t e r i o n d increased 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 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 = 1.85 with 68df, p = 0.05) (Table VI) C r i t e r i o n 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 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 of 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: 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. There was a decrease i n the number of planned nursing a c t i o n s r e l a t e d to 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: nursing a c t i o n i s planned i n order to 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 of nursing a c t i o n s planned to achieve the expected behavioural outcomes increased 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-value obtained was 1.133 with 68df. This t-value was not s i g n i f i c a n t . C r i t e r i o n h: nursing a c t i o n 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 fami 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. The t-value obtained was approximately 0. 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 to r e j e c t the n u l l hypothesis s t a t i s t i c a l 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 . T h e r e f o r e , 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 consi s t e n c y of the implementing phase of the nursing 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. 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 of the implementing phase of the nursing 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 by the graduate nurses. Results The r e s u l t s o f the implementation phase are d i s p l a y e d i n Table V I I . The r e s u l t s are ta 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: nur 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-value obtained was approximately 0, which of course was not s i g n i f i c a n t . 58 TABLE VII 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 Implementation Phase of the Nursing Process C r i t e r i o n Audited Records -Study Group Control Group P r e t e s t P o s t t e s t P r e t e s t P o s t t e s t (N = 35) (N = 32) (N = 36) (N = 36) Nursing A c t i o n Based on I d e n t i f i e d P a t i e n t Problems 47 36 54 38 Nursing A c t i o n D i r e c t e d Toward Expected Be-ha 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 audited C r i t e r i o n 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 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-value o f 1.307 with 68 df was obtained. This t-value 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: 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 . 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 or the c o n t r o l group. The t-value obtained was approximately 0. The n u l l hypothesis was r e t a i n e d due to the f a c t t h at 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 of 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 co n s i s t e n c y of the e v a l u a t i n g phase of the nursing 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. 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 of the e v a l u a t i n g phase of the nursing 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 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 to the number of times nursing a c t i o n was evaluated i n terms of the expected behavioural outcomes. (Table VIII) The t-value 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 C r i t e r i o n Audited Records Study Group Control Group P r e t e s t P o s t t e s t P r e t e s t P o s t t e s t (N = 35) (N = 32) (N = 36) (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 Behav-i o u r a l Outcomes N = number o f records 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 nursing 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 incre a s e i n the mean score obtained on the qu 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) A t - t e s t was computed and the t-value obtained was 3.48 with 68df. This 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 considered 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 that the t-value r e f l e c t s a true 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 Test Results from the Questionnaire on A t t i t u d e Toward the Nursing Process f o r the Study Group and the Control Group Group P r e t e s t P o s t t e s t D i f f e r e n c e Between • Pre and Post Tests Mean Dev i a t i o n Mean De v i a t i o n 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 of the study, i n a d d i t i o n to 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 of 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 62 i t s e l f , w i l l be discussed 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 to 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 of the nursing 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. Therefore 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 nursing 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 to the pro p o r t i o n of records completed by nursing personnel who completed the i n s t r u c t i o n a l program and those who d i d not. Many v a r i a b l e s other than the knowledge and s k i l l of 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 of the nursing process by the graduate nurse i n p r a c t i c e . 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 i n the study group as reasons f o r t h e i r i n a b i l i t y to use the nursing 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 of 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 that they a l l had some idea of what the nursing 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 to 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 nursing 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 are: (1) a method of re c o r d i n g the various phases of the nursing process; (2) absence of 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 nursing 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 to obtain a nursing 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 of care; and (4) inadequate numbers of r o l e models i n the use of the nursing process. Method of 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 recording the various phases of the nursing process. The p a t i e n t records d i d not lend themselves to r e c o r d i n g a problem l i s t , or progress notes. The nursing 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 of care, and subsequent plan of care. The nurses' notes were not used to record the nursing process because they were used by nursing personnel other than those i n the study, who, were not using the nursing process. An attempt was made to use the nurses' notes to record the problem l i s t and subsequent plan of care but nursing personnel not i n the study d i d not understand that method of 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 nursing process, there 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 nursing 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 Licensed 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 Licensed 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 to p a r t i c i p a t e i n the study. The study group f e l t they could not u t i l i z e the nursing process i n t h e i r p r a c t i c e , without the support of the nursing 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 to 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 nursing process could 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 obtain a nursing 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 nursing care. They f e l t that most of t h e i r time was taken up i n such d u t i e s as, medications, checking I.V.'s, and taking care of the immediate needs of each p a t i e n t . I t was suggested that i f u t i l -i z a t i o n of the nursing 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 guid-ance of r o l e models i n the use of the nursing process. I t was f e l t t h at 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 nursing 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 considered i n r e l a t i o n to the r e s u l t s of the study. Woodruff's model on concept formation 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 to provide the graduate nurse with an overview of the nursing process followed 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 i n the c l i n i c a l area where the graduate nurse could concentrate on developing concepts concerning the nursing 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 . T h is meant that the t r i a l phase of concept formation (Figure 1) was inadequately d e a l t with. This 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 planning 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 obtained 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 com-p l e t i o n of 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 of 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, due to the number of nursing 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 nursing process would: (1) i n c r e a s e the frequency with which a nursing h i s t o r y ( d e f i n e d data base) i s obtained; (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 planning, implementing and e v a l u a t i o n phases of the nursing process; and (5) have a favourable e f f e c t on how the graduate nurse views the nursing 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 nursing process. A panel o f three judges was used to a u d i t p a t i e n t records (nursing h i s t o r y , nursing care p l a n , and nurses' n o t e s ) , i n order to o b t a i n data on a l l phases of the nursing process f o r both groups. A q u e s t i o n n a i r e was administered 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 of the graduate nurse toward the nursing 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 nursing 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 of the graduate nurse. Com-p l e t i o n of the program was determined by the attainment of pre-e 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 nursing process i n the study group, 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. These c r i t e r i a were: (1) expected behavioural 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 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. I t must be pointed out t h a t a large c o n t r i b u t i o n to the t-value i n c r i t e r i a 2 and 3 was con-t 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 that the: (1) method of r e c o r d i n g the nursing process; (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 area; (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 of the nursing 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 of s t r u c t u r e d time in 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 of 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 n u l l 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 conc l u s i o n that the completion of 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 nursing 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 part 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 using the nursing process. 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 that i n h i b i t the use of the nursing process i n the p r a c t i c e area. I t became evident during the study that 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 nursing process, were i n v o l v e d i n determining the use of the nursing 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 nursing process and the i n c l u s i o n of a l l nursing 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 nursing process, need to be looked at i n r e l a t i o n to the use of the nursing 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 nursing personnel i n a p a r t i c u l a r area and the comparison of each subjects performance i n the use of the nursing 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 t o o l 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 nursing 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 of the nursing process as a p r a c t i c e t o o l 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 various 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 nursing 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 nursing process. The t o o l s f o r measuring q u a l i t y 71 care that 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 nursing 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 Implications 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 of r e c o r d i n g the nursing process. Although time was considered an important v a r i a b l e i t was thought that 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 of r o l e models i n the use of the nursing 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 recording the nursing process such as problem o r i e n t e d r e c o r d s . 3. P r i o r agreement from a l l nursing personnel i n v o l v e d , con-cerning i n i t i a t i o n of the use of the nursing process as a p r a c t i c e t o o l . 72 SUMMARY This 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 nursing 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 nursing process? T h i s , v o f course, i s the most important question that needs to be answered, but u n t i l more c l i n i c a l areas are using the nursing 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-Century-C r o f t s , 1973, 15. 2 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. 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 Planning, 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. 6 Yura and Walsh. ^ 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: Appleton-Century-Crofts, 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 to  Nursing Care, S a i n t L o u i s : C.V. Mosby Company, 1975. 1 0 Alfano. ^ Doris Bloch, " E v a l u a t i o n of 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 C r i t e r i a , " Nursing  Outlook, May, 1972, 20:5, 323-326. E i l e e n G. Hasselmeyer, Discussant: "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 , Discussant: "Problems i n the Develop-ment 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 Audit 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 Nursing, March, 1974, 74:3, 456-459. 1 9 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. 2 Helen Yura and Mary Walsh, The Nursing Process: a s s e s s i n g , planning, implementing, e v a l u a t i n g , New York: Appleton-Century-C r o f t s , 1973, 19. 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. 7 Marlene G. Mayers, A Systematic Approach to the Nursing Care  Plan, New York: Appleton-Century-Crofts, 1972. Q Dolores E. L i t t l e and Doris L. C a r n e v a l i , Nursing Care Planning, 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 nursing assessment t o o l , P h i l a d e l p h i a : F.A. Davis Company, 1975. 0 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. 1 K.J. K e l l y and K. Hammond, "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. K e l l y , " C l i n i c a l Inference i n Nursing - A Nurse's Viewpoint," Nursing Research, Winter, 1966, 15:1, 23-26. 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 Inference i n Nursing - A n a l y z i n g C o g n i t i v e Tasks Representative 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. Schneider, " 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. 1 6 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 of Information Seeking S t r a t e g i e s , " Nursing Research, F a l l , 1966, 15:4, 330-336. ^ 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 - Re 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 Nursing, U.S. Department o f Health, 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 the 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 to the Nursing Process," American Journal o f Nursing, September, 1972, 75:9, 1589-1591. 23 D.S. Zimmerman and C. Gohrke, "The Goal-Directed Nursing Approach: I t Does Work," American Journal o f Nursing, February, 1970, 70:2 , 306-310. 2 4 Yura and Walsh, 1. 25 L i t t l e and C a r n e v a l i , 1. 78 2 6 Mayers, 12. 2 7 I b i d . 28 Dorothy M. Smith, "A C l i n i c a l Nursing T o o l , " American Journal  of Nursing, November, 1968, 68:11, 2384-2388. 29 V i r g i n i a Henderson, The Nature o f Nursing, 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 Journal 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 Journal o f Nursing, A p r i l , 1965, 65:4, 82-84. 34 M.E. Hamdi and CM. Hutelmyer, "A Study of 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 of Nursing Care Problems," Nursing Research, July-August, 1970, 19:4, 354-359. 3 5 I b i d . J.C. Marshall and S. Feeney, " 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. 37 L.M. McPhetridge, " 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 Factors: P r e l i m i n a r y Study," Nursing Research, July-August, 1973, 22:4, 310-320. 3 8 I b i d . , 320. 39 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 of 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 Diagnosis," American Journal of Nursing, November, 1962, 62:11, 102-104. 44 M.0. Mundinger and G.D. Jauron, "Developing a Nursing Diagnosis," Nursing Outlook, February, 1975, 23:2, 94-98. 4 5 Yura and Walsh, 92. 46 Becknell and Smith, 68. 4 7 Mayers, 28-33. 48 Dorothy M. Smith, "Writing 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 of Nursing, February, 1971, 71:2, 319-320. 4 9 I b i d . . 5 0 Yura and Walsh, 93. 51 Becknell and Smith, 85. I b i d . 53 Mayers, 15. 54 L i t t l e and C a r n e v a l i , 63-64. 55 R.L. C i u c a , "Over the Years with the Nursing Care Plan," Nursing Outlook, November, 1972, 20:11, 706-711. 5 6 I b i d . 80 J.P. G r o s i c k , M. Hagey and I. Johnson, "Nursing Care Plans: Survey of Status and Opinions About Current Usage," Journal of  P s y c h i a t r i c Nursing, November-December, 1967, 5:6, 567-585. 5 8 I b i d . 5 9 I b i d . 6 0 N.C. K e l l y , "Nursing Care Plans," Nursing Outlook, May, 1966, 14:5, 61-64. R.L. Hanson, "The Nursing H i s t o r y and Care Plan: A Throw Away?" Washington State Journal o f Nursing, S p r i n g , 1972, 44: 2 , 21-23. 6 2 Yura and Walsh, 35-67. 6 3 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. 6 5 Yura and Walsh, 108. 6 6 I b i d . 6 7 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: Appleton-Century-Crofts, 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: Appleton-Century-Crofts, 1974. 7^ M.A. Wandelt and D.S., Stewart, S l a t e r Nursing Competencies  Rating S c a l e , New York: Appleton-Century-Crofts, 1975. 7 1 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 of 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. 7 2 Yura and Walsh, 120-121. 81 7 3 I b i d . 7 4 I b i d . 75 M a r r i n e r , 195. 7 6 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. 7 7 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. 78 Doris Bloch, "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, July-August, 1975, 24:4, 256-263. 7 9 I b i d . , 258 80 Wandelt and Ager. 8 1 I b i d . 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. 8^ 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 of Nursing Care," Nursing Research, M a r c h - A p r i l , 1974, 23:2, 108-117 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 H i l g e r . 8 9 C o r n e l l . 82 9 0 T a y l o r . 9 1 I b i d . 9 2 I b i d . 93 R o z e l l a M. S c h l o t f e l d t , D iscussant: "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. 94 y 4 I b i d . 95 J.C. McCloskey, "The Problem-Oriented Records vs the Nursing Care Plan: A Proposal," 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 of North America, June, 1974, 9:2, 215-228. 9 8 M i t c h e l l , 187. 9 9 McCloskey, 493. ^ L. Weed, "Medical Records that Guide and Teach," New England  Journal of Medicine, March 14, 1968, 278:11, 593-600. 1 0 1 Becknell and Smith, 15-17. 102 F. Woolley, N.W. Warnick, R.L. Kane and E.D. Dyer, Problem- Oriented Nursing, New York: Springer 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 Press, 1972. 104 M. Woody and M. M a l l i s o n , "The Problem-Oriented System f o r Patient-Centered Care," American Journal of Nursing, J u l y , 1973, 73:7, 1168-1175. 83 l V 0 B.C. Vaughan-Wrobel and B. Henderson, The Problem-Oriented  System i n Nursing, A Workbook, Toronto: C.V. Mosby Company, 1976. 1 0 6 Yura and Walsh, 23. 1 0 7 Yura and Walsh, 26-31. 1 0 8 Henderson, 6-23. 84 FOOTNOTES CHAPTER III Donald T. Campbell and J u l i a n C. Stan 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 Campbell and Stan l e y , 50. 3 Helen Yura and Mary Walsh, The Nursing Process: a s s e s s i n g , planning,  implementing, e v a l u a t i n g , New York: Appleton-Century-Crofts, 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  Education, 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 Scal 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 I b i d . 9 I b i d . 1 0 Telephone i n t e r v i e w with Mary Fewster, M.S.N., I n s t r u c t o r , Douglas Co l l e g e School o f Nursing, Surrey Campus, B.C., Apri1 12, 1976. 1 1 V i r g i n i a Henderson, The Nature o f Nursing, New York: MacMillan Company, 1966. 1 ? Asahel D. Woodruff, "Cognitive Models of Learning and I n s t r u c t i o n , " i n I n s t r u c t i o n , Some Contemporary Viewpoints, ed. by Laurence S i e g e l , San F r a n c i s c o : Chandler P u b l i s h i n g Company, 1967. 85 I b i d . , 70. 1 5 I b i d . I b i d . , 82. Dorothy M. Smith, "A C l i n i c a l Nursing T o o l , " American Journal  of Nursing, November, 1968, 68:11, 2384-2388. 86 B I B L I O G R A P H Y 87 BIBLIOGRAPHY BOOKS B e c k n e l l , E i l e e n P. and Smith, Dorothy M. 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"A P r a c t i c a l Approach to the Nursing Process," American Journal of Nursing, September, 1972, 75:9, 1589-1591. Chambers, W. "Nursing Diagnosis," American Journal of Nursing, November, 1962, 62:11, 102-104. C i u c a , R.L. "Over the Years with the Nursing Care Plan," Nursing  Outlook, November, 1972, 20:11, 706-711. 89 C o r n e l l , Sudie A. "Development of an Instrument f o r Measuring the Q u a l i t y of Nursing Care," Nursing Research, March-A p r i l , 1974, 23:2, 108-117. Gebbie, K. and La v i n , M.A. " C l a s s i f y i n g Nursing Diagnoses," American Journal of Nursing, February, 1974-, 74:2, 250-253. G r o s i c k , J.P., Hagey, M. and Johnson, I. "Nursing Care Plans: Survey of Status and Opinions About Current Usage," Journal of P s y c h i a t r i c Nursing, November-December, 1967, 5:6, 567-585. Hamdi, M.E. and Hutelmyer, CM. "A Study of the E f f e c t i v e n e s s of and 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, July-August, 1970, 19:4, 354-359. Hammond, K.R. " 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. Hammond, K.R., K e l l y , K.J. C a s t e l l a n , N.J. J r . , Schneider, R.J. " C l i n i c a l Inference i n Nursing - Analyzing C o g n i t i v e Tasks Representative of Nursing Problems," Nursing Research, S p r i n g , 1966, 15:2, 134-138. Hammond, K.R., K e l l y , . K . J . C a s t e l l a n , N.J. J r . , and Schneider, R.J. " C l i n i c a l Inference i n Nursing - Information Units Used," Nursing Research, Summer, 1966, 15:3, 236-243. Hammond, K.R. K e l l y , K.J. C a s t e l l a n , N.J. J r . , Schneider, R.J. and V a n c i n i , M. " C l i n i c a l Inference i n Nursing - Use of Information Seeking S t r a t e g i e s , " Nursing Research, F a l l , 1966, 15:4, 330-336. Hammond, K.R., K e l l y , K.J. and Schneider, R.J. " C l i n i c a l I n f e r -ence i n Nursing - Revising Judgements," Nursing Research, Winter, 1967, 16:1, 38-45. Hanson, R.L. "The Nursing H i s t o r y and Care Plan: A Throw Away?" Washington State Journal of Nursing, S p r i n g , 1972, 44:2, 21-23. Hargreaves, Ian. "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. 90 Hasselmeyer, E i l e e n G. Discussant: "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. H e f f e r i n , E.A. and Hunter, R.E. "Nursing Assessment and Care Plan Statements," Nursing Research, September-October, 1975, 24:5, 360-366. Henderson, V i r g i n i a . "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 Plans," Nursing Outlook, May, 1966, 14:5, 61-64. Komorita, N.I. "Nursing Diagnoses," American Journal of Nursing, December, 1963, 63:12, 83-86. Lewis, L. "This.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 Nursing, A p r i l , 1965, 65:4, 82-84. McCloskey, J.C. "The Problem-Oriented Records vs the Nursing Care Plan: 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 Journal of Nursing, 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, July-August, 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 Nursing, 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 Problem-Oriented Approach," Nursing Forum, 1973, 12:2, 187-209. Mundinger, M.O. and Jauron, G.D. "Developing a Nursing Diagnosis," 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 Control i n P a t i e n t Care," American Journal  of Nursing, 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. Discussant: "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 Journal  of Nursing, November, 1968, 68:11, 2384-2388. Smith, Dorothy M. "Writing 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 of Nursing, 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 that Guide and Teach," New England  Journal of Medicine, 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 Journal of Nursing, 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 Journal of Nursing, February, 1970, 70:2, 306-310. 92 UNPUBLISHED REPORTS Fewster, Mary. "The Development of a Scale 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 of B r i t i s h Columbia, 1975. Research Grants D i v i s i o n of Nursing, U.S. Department of Health, Education and Welfare. Long-Term E f f e c t s of 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 College School of 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 to be 10-15 minutes. I may withdraw from the study a t any time. Signature Date 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 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 content o f the i n s t r u c t i o n a l program and have been informed that the time r e q u i r e d f o r t h i s procedure i s unknown a t present. 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 out 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 -15 minutes. I may withdraw from the study a t any time. Signature Date APPENDIX B PATIENT RECORDS SURREY MEMORIAL HOSPITAL NURSES' NOTES & HISTORY Date 9 7 NURSING CARE AND OBSERVATIONS Admission Interview by Time Admitted walking, wheelchair, s t r e t c h e r , ( C i r c l e ) T P R BP Apex Weight i n K i l o s A l l e r g i e s Dentures Upper Lower Contact Lenses S o f t or hard Glasses P r o s t h e s i s Hearing A i d Di e t Normal S p e c i a l Sleep Well F a i r Poor U r i n a r y I r r e g u l a r i t i e s Bowel I r r e g u l a r i t i e s Medication Taken a t Home: Observation re: 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 Sta t e o f Mind: P a t i e n t ' s Understanding of 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 h o s p i t a l i z a t i o n ) 98 Surrey Memorial H o s p i t a l Form (continued) DATE HOUR MEDICATION AND TREATMENT NOTES 99 Form #22 - 2/74 ORDERED MEDICATION ORDERED INTRAVENOUS ALLERGIES Form # 22 - 2/74 (other side the same) Form 30 - 1/74 NURSING OBJECTIVE DATE TREATMENTS DATE LABORATORY X-RAY MISCELLANEOUS/SPECIAL 100 Form #30 - 1/74 (continued) DIET ACTIVITY BOWEL/BLADDER PHYSICAL TRAITS NPO CLEAR FLUIDS FULL FLUIDS SOFT FULL SPECIAL ( S p e c i f y ) BED REST BRP DANGLE CHAIR WHEELCHAIR WALKER UP AD LIB CRUTCHES BRP CATHETER INCONTINENT COMMODE COLOSTOMY CLINITEST B.M. HEMIPLEGIC L R PARAPLEGIC QUADRAPLEGIC BLIND L R DEAF L R SPEECH IMPEDIMENT OTHER ( S p e c i f y ) FLUIDS HYGIENE P a t i e n t P r o f i l e - Prev. Admis. NPO I/V INTAKE & OUTPUT FORCE RESTRICT TO BED BATH PARTIAL BATH SELF BATH SHOWER TUB DENTURES ORAL CARE P e r t i n e n t Events Occupation FEEDING SIDE RAILS SELF ASSIST FEED CONSTANT NIGHT ONLY GOAL UPDATED PATIENT NEED/PROBLEM AND OBJECTIVES NURSING APPROACHES/SOLUTION/ ACTION — . ADM DATE BP AGE PC RELIGION WT DIAGNOSIS SURGERY DELIVERY PO PP NAME DOCTOR CONSULTANT APPENDIX C QUESTIONNAIRE UNIVERSITY OF BRITISH COLUMBIA SCHOOL OF NURSING Some Opinion Items Concerning the Nursing Process The nursing process i s a systematic approach to nursing care which i n v o l v e s t a k i n g a nursing h i s t o r y , a n a l y z i n g the data, planning, implementing and e v a l u a t i n g p a t i e n t care. The aim o f t h i s s e t o f items i s to determine how nurses view the nursing 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. S t r o n g l y Agree Agree Undecided Disagree S t r o n g l y Disagree 1. The time consuming nature of the nursing process negates i t s value as a systematic approach to p a t i e n t care. 2. The nursing 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 nursing 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 of the p a t i e n t than nursing based on i n t u i t i o n . The nursing process i s slow, l a b o r i o u s and a waste of time. 7. 8.. The use of the nursing process improves communication between nurses. 9. The nursing process should be used because the p a t i e n t has more input i n t o his care. o CO 10. Using the nursing process makes the nurse more aware of the p a t i e n t as a person. 11. The nursing process should be used only f o r long term p a t i e n t s . 12. Use of the nursing process helps most nurses to c l a r i f y goals of p a t i e n t care. 13. Having to f o l l o w the nursing process does not allow the nurse to use her own judgement. 14. The nursing process i s a valuable means of pro-v i d i n g c o n t i n u i t y i n p a t i e n t 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 nursing 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 of the heal t h team. 17. The nursing process i s a good means of evalu-a 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 invasion o f the p a t i e n t s p r i v a c y . 20. A l l nurses should be encouraged to use the nursing process. S t r o n g l y Agree Agree Undecided Disagree S t r o n g l y 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 of 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 of the research 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 nursing process. We have enclosed 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 using a consensus approach through a panel of experts. We b e l i e v e you are such a person and, t h e r e f o r e , hope that you w i l l f e e l motivated to help us. Please look through the items and then respond f o r each item how you estimate 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 extent 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 using the c o e f f i c -i e n t of 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 e s t a b l i s h e d s i g n i f i c a n c e l e v e l . 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 of 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 of the Nursing Process i n P r a c t i c e . She and I, both, look forward to seeing 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. Overview o f the Nursing Process A. D e f i n i t i o n B. Reasons f o r Using the Nursing Process I I . 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 I I I . The Nursing Process Within the T h e o r e t i c a l Framework A. A s s e s s i n g B. Planning C. Intervening D. E v a l u a t i n g IV. C l i n i c a l P r a c t i c e 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 nursing process w i t h i n a t h e o r e t i c a l framework. Written Assignment - the assignment w i l l c o n s i s t o f the nursing 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 nursing process. 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 . n o I. Overview of the Nursing Process A. D e f i n i t i o n The nursing process i s an order l y , systematic manner of determining the patients problems, making plans to solve them, i n i t i a t i n g the plan or assigning others to implement i t , and evaluating the extent to which the plan was e f f e c t i v e . ! In recent years the nursing process has been discussed quite extensively i n nursing l i t e r a t u r e . I t i s viewed as a highly d e s i r a b l e , i f not e s s e n t i a l , method of giving care. V a r i a t i o n i n the number and names of the d i f f e r e n t phases of the nursing process are found in the l i t e r a t u r e , but there i s agreement that the nursing process i s a systematic approach to nursing care, which r e l i e s heavily on the nurses a b i l i t y to problem-solve and make dec i s i o n s . The nursing process i s a continuous process, which i n r e a l i t y cannot be c l e a r l y separated into d i f f e r e n t phases. However, i n order to study the nursing process i t must be separated, keeping in mind that i t i s an a r t i f i c i a l separation and constant overlapping of each phase occurs. This d i f f i c u l t y i n separating the nursing process into various phases probably accounts f o r the v a r i a t i o n i n the number and names of the phases found in the l i t e r a t u r e . For the purpose of th i s program the nursing process w i l l be divided into four phases: assessment; planning; intervention;and evaluation. B. Reasons f o r Using the Nursing Process Why i s the nursing process considered to be e s s e n t i a l f o r q u a l i t y care to be assured? Probably one o f the most s i g n i f i c a n t reasons, i s that nursing care i s planned around i n d i v i d u a l patient problems rather than tasks that must be done. When the problem solving approach i s not used i n giving care, tasks are completed as needed and i n d i v i d u a l p a t i e n t problems are l o s t i n a sea of routines. Other s i g n i f i c a n t reasons f o r using the nursing process are: (1) evaluation of nursing care by comparing patient outcomes with predetermined patient goals; (2) a c t i v e p a r t i c i p a t i o n by the patient and/or his family in his care; (3) accumulation of a body of knowledge concerning patient problems and e f f e c t i v e nursing intervention-, and (4) increased opportunity f o r the nurse to make decisions regarding patient care. The reasons given are only a few of the many f o r using the nursing process, and they presuppose that a permanent record i s kept of the nursing process on each patient. Without the use of the nursing process there i s no s a t i s f a c t o r y method of assessing the benefit the patient receives from the nursing care. Yura Helen, Walsh Mary B., The Nursing Process: assessing, plan- ning, implementing, evaluating. Appleton-Century-Croft, New York, 1973, p. 23. I l l I I . T h e o r e t i c a l Framework A. D e f i n i t i o n 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 at and o r g a n i z i n g phenomena, and can be e i t h e r a philosophy or 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 are 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 out 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 not viewed i n t h i s manner. The nursing process could be used whether o r not man was viewed as unique, with d i g n i t y and worth, but 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 hea 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 po s s i b l e . 2 she goes on to say: Thi s aspect o f her 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 out 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 of 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 improve-ment 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 of the team should make such heavy demands on another member that any one of 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 of man's goals i s good h e a l t h . She equates good health 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 of Nursing. MacMillan Company, New York, 1967, p. T5. 3 I b i d . 112 c o n s t a n t l y s t r i v i n g to a s s i s t the p a t i e n t to achieve that indepen-dence. 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 are common to a l l men. Each man i n t e r p r e t s his needs i n such a way that 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 hi m s e l f what hea l t h means to him. Therefore, 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 to 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. Breathe normally. 2. Eat and d r i n k adequately. 3. E l i m i n a t e body wastes. 4. Move and maintain d e s i r a b l e posture. 5. Sleep and r e s t . 6. S e l e c t s u i t a b l e c l o t h e s - dress and undress. 7. 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 clean and well groomed and p r o t e c t the integument. 9. Avoid dangers i n the environment and avoid i n j u r i n g others. 10. Communicate with others i n expressing emotions, needs, f e a r s , or o p i n i o n s . 11. Worship according to one's f a i t h . 12. Work i n such a way that there i s a sense o f accomplishment. 13. Play or p a r t i c i p a t e i n various forms o f r e c r e a t i o n . 14. Learn, d i s c o v e r , or s a t i s f y the c u r i o s i t y t h a t leads to normal development and hea 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 that there are 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 hat 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 progr e s s i o n to the c r e a t i v e phase can be accomplished through the use of the nursing process. The nurse, while using the nursing process, can be c r e a t i v e i n planning nursing 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 . I l l . 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 are r e a l l y two parts to the assessment phase.; the nursing h i s t o r y or 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 den t i f y problems. There i s very often no prescribed h i s tory tool to insure that there i s information gathered in a l l necessary areas. Usually the amount of information obtained de-pends on what a pa r t i cu l a r nurse decides to ask the pat ient , and how busy she i s at the time. A doctor is often judged on his a b i l i t y to take a thorough and accurate medical h i s tory. You may say; how w i l l he know what medical problems the pat ient has unless he takes a medical h istory which i s thorough and accurate? The same thing applies to nursing, fo r i f the nurse does not c o l l e c t a thorough and accurate history in a systematic way, how can she possibly assess the pa t ien t ' s nursing needs. The answer then i s in the use of prescribed h i s tory tool based on a theoret ica l framework, when gathering data from the pat ient. This data base contains the information necessary from which patient problems are i d e n t i f i e d . The theoret ica l framework provides the d i rec t i on fo r the se lect ion of areas on which information i s gathered from the pat ient . The h i s tory tool used for th 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 tory tool developed by Dorothy Smith at the Univers i ty of F l o r i da , and the h istory tool that i s in use at the Surrey Memorial Hospital at the present time. When taking a nursing h istory inform the pat ient that the nursing h istory w i l l enable the nursing personnel to be of greater serv ice to him and obtain his permission. Once the h i s tory has been taken the problem l i s t can be com-p i l ed . This seems to imply that no further information w i l l be gathered once the i n i t i a l h i story has been taken, which of course i s not true as new information i s constantly being obtained and the problem l i s t a l tered 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 pat ient is able to meet a l l his basic human needs. I f he cannot meet one or more needs without ass istance, that const itutes a pat ient problem. The i d e n t i f i c a t i o n of patient 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 den t i f i ed problems and may miss problem areas. I t would be an impos s i b i l i t y to think that a nurse could i den t i f y a l l problems a pat ient 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 on there i s much less l i ke l i hood of missing major problem areas. Another problem that often occurs, when a systematic method of data co l l e c t i on i s not used, i s that problems i den t i f i ed are based so le ly on i n t u i t i o n and are not always communicated to the rest of the s t a f f , thereby severely r e s t r i c t i n g the assistance the pat ient 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 pat ient and/or his family to insure that the problems i d e n t i f i e d by the nurse are in agreement with the problems i d e n t i f i e d by the pat ient . 114 B. Planning Once the problems are i d e n t i f i e d and v e r i f i e d w i t h the 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 or d e r o f p r i o r i t y . R e a l i s t i c goals are 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 to 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 are 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 , or 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 the 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 or 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 h i s care as p o s s i b l e . This d e f i n i t e l y gives the nurse guidance i n t h a t the 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 heal t h team. While implementing the plan the nurse continues to 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 are 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 are recorded. D. E v a l u a t i n g The e v a l u a t i o n phase i s c a r r i e d out i n r e l a t i o n to the pre-determined goals that 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 (or to what extent) the needs o f the p a t i e n t are 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 hi s 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 infor 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 that e i t h e r the problem i s so 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 nursing 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 sep-a r a b l e , but flow together and c o n s t a n t l y overlap each other. You w i l l be provided with the o p p o r t u n i t y to use the nursing process and w i l l r e c e i v e information and guidance that w i l l enable you to meet the o b j e c t i v e s of the program. 

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