Making the Transition from LPN to RN

Making the Transition from LPNRN to Making the Transition from LPNRN to R O S E K E A R N E Y- N U N N E RY F. A...

Author: Rose Kearney-nunnery

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Making the Transition from

LPNRN to

Making the Transition from

LPNRN to

R O S E K E A R N E Y- N U N N E RY

F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2010 by F. A. Davis Company Publisher, Nursing: Lisa B. Deitch Director of Content Development: Darlene D. Pedersen Senior Project Editor: Padraic J. Maroney Design and Illustrations Manager: Carolyn O’Brien Cover Photo: Courtesy of Veer

Copyright © 2010 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Kearney-Nunnery, Rose. Making the transition from LPN to RN / Rose Kearney-Nunnery. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8036-2148-0 ISBN-10: 0-8036-2148-5 1. Nursing—Study and teaching (Continuing education) 2. Practical nurses—Education. 3. Career development. I. Title. [DNLM: 1. Nursing. 2. Career Mobility. 3. Education, Nursing, Baccalaureate. WY 16 K24m 2010] RT76.K43 2010 610.73076—dc22 2009010554 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-2148-5/10 0 + $.25.

To my late husband Jimmie E. Nunnery for his love, tolerance, and support to me and for the nursing profession

PREFACE Healthcare professionals are faced with new knowledge and challenges on a daily basis. We strive to focus on the needs of individuals and groups in our daily practices. Well educated and experienced nursing professionals are essential to address healthcare of clients with our focus on human beings in their unique environments with their individual healthcare needs that are addressed through nursing care. However, ongoing professional development is vitally important with our rapidly expanding knowledge base and the dynamic changes continually occurring in healthcare. In our respective nursing roles we strive to expand knowledge, become involved within the profession and in interdisciplinary practice, use evidence of effective practice and expanding technologies, and broaden the vision of profes¬sional practice. This book is directed to LPNs returning to school as students pursuing their degree and professional practice credentials. We also recognize that colleagues in your classes may be paramedics or other healthcare paraprofessionals similarly in transition for credentials for professional nursing practice. The intent is to challenge and assist you for professional practice. The professional concepts and topics presented build on your prior experiences in healthcare. The aim is to engage you intellectually in an ongoing professional dialogue and journey with your peers, colleagues, and instructors, broaden your path, and build on your preexisting knowledge and experiences. You, the LPN student or paramedic have valuable prior experiences and are challenged to delve further into professional education. The book is written for the adult learner with the characteristics of self-direction, prior experiences, applicability to practice, and motivation to meet the challenge to expand your knowledge base. The content is divided into three sections. Each chapter contains chapter objectives, key terms, and key points, chapter exercises to assist you in meeting the chapter objectives, references, bibliographical sources, and online resources. Interactive exercises are provided on an Intranet site to truly engage you in active application of the content. The book’s Intranet site also contains a glossary of terms, important Internet links, discussion sections, and bonus information as Web lessons in presentation graphics with interactive challenges and Web links as one of the interactive exercise for each chapter. You also can test your knowledge with a short game on some of the chapter content. In Section I, the concepts of professional nursing practice are introduced. This is the start of your career journey, the journey of a lifetime. In Chapter 1, you consider the multiple roles you will be negotiating. Returning to school is not an easy decision, and strategies for success in the student role are reviewed. Chapter 2 focuses on professional practice parameters and the characteristics of professional nursing as a profession. We focus on the challenge to demonstrate the core competencies for all healthcare professionals along with an opportunity to analyze your personal perspectives of transforming your role as a nurse. Chapter 3 introduces the theoretical basis for professional practice and reviews some of the borrowed and classic nursing theories used in professional practice. Section I concludes with a discussion of legal and ethical issues in professional practice and an introduction to the American Nurses Association Code of Ethics for Nurses in Chapter 4. These are the beginning tools you vii

will need as you pursue your education for professional nursing and expand your scope of practice. The demonstration of critical thinking, clinical judgment, and the use of the nursing process are covered in Section II. We consider both the dependent and the independent roles of the professional nurse. In Chapter 5, we look to refinement of communication skills and the skills of critical thinking necessary for implementation of the nursing process. In Chapter 6, we focus on the imperatives for client safety that require attention and diligence in the healthcare setting and within the nursing process. In addition to safety, health promotion and disease prevention are important considerations as we use this process unique to nurses. From a brief introduction to the nursing process in Chapter 6, we move to each step of the nursing process in the following chapters. Critical thinking is a necessary behavior. In Chapter 7, we focus on assessment. More than gathering data, now we focus on the analysis of objective and subjective data obtained from multiple sources in the health history and physical assessment activities that are prerequisites for working with the client in the development of a plan of care. The assessment process also requires a frame of reference and we will organize assessment data according to Gordon’s (2006) 11 functional health patterns. Once analysis of the initial data has occurred, we move to developing and prioritizing nursing diagnoses and a mutually agreeable plan of care for the client. In Chapter 8, Teresa S. Burckhalter takes a unique approach to developing nursing diagnoses in accordance with NANDA criteria. The focus is on both actual and risk diagnoses with the identification of the problem, the etiology, and in the case of actual diagnoses, the signs and symptoms. Another means for application of critical thinking skills is the use of concept maps that are described. Chapter 9 looks at clinical decision making and implementing the nursing process. Techniques along with the importance of client teaching are highlighted. Evaluation is vital to the success of a plan of care for a client. Section II concludes with a focus on outcomes. Evaluation of outcomes and revisions to a plan are a professional obligation. An important component of evaluation is leadership and professional practice standards. And finally, in Section III, we look to your continued professional journey and focus on basing your practice on evidence of efficacy and ongoing growth and planning for your future. Chapter 11 introduces you to the concept of evidence-based practice. The core competencies for all health professionals require that practice is based on current knowledge that is safe and effective. Tradition is no longer used to guide practice. Rather, practice must be based on new knowledge, critical reflection, and documented evidence. You are truly at a stage of transition in your career path. This transition is one of many as you chart your continuing journey in your professional career. Chapter 12 will help you plan for the future and for your ongoing professional and personal development. Leadership, collaboration, collegiality, and quality improvement are vital activities for the professional nurse to drive changes in the care of plan or to direct the plan of care in accordance with the wishes of the client/family. You have many choices and challenges in your future with transformative learning. Enjoy the journey and the new horizons in your future. Rose Kearney-Nunnery viii Preface

CONTRIBUTORS Teresa Burckhalter, MSN, RN, BC Nurse Educator Technical College of the Lowcountry Beaufort, South Carolina

ix

REVIEWERS Mope T. Adeola, MSN, CNS, OCN Clinical Assistant Professor Purdue University West Lafayette, Indiana Cynthia Anschutz, MSN, RN Nursing Educator North Central Kansas Technical College Hays, Kansas Marilyn Brady, PhD, RN Nursing Programs Department Head Trident Technical College Charleston, South Carolina Barbara Chamberlain, MSN, APN, C, CCRN, WCC Critical Care Advanced Practice Nurse Kennedy Health System Turnersville, New Jersey Michelle Cook, RN, MS Professor Mass Bay Community College Framingham, Massachusetts Kim Cooper, RN, MSN Nursing Department Chair Ivy Tech Community College Terre Haute, Indiana Irene Dunn, PhD, MSN, RN Professor El Paso Community College El Paso, Texas Marie Esch-Radtke, MS, RN Nursing Faculty Highline Community College Des Moines, Washington Julia M. Fine, RN, PhD, FNP-BC Associate Professor Indiana State University Terre Haute, Indiana Dori Gilman, RN, BS, MS Nursing Instructor/LPN Coordinator North Country Community College Saranac Lake, New York

Ruth Gladen, BSN, MS ASN Program Director North Dakota State College of Science Wahpeton, North Dakota Traci Hardell, RN, MN Instructor Salt Lake Community College Salt Lake City, Utah Karen Joiner, MS, ARNP LPN2RN Online Option Coordinator; Nursing Instructor Lower Columbia College Longview, Washington Diana Jones EdD, MS, RN Assistant Professor Slippery Rock University Slippery Rock, Pennsylvania Kathleen C. Jones, MSN, RN, CNS Associate Professor Walters State Community College Morristown, Tennessee Sandra Melton, PhD, APRN, BC Professor and Assistant Director Ventura College Ventura, California Georgia Moore, PhD, MSNed, RN-BC Consultant Louisville, Kentucky Seaneen Noonan, RN, MSN Assistant Director, RN Program Sacramento, California Irene Owens, MN, APRN Nursing Instructor Lake Sumter Community College Leesburg, Florida Linda Pasto, MS, RN, CN Professor Tompkins-Cortland Community College Dryden, New York

xi

Barbara Patterson, RN, MS, EdD Associate Dean, School of Nursing Southwestern Oklahoma State University Weatherford, Oklahoma

Patsy M. Spratling, MSN, RN, COSC Associate Degree Nursing Faculty Holmes Community College Ridgeland, Missouri

Thomas L. Petricini, RN, MSN Nursing Instructor Sharon Regional Health System Sharon, Pennsylvania

Thelma Stich, PhD, RN, LC Nursing Entrepreneur and Sole Proprietor StudentNurseTutor.com Staten Island, New York

Rebecca Reed, BSN, RN Coordinator Learning Resource Memorial Hospital School of Nursing Albany, New York Jeannette L. Sasmor, RNCe, MEd, EdD, FAAN Adjunct Faculty Rio Salado College Tempe, Arizona Alita K. Sellers, MSN, PhD, RN Professor West Virginia University at Parkersburg Parkersburg, West Virginia

xii Reviewers

Lisa Streeter, MS, RN Instructor St. Elizabeth College of Nursing Utica, New York

ACKNOWLEDGMENTS

Numerous people have been a large part of this process. Family members, friends, and colleagues have more than tolerated my preoccupation with the profession. My respect is extended to all my professional colleagues across the country for the opportunities they provided for reflection, discussion, and debate. My particular thanks is extended to my colleague, Teresa S. Burckhalter, who shared her expertise and insights in Chapter 8. Padraic Maroney merits particular credit for this project by his assistance and tolerance of the multiple electronic communications he received from me. And, my thanks to my late husband, Jimmie E. Nunnery, for his tolerance to my tireless dedication to the nursing profession. As a final note, I cannot describe the endless encouragement from my professional colleagues and friends, all of whom added to this challenge for continued enhancement of the profession and ongoing professional development. And to all students who strive to achieve the next step, my endless encouragement and enduring respect! Rose Kearney-Nunnery

xiii

CONTENTS Section 1 Beginning Your Journey 1 2 3 4

Multiple Roles Professional Practice Parameters Theory Ethics

Section 2 Clinical Judgement and the Nursing Process 5 Decisions and Approaches: Effective Communication Skills 6 The Imperative for Safe Nursing Care and Use of the Nursing Process 7 Assessment 8 Diagnosis and Planning Teresa S. Burckhalter, MSN, RN, BC 9 Implementation 10 Evaluation

Section 3 Concepts for Your Continuing Journey 11 Evidence-based Practice 12 Planning Your Future

Appendix:

1 1 3 15 28 44

59 61 78 94 109 127 147

161 162 178

191

A Dosage and Solution Review and Resources 191 B Nursing Diagnosis 198 C Nursing Interventions Classiﬁcation (NIC) and Nursing Outcomes Classiﬁcation (NOC) Systems 205 D Your Transition Plan 220 E Assessment Guidelines 222 F Bridges and Barriers to Communication— A Check Sheet 224 G Theories Used in Nursing 226 H Concept Mapping: A Tool 228

Index

59

161

229 xv

Section 1

Beginning Your Journey

I believe that we are solely responsible for our choices, and we have to accept the consequences of every deed, word and thought throughout our lifetimes. Elisabeth Kübler-Ross

I

n this initial section, the concepts of professional nursing practice are introduced. This is the start of your career journey, the journey of a lifetime. In Chapter 1, you consider the multiple roles you will be negotiating as you pursue your degree. Returning to school is not an easy decision, and strategies for success in the daunting process of returning to the student role are reviewed. Chapter 2 focuses on professional practice parameters and the characteristics of professional nursing as a profession. A focus on the core competencies for all healthcare professionals presents a challenge for both professional and interdisciplinary practice along with an opportunity to analyze your personal perspectives of transforming your role as a nurse. 1

Section 1

(continued)

Chapter 3 introduces the theoretical basis for professional practice and reviews some of the borrowed and classic nursing theories used in professional practice. Section I concludes with a discussion of legal and ethical issues in professional practice and an introduction to the American Nurses Association Code of Ethics for Nurses in Chapter 4. These are the beginning tools you will need as you pursue your education for professional nursing and expand your scope of practice.

2 Section 1 l Beginning Your Journey

CHAPTER 1

Multiple Roles CHAPTER OBJECTIVES After completing this chapter, you will be able to: 1. Evaluate your reasons for continuing your nursing education. 2. Examine the multiple and sometimes competing roles of the adult returning to school. 3. Evaluate your knowledge, skills, and abilities. 4. Identify your learning style and the strategies used to best address your individual learning preferences. 5. Evaluate your personal and collegial resources to assist with your success.

ongratulations! You have decided to actually take the next step in your nursing career by returning to school. It is not merely seeking your degree in nursing. This is a time to celebrate the talents you bring with you to your continuing knowledge development. It is a time for discovery, reflection, and professional development. As a licensed practical nurse (LPN), you may feel that you have been doing the same skills as a registered nurse (RN), but without the recognition of these skills. In some cases, you are. However, consider a dressing change or another patient activity. Have you thought about the client’s home environment and how this activity may be performed following discharge? Now is the opportunity to consider further learning and development to transform your career and enhance your knowledge base. Unlike a child in school, the adult learner brings a wealth of experience to the learning environment. The experiences may be good, bad, or indifferent but they occurred in a certain environment or context and have meaning to the individual. To understand this meaning requires careful examination of the situation.

C

Key Terms Transition Transformative learning Roles Learning Knowledge Skill Ability Learning style Resources

Chapter 1 l Multiple Roles 3

Reasons for Returning to School Consider the many reasons for returning to school. You may think the recognition for your work and pay differential are the primary reasons. These may be considerations but you are embarking on a journey of professional development that will further your knowledge, skills, and abilities compared with just a quick fix to a distressing situation. You will be facing change. Change is a daily occurrence in society. Think about the number of times you have heard of changes in political forces and healthcare organizations. And more people are beginning to embrace change since Johnson (2002) published his now classic Who Moved My Cheese? comparing the mice and the Littlepeople doing simple things that can either work or immobilize the situation when things change. Some people wait for things to return as experienced in the past, while others seek out new opportunities. Still, making change is not an easy process. Rather than focusing on change as a situation like moving to a new town, Bridges (2003) looks at the psychological processes in three phases of transition (Box 1–1) where people must “come to terms with the details of the new situation that the change brings about” (p. 3). These three phases of transition interact with one another and may occur at the same time, as seen through his model (see Fig. 1–1). In the initial phase of Bridges’ theory, people must first “let go” of the comfort and safety in their day-to-day lives and experience loss. Resistance is to be expected and Bridges (2003) defines this initial stage as an ending in that “before you can learn a new way of doing things, you must unlearn the old way” (p. 23). He describes a grief and mourning process requiring acceptance and assistance. Now that you have made the decision to return to school, make a list of your personal reasons for returning to school. Refer back to these reasons as you end the first stage of your nursing career. Seek out friends, colleagues, or your faculty advisor to assist you in making this transition. Congratulations! You are in phase one for your transition to professional practice and stepping into the uncertainty of phase two in your transition! Bridges (2003) describes the second stage, the Neutral Zone, as one of great uncertainty, chaos, and the opportunity for innovation. People have given up the old way of doing things but need support in innovation and assistance in the process. This will be your educational program of studies. Stressors that you will need to address while in this neutral zone will emerge not only in the educational setting, but also in your personal life and work environment. For example, gathering data is within the scope of practice of the LPN but assessment is in the RN’s scope of practice. You will be facing both roles: one as a LPN while at work and the other as a student in the classroom and clinical settings. To make the step into the second phase of your transition, look further into your reasons for returning to school. BOX 1–1 Bridges’ Stages for Do you want to know and do more in practice? Do you want to expand your scope of practice? You are an adult learner Managing Transitions with a specific and earned frame of reference but you also ✻ Ending, Losing, Letting Go want new information and the opportunity to experience a ✻ The Neutral Zone new challenge. ✻ The New Beginning The third stage is the New Beginning, described as a release of new energy in a new direction and with a new Source: Adapted from Bridges, W. (2003). Managing identity (Bridges, 2003, p. 57). This is your goal as an RN transitions: Making he most of change (2nd ed.). Cambridge, MA: DaCapo Press. for the transition to professional practice. 4 Section 1 l Beginning Your Journey

The Ending of the Old Way

The Beginning of the New Way Commitment, integration, action

Denial The Neutral Zone Bargaining, minimisation Anger, blame

Testing for purpose Transition Process Sadness, depression

Vision of the future

Acceptance, creativity

Figure 1–1 Bridges’ Three Phases of Transition. From Bridges, W. (2003). Managing transitions: Making the most of change (2nd ed.). Cambridge, MA: DaCapo Press, p. 5.

Mezirow (1991, 2000) views adult development and education as transformative learning and proposes that adults learn in one of four ways: ■ ■ ■ ■

By elaborating existing frames of reference. By learning new frames of reference. By transforming points of view. By transforming habits of mind (Mezirow, 2000, p. 19).

Building on your knowledge base and your personal frame of reference allows you to learn and add new perspectives. This process will further allow you, the adult learner, to transform your views in new ways and create new ways of approaching the world and nursing practice. Reflection and interpretation are necessary to understand your perceptions of self and the world. Armed with technical skills and practical experience from your LPN practice, you will chart a course into critical thinking and clinical judgment that embodies professional practice. As an adult learner, you will be facing competing roles and responsibilities in the process. Consider the multiple roles of the adult learner compared with the roles of the traditional high school graduate student. The traditional student, who often is economically supported, identifies an interest area or “major” and starts to attend classes at a college or university to focus on the development of his or her career. Engagement in the social environment is a major component with the traditional learner. Does this sound like you?

Competing Roles As an adult, you are already engaged in multiple roles. Roles are organized behavioral patterns and expectations for a given position and accompany a specific situation or circumstance (Bailey & Yost, 2004, p. 1). Now consider the multiple roles and positions in your unique circumstances. You are probably employed as an LPN. Providing nursing care has expectations in both the state law for practice and the job description at your place of employment. There is also the requirement of direction and supervision for LPN practice. In addition, there also are the less formal expectations of your supervisors and colleagues at work. Have you ever called your State Board of Nursing about a practice issue or asked a supervisor about the LPN scope of practice? How are your coworkers and supervisors reacting to your return to school? Consider the apparent and hidden behaviors. These will all have an impact on your progress. Align yourself with positive influences and try not to be drawn into negativity. Chapter 1 l Multiple Roles 5

You also are a member of a family. This family may be an extended family with intergenerational considerations, a single partnership situation, a single parent position, or even a member of a social or religious group. Your roles and responsibilities for caregiving occur by virtue of your membership in this unique group. You may be a parent, concerned about your child’s progress in elementary school or their involvement with a particular social group in high school. You may be living close to extended family members or be isolated by miles or situations. These are all considerations of your unique situation. Now that you have considered both your family and work-related roles and responsibilities, what about you? What are your deeply held wishes and desires—personal, careerrelated, and family inspired? This is where issues involving competition and conflict can occur. Think about the questions posed in Box 1–2 and add others that apply to your personal situation. These are all competing roles. You made the right decision to return to school. Now relax and prepare. Plan to streamline your life (work, school, and personal) and prepare for dealing with competing roles and responsibilities. You are charting your career path into professional practice. LEARNING AS EMPOWERMENT Learning is the perception and assimilation of the information presented to us in a variety of ways. Learning is knowledge and contains the following characteristics: ■ Perception of new information ■ Reaction to the information ■ Ability to recall or repeat the information

BOX 1–2

What Are Your Competing and Multiple Roles?

✻ Will your employer adjust your work schedule next semester for you to

be in clinical at school? ✻ How did your coworkers react when they found out you were taking this

course (CNAs, LPNs, RNs, others…)? ✻ What about the prerequisite courses for the nursing program, for example

statistics? ✻ What study materials do you have readily available? ✻ How are your computer skills? ✻ What are the expectations of your partner, family, or child(ren) for your

returning to school: high/low/none, supportive/nonsupportive? ✻ What are your expectations? ✻ How much time will be needed for each of your roles? ✻ Do you have resources for childcare? ✻ Did you apply for tuition assistance through your employer or at the

college? ✻ Do you have loans and are they worrisome? ✻ Do you have reliable transportation to get to work, classes, and clinicals? ✻ Did this course seem like a good plan at the time but now you are

having second thoughts? ✻ Others????


■ Understanding as rejection or acceptance of the information ■ Use of the information in a similar situation ■ Critical analysis of the information ■ Incorporation of the information into the value system ■ Use of the information in various situations and combinations An increasing complexity emerges here as the learner moves from receiving and recalling information through understanding, applying, analyzing, and evaluating the information to create new applications. There are three domains or categories of learning: affective, cognitive, and psychomotor. The affective domain includes attitudes, feelings, and values; for example, how you feel about returning to school. Your perception and value for the positive effects on your life will influence your progress. The cognitive domain involves knowledge and thought processes within an individual’s intellectual ability. This cognitive domain involves your understanding the information received about pathophysiology, practice parameters, and the other areas for knowledge acquisition. The psychomotor domain is probably the one you are most comfortable with and involves the processing and demonstration of behaviors, as with the performance of a skill like a dressing change. It is important to consider these three domains in your learning activities. Learning activities can be very different for the three domains, but continued learning is empowerment. Remember, to achieve a lasting change in an observed behavior (psychomotor domain), the value of that change (affective domain) and the intellectual capacity to understand and process the information for behavioral changes (cognitive domain) must first be present. What are some of your individual learning needs? YOUR TRANSITION Your learning needs and transition plans for professional practice should be designed specifically to your situation, knowledge, skills, and abilities. Knowledge is the accumulation of the appropriate information through learning and experience. Skill is the ability to retrieve this knowledge through mental and psychomotor activities and apply it appropriately to the situation. Ability is your competence and proficiency in the demonstration of the knowledge and skill. Your personal plan needs to address these factors for success in ® your RN program and on the NCLEX-RN . So what are the particular factors in your life? Look at your educational goals first. ■ What is your timeline? ■ Is it realistic? ■ What adjustments could be made? In order to answer these questions, think about your knowledge level. ■ What do you really know about the program and the commitments that will be needed? ■ What information have you received on the program or your status? ■ Have you even applied to a specific nursing program? Chapter 1 l Multiple Roles 7

Consider the information you have already received as well as the information you still need but were reluctant to ask. Once you have your timeline, consider the factors that will promote your success. First, consider the time required for the program. If you are employed, what adjustments to your schedule will need to be made? Some nursing programs require a certain number of courses arranged in a specific semester plan with classes, labs, clinicals, online activities, and library research. Speaking of online activities, how are your computer skills? Do you have computer access and do you know how to view presentation graphics and attach files to an e-mail? Have you completed some of the prerequisite work? Have you plotted other required courses into your timeline? What about joining a class of students as an advanced placement student? Consider the following example. You have been in the LPN role in practice and have been exempted from a class that just had content on evidenced-based practice in a specific area with which you are not familiar. How will you prepare to enter the course together with the other students? Will you review course syllabi and materials for the courses you exempted? Do you have resources for review? And how much do you really remember from your Practical Nursing Program, especially in areas in which you have not yet had a role, such as care of the family in a community setting? Are there particular areas that you want to do some enhancement work? And what “questionable” work habit will you need to discard? Your program may offer review or tutorial requirements to allow you to refresh certain content areas or to learn about new areas such as genetics and genomics that were not known at the time of your program. If review opportunities are available, take advantage of them and take them seriously. You may not be aware of all the Do Not Use abbreviations that may be listed in the practice setting to promote safety. Review and refreshment opportunities can add to your personal knowledge, skills, and abilities. Look further at your present job. Will the schedule permit you to stay in that job, perhaps on a reduced schedule? Will you need to find another job? How will your peers at work react to you once you are really progressing through the program? You may experience unanticipated reactions, including hostility. How will you deal with this? And how will you focus on the scope of practice and the differences at work versus in the student role? In addition, how will you allow yourself to be open to new ideas? Be sure to recall all of your critical thinking skills! Now, think about the costs. You may have considered the cost of tuition, books, and materials, but what about costs related to additional travel to clinical sites, time spent not working, childcare, and perhaps prepared meals? What other costs will be unique to your situation? Consider your family and significant others. What will their reactions and needs be with you in a RN program? What support systems are available and what further ones may be needed by you and family members? You need to consider educational commitments required during a semester and differentiate those from family activities that can become prominent during semester breaks. This may be the opportunity to have a “family” meeting to discuss the situation. Nurses often do not like to ask for help, but perhaps family members can be enlisted to take on some of the household chores. You may get to a point down the road when your son or daughter scolds you, telling you that you had better get your school work done in order to play! Your own health is also a consideration. How will you take care of your health? Remember, to effectively care for others, you must take good care of yourself. All of this requires prioritization of needs, roles, and activities, and especially time management skills. 8 Section 1 l Beginning Your Journey

ADDRESSING TIME MANAGEMENT Let’s look at your time management skills. Consider what you do well and what can be further developed. Identify your “time wasters” and your “time enhancers.” This will require much reflection on your part, as it is not a one-size-fits-all situation. You are unique as are your environment and the people around you. Someone once asked me how I had the time to do a particular activity. My first response was, “I make the time.” Then I added, “I get up an hour earlier because that time seems to work best.” On further reflection, I considered how I do something as simple as errands and shopping. I plan ahead, drive in one direction to complete required activities and then complete others on the return direction without the time waster of crossovers and specific traffic signals. It’s all about reflecting on the activity and planning ahead, as with a dressing change and having all the materials at hand and the time set aside. Remember, no one has yet figured out how to add more minutes to the day. So, within that 24-hour period, you must determine efficient use of time. Look at the factors identified in Box 1–3. You may have others you will want to add. Consider these factors to develop your roles and profile for effective time management, whether at work, at home, at school, or in the library. Be honest and realistic, but do not get lost in the details. YOUR LEARNING STYLE Learning styles and associated inventories have been discussed with varied research for more than 50 years in an attempt to improve teaching and learning outcomes (see Box 1–4 on the Myers-Briggs Inventory). The research and the discussion continue as we seek to better understand how individuals acquire meaning and knowledge. Increasingly we are concerned with the active involvement of the learner in the process, for learning to truly occur. Your learning style or preference is simply the way you best perceive, think, organize, use, and retain knowledge. To understand this concept, recall colleagues in the same learning environment and observe those who took a lot of notes, those who just listened, and those who made notes or drawings on what they interpreted the message in the lecture to be. Understanding the differences in learning styles can help teachers and learners make more informed decisions about which learning activities will be useful or productive to them as individuals and as members of learning groups or communities. BOX 1–3

Factors to Consider for Efficient Time Management

Family ✻ Meals ✻ Homework ✻ Laundry ✻ Relationships ✻ Social obligations Work ✻ Work schedule ✻ Hours and fatigue ✻ Coworkers and colleagues ✻ Practices to refine ✻ Scope of practice

School/College ✻ Costs ✻ Transportation ✻ Learning needs ✻ Course requirements ✻ Academic schedule and timeline Personal ✻ Health and fitness ✻ Hope and aspirations ✻ Spirituality ✻ Knowledge, skills, and abilities ✻ Individual needs


BOX 1–4

Myers-Briggs Inventory

The Myers-Briggs Inventory was developed and has been widely used in education and business applications for learning styles with the use of four scales to identify 16 personality types that can be further classified for learning preferences: ✻ Introversion–Extroversion ✻ Sensing–Intuition ✻ Thinking–Feeling ✻ Judging–Perceptive

The main types of learning styles look at preferences for: ■ Visual learning (reading or watching). ■ Auditory (listening or talking). ■ Kinesthetic (doing or participating).

For example, some learners are highly visual in the way they perceive information and derive meaning. For these learners, structured lectures with few visual aids is a less desirable learning environment than one enhanced by visual aids. Others learn better through the written word, either by reading or note taking. Learners who are highly auditory in their learning preference derive greater meaning from just listening to the information. One of the exercises at the end of this chapter is the identification of your particular learning style. The learning environment for health professionals has changed. The explosion of knowledge that continues on a daily basis no longer allows for the memorization of discrete facts. Health professionals must understand the underlying concepts, discover new information, reflect on applications, and apply relevant knowledge to their situation. Reflection and critical thinking is an important part of this process. The learner is now active in the process, no longer focusing on the teacher as the “Sage on the Stage.” The teacher is now the facilitator of learning rather than the talking head. You, as the learner, are the active one, seeing how information fits with facts and perceptions. Recall that with Mezirow’s (2000) transformative learning, the adult learns by elaborating existing frames of reference, learning new frames of reference, transforming points of view, or transforming habits of their mind (p. 19). By building on your knowledge base and your personal frame of reference, you will be adding and learning new perspectives. This process will further allow you as the adult learner to transform your views in new ways, and create new ways of approaching the world and nursing practice.


Learning occurs through reflection and interpretation to understand perceptions of the self and the world. But you also need to identify and organize your resources. GARNERING RESOURCES Consider the resources that you will need to assist you as a student. Perhaps the initial things that come to mind are books, a stethoscope, a uniform, and car repairs to get to class. However, you should look beyond supplies and reliable transportation. Resources are tools or means of support. Consider those things and people that you will need to help you study, prepare assignments, succeed on examinations, and thrive in your education. Studying Once you understand your learning style, you can look to the resources needed to capitalize on your assets. Remember, once you know your style, you will still be in a group with individuals who may use varying styles. If you learn best through participation in discussions, you may want to find a compatible study group. But a word of caution: study groups are not for everyone and can be time wasters if the group is not focused, compatible, and committed to ground rules when preparing for the topic prior to the meeting. In addition, some individuals are more solitary and need to think about something for a while and work it out in their frame of reference before being put on the spot in a discussion. Your environment is another area you need to carefully consider, as to where you best think and concentrate. Do you need a quiet environment or background music? Think about what helps you to understand information and see relationships. Do you have a favorite place in the house without excessive distractions? Again, you must determine your best environment to concentrate and be open to new information. Preparing Assignments This is an area feared by many returning students, as they face a blank piece of paper or computer screen with only a blinking cursor. First, write or type the expectation. It may help to see it in your own writing or viewing it isolated from the distraction of other course expectations and grading criteria. Make sure you have sufficient access to a reliable and accessible computer for word processing, electronic mail, the Internet, and presentation graphics. This does not mean competing with your spouse or children for time online! Locate the dictionary tool in the word processor and make sure you have the spelling and grammar checking tools activated to assist you in the composition process. You also will need to become comfortable with publication style required by your school or instructor. One popular style is by the American Psychological Association (2009), which you may be required to use as a resource. These basic tools and your development of skill in these areas will assist you as you address the requirements of an assignment, whether a case study or scholarly paper. You CAN do it. Another valuable resource is your college librarian, who can help you effectively search for materials, access databases, and provide you with interlibrary loan materials. They can even assist you with accessing the library remotely over the Internet, which may help with your time management and diminish travel time to the library. But use all your time management skills when searching online to avoid the distractions and volume of information you can get lost in. Sooner or later in your program of study you will have a group assignment where the group earns the grade, not individuals. This type of activity can be a wonderful team experience or a disaster with a noncooperative member. Peer pressure and, if this is not


effective, consultation with your instructor is warranted. Remember, teams are an important part of healthcare and we need to continually refine our skills in this area. Taking Examinations The thought of taking tests is one of the most threatening to the adult learner. Stress management and deep breathing may help. Some of the most important considerations are adequate rest and being confident in your preparation and understanding of the content. Understanding of the information is critical, especially because test questions in nursing focus on critical thinking and rarely involve the simple recall of isolated facts. So, once again, unlike simple memorization of facts such as the bones and muscles of the leg, more complexity is added for application of this information to a client situation. Grades also are an issue to the adult learner. Remember, a grading scale is just that: a scale that varies. There are certain acceptable numbers on your bathroom scale, just as there should be acceptable numbers or letters for a grading scale. There will be times when you excel and others when you succeed but do not achieve the “A.” That’s okay. Give yourself permission to be human and not always receive the top grade in the course. Understanding, retention, and application of knowledge are the more important considerations. Thriving One of the most important actions you can take as you pursue your nursing degree is to thrive on the acquisition of your new knowledge, skills, and abilities. Lifelong learning is a component of professional nursing. From your LPN practice, armed with technical skills and experience in the practice setting, we chart a course into critical thinking and clinical judgment that embody professional practice. You have taken the first step in your ongoing learning. Enjoy the journey each step of the way.

KEY POINTS • In the process of change, Bridges (2003) looks at the psychological processes in three phases of transition during which people must “come to terms with the details of the new situation that the change brings about” (p. 3). 12 Section 1 l Beginning Your Journey

• Mezirow (1991, 2000) views adult development and education as

•

• • • • • •

transformative learning and proposes that adults learn in one of four ways: ➡ By elaborating existing frames of reference. ➡ By learning new frames of reference. ➡ By transforming points of view. ➡ By transforming habits of mind (Mezirow, 2000, p. 19). Roles are organized behavioral patterns and expectations for a given position and accompany a specific situation or circumstance (Bailey & Yost, 2004, p. 1). Learning is the perception and assimilation of the information presented to us in a variety of ways. Knowledge is the accumulation of the appropriate information through learning and experience. Skill is the ability to retrieve this knowledge through mental and psychomotor activities and apply it appropriately to the situation. Ability is your competence and proficiency in the demonstration of the knowledge and skill. Learning style or preference is simply the way you best perceive, think, organize, use, and retain knowledge. Resources are tools or means of support. For your educational goals, consider those things and people that you will need to help you study, prepare assignments, succeed on examinations, and thrive in your education.

THOUGHT AND DISCUSSION QUESTIONS: Interactive Exercises

1. Reflect carefully and identify your reasons for continuing your nursing education. 2. Identify all your current roles. Which ones can be streamlined? 3. In a three-column format, identify what you perceive to be your knowledge level and your associated skills and abilities in the following areas: • Medical-surgical nursing • Maternal-child health • Gerontological nursing • Mental-health nursing 4. What resources can you classify as readily available, sometimes available, or in need of locating? Go to the Intranet site to complete the interactive exercises provided for this chapter.


REFERENCES American Psychological Association. (2009). Publication manual of the American Psychological Association (5th ed.). Washington, DC: Author. Bailey, J. R., & Yost, J. H. (2004). Role Theory: Foundations, Extensions, and Applications. BookRags. Retrieved November 24, 2006 from, http://www.bookrags.com/other/sociology/role-theory-foundations-extensions— eos-04.html Bridges, W. (2003). Managing transitions: Making the most of change (2nd ed.). Cambridge, MA: DaCapo Press. Johnson, S. (2002). Who moved my cheese? New York: G.P. Putnam’s Sons. Mezirow, J. (1991). Transformative dimensions of adult learning. San Francisco: Jossey-Bass. Mezirow, J. (2000). Learning to think like an adult: Core concepts of transformation theory. In J. Mezirow and Associates, Learning as transformation: Critical perspectives on a theory in progress (pp. 3–33). San Francisco: Jossey-Bass.

ONLINE RESOURCES American Nurses Association: http://nursingworld.org/nursecareer/ Allnurses.com: http://allnurses.com/ National League for Nursing: http://www.nln.org/Careers/resources.htm


CHAPTER 2

Professional Practice Parameters CHAPTER OBJECTIVES After completing this chapter, you will be able to: 1. Identify the components of professional nursing practice. 2. Examine the scope of practice for licensed nurses in a state’s rules and regulations. 3. Relate the core competencies for health professionals to professional nursing practice. 4. Describe clients of professional nursing practice. 5. Discuss responsibility and accountability in professional nursing practice.

s a licensed practical nurse (LPN) pursuing a degree in nursing, it is time to analyze the different scopes of practice, for both the LPN and the RN. In today’s practice environment, that may seem somewhat vague. But look further. You are at the gateway for professional nursing practice. To advance in your career, you must broaden and build on your knowledge base. You will be actively involved in thinking and acting in new ways. How exciting! From your LPN practice, armed with technical skills and experience in the practice setting, you will chart a course into critical thinking and clinical judgment that embody professional practice. As a start, consider the characteristics of a profession.

A

Characteristics of a Profession When we think about a profession, we envision a unique career. This career is built on a distinct knowledge base and guided by systematic theory with the authority to provide a distinct service. In addition, this distinct service is provided in an ethical manner with prescribed standards of practice. A profession is guided by systematic theory, on which its knowledge base is built. The use of theory includes theories specific to the nursing discipline as well as those theories adapted from other scientific disciplines. We will look further at theories applicable to nursing in the next chapter when we consider the four metaparadigm

Key Terms Profession Parameter Licensure Continuing competency Nursing education Code of ethics Professional culture Core competecies Autonomy Responsibility Accountability Self-regulation Community service Theory use, development, and evaluation Evidencebased practice

Chapter 2 l Professional Practice Parameters 15

concepts of nursing—human beings, the environment, health, and nursing. But, more about those concepts later. Another requirement for a profession is authority. Yes, clients see nurses as authority figures not simply because they are providing care or information, but also because they have the knowledge and skill to make professional judgments. Clients who see nurses as experts in providing needed healthcare view the profession as having more authority in healthcare judgments. On the basis of this perception of authority, society grants the profession and its practitioners certain rights, privileges, and responsibilities within an authorized scope of practice. The professional community is responsible for ensuring safe and effective practice within the discipline. Professional and legal regulation of nursing practice occurs through statutes, rules and regulations, definition of practice, and expectations for practitioners. Powers for entry and continuity in the profession are granted through licensure with practice parameters dictated in the state practice acts. These laws define a specific practice and provide regulatory powers at the state level for the board, licensing of professionals and protection of title, general practice standards, approvals for educational programs, and disciplinary procedures. Look further at some components of professional practice.

Practice Parameters A parameter is a boundary or limit. In professional practice, these parameters prescribe the boundaries of practice within specified areas and limits. At times, these limits seem vague with many professionals performing a similar task, such as taking a blood pressure. However, the parameters or practice limits are defined more specifically to the profession. Each state and several U.S. territories have laws that regulate practice for licensed practical/vocational nurses (LPNs/LVNs), registered nurses (RNs), and advanced practice nurses (APRNs). Included in these laws is the empowerment of the Board of Nursing or the Board of Nurse Examiners. Four states (California, Georgia, Louisiana, and West Virginia) have separate boards of nursing for LPN and RN practice, and some states (Nebraska) have separate boards of nursing for nursing (LPN and RN practice) and advanced practice nursing (APRN).


These boards license or authorize nursing practice. Boards of nursing may further regulate unlicensed assistive personnel (UAPs) through regulations for registry, certification, or even licensure. Within regulation, licensure is the most rigorous form, followed by certification through another recognized entity, and then registry, to register practice in alignment with specified requirements. But what does licensure really mean? When you completed your practical or vocational nursing program, you were approved to take the National Council Licensing Examination (NCLEX) for Practical Nursing (NCLEX-PN®) as a demonstration of minimal competence to enter practice. The NCLEX-PN® test plan and associated content is based on current job analysis studies and is an entry level examination. Your success in this computer adaptive testing environment allowed you to be licensed as an LPN or LVN. But, haven’t you come a long way since your first day in practice? Benner (1984) has described the following five levels of competency in clinical nursing practice for the RN: novice, advanced beginner, competent, proficient, and expert (p. xvii). The novice is new to practice. However, as experience with clinical judgment and decisions increase, the professional is expected to become a competent, proficient, and an expert care provider. Along this continuum, the expert has an enormous background and has an intuitive grasp of each unique patient care situation as they are encountered (Benner, 1984). For the higher the levels of competence or expertise clients perceive in any profession, the greater trust or authority they place in the practitioners of that profession. Clients who see nurses as experts in providing needed healthcare view the profession as having more authority in healthcare judgments. On the basis of this perception of authority, society grants the profession and its practitioners certain rights, privileges, and responsibilities. This includes licensure. Licensure is the authority granted by the state board to practice within specified parameters after meeting specified requirements. Professional nursing practice as a RN has a similar testing environment but a different test plan. The RN test plan and the associated content is based on current professional job analysis studies and also is a psychometrically sound and legally defensible examination. This examination (NCLEX-RN®) will be your challenge for entry into professional nursing upon successful completion of your current studies. Consider some of the differences in the NCLEX-PN® and the NCLEX-RN®. Although both licensure examinations are built around clients’ needs in the areas of a safe and effective environment, health promotion and maintenance, psychological integrity and physiological integrity, the percentages of test questions vary for the different areas, based on the results of current practice responsibilities and current job analyses studies. One of the most important differences is in the area of safe and effective care. The NCLEX-PN® focuses on coordinated care and the NCLEX-RN® focuses on management of clients in all settings. This important difference will be the focus of your continued education for professional nursing. Although the state laws must be appropriate for the requirements and language in that state, the laws generally contain similar requirements, especially related to scope of practice. All 50 states and four U.S. territories are members of the National Council of State Boards of Nursing (NCSBN) whose mission is to provide leadership to advance regulatory excellence for public protection (NCSBN, 2007). As part of the resources for the member boards, NCSBN provides a model act and model rules to promote best practices and


consistency among states. These models provide guidance for language in the state laws. Consider some of the practice parameters in these models illustrated in Table 2–1 for the three different scopes of practice. Remember, states do differ. Some have differing requirements for demonstration of continued competence for relicensure. Other states may officially recognize APRNs whereas others may require a separate license for APRN practice. Commonalities exist for all three scopes of practice; for example, being a client advocate. However, there also are limitations, such as supervision, delegation, and assessment.

TABLE 2–1

NCSBN Model Practice Act and Regulations on Scope of Nursing Practice

Licensed Practical/ Vocational Nurse (LPN/LVN) A directed scope of nursing practice under the direction of the RN, APRN, licensed physician, or other healthcare provider authorized by the state. Practice is guided by nursing standards established or recognized by the board and includes participation in the components of the nursing process, especially for patients/clients with stable conditions.

Registered Nurse (RN) A full scope of nursing and caring for all clients in all settings including providing comprehensive and extensive nursing care for clients, including collaborating with healthcare team to develop and provide an integrated client-centered healthcare plan. This includes acquiring and applying critical new knowledge and technologies and management and supervision of the practice of nursing.

Advanced Practice Registered Nurse (APRN) An advanced scope of practice by nurse practitioners, nurse anesthetists, nurse midwives, or clinical nurse specialists based on knowledge and skills acquired in basic nursing education, graduation/ completion of a graduate level APRN program with national accreditation, and current national certification acceptable to the board for the APRN role and specialty. APRN practice supersedes that of the RN and includes performing acts of advanced assessment, diagnosing, prescribing, selecting, administering and dispensing therapeutic measures, including drugs and controlled substances.

Source: National Council of State Boards of Nursing. (2008). Model nursing act and rules. Retrieved on May 8, 2008 from, https://www.ncsbn.org/Model_Nursing_Act_and_Rules_Full.pdf


Much debate has surrounded the issue of assessment, with the LPN performing a focused assessment and the RN responsible for the comprehensive assessment. Yes, as a LPN, you are actively involved in data collection and contributing to a client-centered plan of care. But recall, LPN practice is under the direction of a RN, APRN, licensed physician, or other authorized healthcare provider. The RN is involved in dependent and independent decisions in the client’s care. Refer to Table 2–2 on the NCSBN positions on different forms of assessment. The regulations associated with each State Practice Act explain the implementation of the law and provide further information on standards of nursing practice. For example, consider the additional standards of practice specified by the NCSBN Model Rules for the RN in client assessment listed in Box 2–1. Scope of practice in this area is a matter of depth, breadth, analysis and synthesis of information, and taking the appropriate action. Critical thinking and clinical judgment are vital activities in RN practice, as we will investigate further in Chapter 6. The profession is regulated through licensure to enter the profession as well as for continuing competency requirements for ongoing practice. This assessment of continuing competence may require continuing education, ongoing documentation of safe practice, certification, or periodic assessment. The charge of each state board of nursing is to protect the health and safety of the clients of nursing. The licensing authority focuses on safe provision of nursing care to the public. This safety is easily tested on entry into practice but becomes more complex with continuing competency, which requires involvement of both the professional and his or her supervisor. An important component also is an effective peer review process so the RN can continue to develop along that novice-to-expert continuum. In addition to state licensure for nursing practice, some states participate in the mutual recognition model for licensure and are part of the Nursing Licensure Compact (NLC). If a state board of nursing is a member of the NLC, specific language is included in the practice act. This regulatory language allows licensure in the state of residence and practice privileges in remote states that also are members of the NLC. The NLC operates on the same concept as getting a driver’s license. You meet specified requirements and are given a license in your home state. However, just as with a driver’s license and driving

TABLE 2–2

NCSBN Differentiation, Focused, and Comprehensive Nursing Assessments

LPN/VN Role: Focused Nursing Assessment A focused assessment is an appraisal of an individual’s status and situation at hand, contributing to comprehensive assessment by the registered nurse, supporting ongoing data collection, and deciding who needs to be informed of the information and when to inform.

RN Role: Comprehensive Assessment Providing comprehensive and extensive nursing assessment of the health status of clients, recognizing alterations to previous client conditions, synthesizing information on the client’s condition; evaluating the impact of nursing care, making independent decisions and nursing diagnoses, planning nursing interventions and evaluating the need for different interventions, and the need to communicate or consult other health team members.

Source: National Council of State Boards of Nursing. (2008). Model nursing act and rules. Retrieved on May 8, 2008 from, https://www.ncsbn.org/Model_Nursing_Act_and_Rules_Full.pdf


BOX 2–1

NCSBN Standards of Practice for the RN in Client Assessment

The Registered Nurse ✻ Conducts a comprehensive nursing assessment that is an extensive data collection (initial and ongoing) regarding individuals, families, groups, and communities. ✻ Detects faulty or missing patient/client information. ✻ Applies nursing knowledge effectively in the synthesis of the biological, psychological, social and cultural aspects of the client’s condition. ✻ Uses this broad and complete analysis to plan strategies of nursing care and nursing interventions that are integrated within the client’s overall healthcare plan. ✻ Provides appropriate decision-making, critical thinking and clinical judgment to make independent nursing decisions and nursing diagnoses. ✻ Seeks clarification of orders when needed. ✻ Implements treatments and therapy, including medication administration, delegated medical and independent nursing functions. ✻ Obtains orientation/training for competence when encountering new equipment and technology or unfamiliar care situations. ✻ Demonstrates attentiveness and provides client surveillance and monitoring. ✻ Identifies changes in client’s health status and comprehends clinical implications of client signs, symptoms and changes, as part of expected and unexpected client course or emergent situations. ✻ Evaluates the impact of nursing care, the client’s response to therapy, the need for alternative interventions, and the need to communicate and consult with other health team members. ✻ Documents nursing care. ✻ Intervenes on behalf of client when problems are identified and revises care plan as needed. ✻ Recognizes client characteristics that may affect the client’s health status. ✻ Takes preventive measures to protect client, others and self.

according to the laws of the state, when you practice in another state as part of the NLC, you must know the laws of that state and practice accordingly. STANDARDS OF PRACTICE Definition of practice and specific practice standards are further specified within the professional community through major nursing associations. The American Nurses Association (ANA) has specified a variety of practice standards for the profession, both general and specific to certain practice areas. The ANA has prepared several specialty standards documents jointly with the particular specialty organization to reflect the expectations for specialized professional practice. The publication Nursing: Scope and Standards of Practice (ANA, 2004), prescribes general standards of care and standards of professional performance for all RNs. Standards of care address safe practice and use of the nursing process with the actions of assessment, diagnosis, outcome identification, planning, implementation, and evaluation (ANA, 2004). Standards of professional performance are expected professional roles and behaviors, 20 Section 1 l Beginning Your Journey

including quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, resource utilization, and leadership (ANA, 2004, p. 3). Practice standards and expectations also have been developed by selected specialty organizations and are included in the certification process, as a credential attesting to a level of competency in a selected area. PROFESSIONAL EDUCATION Another area in which the community grants a profession certain privileges on the basis of professional knowledge is with the education process. Formal educational settings for professional nursing occur in institutions of higher learning with liberal and specialized learning requirements. Educational programs are both approved at the individual state level, as by the Board of Nursing, and are accredited at the national level by the National League for Nursing Accrediting Commission (NLNAC) and the Commission on Collegiate Nursing Education (CCNE). Development, implementation, and evaluation of the organization, curriculum, faculty, students, graduates, facilities, and program resources are important considerations within the accreditation and reaccreditation process and focus on excellence and ongoing improvement in the educational process. The educational background required for professional practice is specified to ensure safe and effective practice. In nursing education, the basic education required for the RN varies, with differences among baccalaureate, associate degree, diploma education, and entry-level graduate programs. Baccalaureate programs are 4 to 5 years in duration and include courses in arts and sciences that complement the professional component of the major. Associate degree programs in nursing are generally offered through community colleges and are usually 2-year programs with arts and sciences courses that may be taken part-time, thus extending the 2-year time frame. Diploma nursing programs are available in various states and are usually 3 years in duration and associated with hospitals and postsecondary institutions. As a LPN, you will probably be entering one of these programs as an advanced placement student in recognition of your prior education and experience in healthcare. But within each type of educational program, curricula and requirements are guided by general standards. Nursing curricula must contain essential content and academic credit required by state boards of nursing, higher education boards, professional associations, and national accrediting bodies. Consumers of nursing care can be confused by the different educational routes leading to the title of registered nurse. The Pew Health Professions Commission (1995) critically reviewed the various health professions and recognized the value of multiple entry points to professional nursing practice but recommended the differentiation of practice and encouraged strengthened career ladder programs (p. 34). The concept of a career ladder places value on continuing your education and the acquisition of additional knowledge, abilities, and skill sets to provide appropriate and acceptable client-centered care. CODE OF ETHICS The conduct of one’s practice in an ethical manner is another requirement for a profession, including careful adherence to client confidentiality. The ANA’s Code of Ethics for Nurses is the ethical standard for professional nursing practice. As the ANA states, the “code makes explicit the primary goals, values, and obligations of the profession” through nine “nonnegotiable” provisions (ANA, 2001, p. 5). We will look at the Code of Ethics for Nurses in more detail in Chapter 4. Chapter 2 l Professional Practice Parameters 21

OUR CULTURE Another characteristic of professional community is our unique professional culture. This culture includes our professional groups and associations that guide practice, education, and sharing of mutual values. These professional organizations or associations do vary in purpose or mission and membership. The purpose of some professional organizations, such as the ANA, is to represent the profession on a national basis. Specialty groups, with a more specific focus, promote education, skills, standards, and perhaps certification opportunities for a particular segment of the profession, for exam ple, the American Association of Critical Care Nurses. Each organization has a unique philosophy or mission directed at professional nursing practice. These organizations communicate values and norms in official publications, position statements, and specified practice standards. They provide educational opportunities and foster expansion of our knowledge base. Consider three of the organizations that represent professional nursing practice and education listed in Table 2–3. ANA and its state and territorial associations focus mainly on the profession as an entity, with concern for the health of society as well as the welfare of professional nurses through standards, official position statements, political action initiatives, and certification options for specialty practice. The National League for Nursing (NLN) has initiatives related to excellence in nursing education and accreditation of nursing education programs. Whereas, the National Council of State Boards of Nursing is composed of the regulatory boards for the 50 states, the District of Columbia,

TABLE 2–3

The Focus of Selected Professional Organizations

Organization American Nurses Association (ANA) and associated constituent state associations and organizational affiliate members Founded 1897 http://www.nursingworld.org

National Council of State Boards of Nursing (NCSBN) Founded 1978 (previously a component of ANA) http://www.ncsbn.org National League for Nursing (NLN) and associated constituent leagues Founded 1952 http://www.nln.org

Focus, Mission, & Membership Focus: Professional nursing Mission: “. . . Advances the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on healthcare issues affecting nurses and the public” (ANA, 2007, p. 1). Membership: Individual professional nurse membership Focus: Nursing regulation and public protection Mission: “. . . Composed of Member Boards, provides leadership to advance regulatory excellence for public protection” (NCSBN, 2007, p. 1). Membership: All state boards of nursing in the 50 states, the District of Columbia, and four U.S. territories Focus: Nursing education Mission: “. . . Advances excellence in nursing education that prepares the nursing workforce to meet the needs of diverse populations in an ever-changing healthcare environment” (NLN, 2007, p. 1). Membership: Individual and agency (diploma programs, associate degree programs, baccalaureate and higher degree programs) membership

Note: Reference citations in table are excerpts from online resources of the respective nursing organizations.


and the U.S. territories and provides the NCLEX licensing examinations for its member boards.

Core Competencies Recent reports from the Institute of Medicine (IOM) on quality initiatives for healthcare called for changes in education of health professionals. In 2003, the IOM identified five core competencies (Box 2–2) for all health professionals with the vision that “all health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics” (Greiner & Knebel, 2003, p. 45). Now you are probably thinking that providing patient-centered care is a constant in your practice. However, think about it. ■ Are you really working as part of an interdisciplinary team or are you working under the direction of another healthcare provider? Working as part of an interdisciplinary team involves collaboration and collegiality, which we will focus on further in Chapter 12. ■ Are you using evidence-based practice or traditional BOX 2–2 Core Competencies practice? The use of evidence-based practice is critfor Health ical to current practice and Chapter 11 will emphaProfessionals size this professional requirement. ■ How are you using quality improvement focused on ✻ Provide patient-centered care client outcomes? Critical thinking skills and evalua✻ Work in interdisciplinary teams tion activities as part of the nursing process lead to ✻ Employ evidence-based practice this function of the healthcare professional. ✻ Apply quality improvement ■ How are you using informatics beyond ordering, ✻ Utilize informatics checking lab values, giving medications, and documenting? The electronic health record and technolData from Greiner, A. C., & Knebel, E. (Eds.). ogy are tools that are in constant refinement and Source: (2003). Health professions education: A bridge to quality. Washington, DC: Institute of Medicine. provide enhanced tools for quality healthcare.


This is your opportunity to consider the differences in the various scopes of practice and critically examine your current role and future possibilities. What is your responsibility and accountability? Autonomy, Responsibility, and Self-Regulation Autonomy involves independent judgment and self-governing within the scope of the RN’s practice. However, clinical judgment is dynamic in response to people’s healthcare needs. Autonomy is not a part of the LPN scope of practice. Recall that LPN practice is a directed scope of nursing practice under the direction of the RN, APRN, licensed physician, or other healthcare provider authorized by the state. RNs must make the time and commitment to ensure that high-quality care and standards are present and upheld. This involves critical thinking, communication, collaboration, clinical judgment, and leadership. Important concepts in this area are professional responsibility and accountability. In the Code of Ethics for Nurses, responsibility is defined as accountability for performance of the duties associated with the professional role, and accountability as being answerable to oneself and others for one’s judgments and actions in the course of nursing practice, irrespective of healthcare organizations’ policies or providers’ directives (ANA, 2001, pp. 16–17). Nurses are accountable both to themselves and their clients for good clinical judgment and clinical care. There is that word judgment again. In RN practice, judgment is more than decision making. It requires critical reflection, analysis, and evaluation of a situation that is dynamic and multifaceted. The ANA’s Nursing’s Social Policy Statement (2003) describes self-regulation as both personal accountability for the knowledge base for practice and participation in the peer review process (p. 11). Professional responsibility and accountability involve upholding quality standards as well as developing and critically analyzing those standards and the outcomes. Professionals are responsible and answerable to clients for nursing care outcomes. RNs are actively involved in supervising, delegating, and evaluating others with the skills of critical thinking, clinical judgment, expertise, and advocacy beyond a narrowly defined job description, institutional procedure manuals, or additional on-the-job training. The regulation of nursing practice includes self-regulation expected of the professional as well as professional regulation through the defined scope of practice, further education, certification, and adherence to the code of ethics. An important component is the peer review process and a commitment to continued competency as an ongoing quest for best practices and expertise. Additional Components of Professionalism Community service is another characteristic of professionalism in nursing. RNs are orientated to service to clients, the community, and society at large. They frequently lead health-promoting activities in their employment role, their professional community, and among their families and acquaintances. They reach out to others with information on health or means to foster wellness in their communities. Although all professions have systematic theory and knowledge on which to base their practice, another characteristic of professionalism in nursing involves theory use, development, and evaluation. Theory is essential to guiding the practice and research of a profession. Nursing, as an evolving and dynamic profession, demands that its professionals develop, refine, and evaluate theory. We not only use theory but also are constantly involved in critical analysis of the theory as clients, healthcare, and environments change.


We are consistently expanding and refining our knowledge base. The challenge is to collect, analyze, and report data on efficacy related to trends in clients’ outcomes. These trends provide information that expands and refines the profession’s knowledge base. The need for data collection and analysis leads to research and a focus on outcomes and documented efficacy. Recall that one of the core competencies for health professionals is the use of evidencebased practice. Greiner and Knebel (2003) define evidence-based practice as the integration of the best research with clinical expertise and the client’s values for optimum care as well as participation in learning and research activities (pp. 45–46). In addition, one of the interpretative statements of the Code for Ethics for Nurses states, “all nurses working alone or in collaboration with others can participate in the advancement of the profession through the development, evaluation, and application of knowledge in practice” (ANA, 2001, p. 23). The use of evidence-based practice and awareness of research and the current documented evidence adds to our knowledge base, enhances our practice, promotes improved outcomes for our clients, and fosters practice based on evidence of efficacy rather than tradition or trial and error. Fulfilling the characteristics described as the professional parameters of the RN is the challenge of professionalism in nursing. Professionalism is an attribute in constant refinement. Consider the following six essential features of professional nursing identified in the ANA’s Nursing’s Social Policy Statement (2003): ■ Provision of a caring relationship that facilitates health and healing. ■ Attention to the range of human experiences and responses to health and illness within the physical and social environments. ■ Integration of objective data with knowledge gained from an appreciation of the patient or group’s subjective experience. ■ Application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking. ■ Advancement of professional nursing knowledge through scholarly inquiry. ■ Influence on social and public policy to promote social justice (p. 5). Along with these criteria are interwoven ethical principles, standards of practice, and professional performance expectations. Just imagine how your nursing practice will be enhanced by your ongoing quest for knowledge and refinement of your professional identity.

KEY POINTS • A profession is built on a distinct knowledge base and guided by systematic theory with the authority to provide a distinct service in an ethical manner with prescribed standards of practice. • A practice parameter prescribes the boundaries of practice within specified areas and limits.


• Licensure is the authority granted by the state board to practice within •

• • •

•

•

•

•

specified parameters after meeting specified requirement. The basic education required for a RN varies, with differences among baccalaureate, associate degree, diploma education, and even some entry-level graduate programs. Continued competency as an ongoing quest for best practices and expertise. The ANA’s Code of Ethics for Nurses is the ethical standard for professional nursing practice. Another characteristic of professional community is our unique culture that includes our professional groups and associations that guide practice, education, and sharing of mutual values. The five competencies for health professionals are: providing patientcentered care, working in interdisciplinary teams, employing evidencebased practice, applying quality improvement, and using informatics (Greiner and Knebel, 2003). Autonomy involves judgment and self-governing within one’s scope of practice. This self-governing requires ongoing evaluation of both responsibility and accountability in professional practice. In the ANA’s Code of Ethics for Nurses, responsibility is defined as accountability for performance of the duties associated with the professional role, and accountability is being answerable to oneself and others for one’s judgments and actions in the course of nursing practice, irrespective of healthcare organizations’ policies and providers’ directives (ANA, 2001, pp. 16–17). Additional components of professional nursing practice include a commitment to community service, theory use, development and evaluation, and evidence-based practice.


1. Describe your current role in data 3. Explain your views on responsibility and accountability. collection and contributing to the client-centered plan of care. 4. Imagine putting on a pair of Interview your RN supervisor on glasses that allow you to look at his/her role in client assessment. the world differently. How can you now see your work setting differ2. Think about how you demonently? Think of an innovation you strate the five core competencies would like to try to improve care of health professionals (Box 2–2) for clients in the setting. and compare your behaviors with your peers in a discussion to be scheduled by your instructor. Go to the Intranet site to complete the interactive exercises provided for this chapter.


REFERENCES American Nurses Association. (2001). Code of ethics for nurses with interpretative statements. (Publication No. CEN21 10M 08/01). Washington, DC: American Nurses Publishing. American Nurses Association. (2003). Nursing’s social policy statement (2nd ed.). (Publication No. 03NSPS 15M 09/03). Washington, DC: American Nurses Publishing. American Nurses Association. (2004). Nursing: Scope and standards of practice. (Publication No. 03SSNP). Washington, DC: American Nurses Publishing. American Nurses Association. (2007). About the American Nurses Association. Retrieved May 1, 2007 from, http://www.nursingworld.org/about/mission.htm Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Greiner, A. C., & Knebel, E. (eds.). (2003). Health professions education: A bridge to quality. Washington, DC: Institute of Medicine. National Council of State Boards of Nursing. (2007). About NCSBN. Retrieved September 23, 2007 from, http://www.ncsbn.org/182.htm National Council of State Boards of Nursing. (2008). Model nursing act and rules. Retrieved on May 8, 2008, from, https://www.ncsbn.org/ Model_Nursing_Act_and_Rules_Full.pdf National League for Nursing. (2007). About the NLN: Mission and goals. Retrieved September 23, 2007 from, http://www.nln.org/aboutnln/ourmission.htm Pew Health Professions Commission. (1995). Critical challenges: Revitalizing the health professions for the twenty-first century. San Francisco: USCF Center for the Health Professions.

BIBLIOGRAPHY Corrigan, M. S., Donaldson, M. S., Kohn, L. T., Maguire, S. K., & Pike, K. C. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Kohn, L. T., Corrigan, M. S., & Donaldson, M. S. (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press. National Council of State Boards of Nursing (2005). NCLEX-PN® examination: Test plan for the National Council Licensure Examination for Licensed Practical/Vocational Nurses. Retrieved September 23, 2007 from, https://www.ncsbn.org/PN_test_plan_05_Web.pdf National Council of State Boards of Nursing (2007). NCLEX-RN® examination: Test plan for the National Council Licensure Examination for Registered Nurses. Retrieved September 23, 2007 from, https://www.ncsbn.org/ RN_Test_Plan_2007_Web.pdf O’Neil, E. H. (1998). Recreating health professional practice for a new century. San Francisco: Pew Health Professions Commission.

ONLINE RESOURCES American Association of Colleges of Nursing: http://www.aacn.nche.edu American Nurses Association: http://nursingworld.org National Council of State Boards of Nursing: http://ncsbn.org National League for Nurses: http://www.nln.org


CHAPTER 3

Theory CHAPTER OBJECTIVES

Key Terms Metaparadigm concepts Paradigm Theory Model Framework Conceptual model or framework Concept Propositions Hierarchy of needs Developmental theories Systems theory Nursing models

After completing this chapter, you will be able to: 1. Define basic terminology to understand the use of theory in nursing practice. 2. Discuss how the hierarchy of needs and stages of development are used to guide practice. 3. Identify selected theories and how they are used to guide practice. 4. Review selected theories developed for use in professional nursing practice. 5. Explain how theory defines and guides professional practice.

ecall that one of characteristics of a profession is that it is built on a theoretical base. This base includes theoretical foundations unique to the profession as well as those adapted from other scientific disciplines. In Chapter 2, we viewed the parameters of professional practice. In this chapter we will look closer at theory that guides nursing practice with the metaparadigm concepts of nursing. These metaparadigm concepts are the

R


overall concerns to the discipline and include human beings, health, the environment, and nursing. Further narrowing down to a practice area is the paradigm. The practice paradigm still addresses the four metaparadigm concepts of nursing but is specific to a practice area; for example, gerontology versus the care of children. Kuhn (1970) described a paradigm as “universally recognized scientific achievements that for a time provide model problems and solutions to a community of practitioners” (p. vii). When the paradigm is no longer useful in explaining phenomena, practice, and research in that particular scientific community, a paradigm shift occurs, and a new structure evolves. A practice paradigm is how professional practice is viewed, interpreted, and provided. In the professional culture of nursing, these are the values, attitudes, beliefs, and practices unique to the profession. In nursing, this provides us with our worldview. These are the concepts and the relationships in the various theoretical structures upon which we base nursing practice, research, administration, and education.

Theory Development and Application Professions such as nursing are based on unique theory. Kerlinger and Lee (2000) define a theory as “a set of interrelated constructs (concepts), definitions, and propositions that present a systematic view of phenomena by specifying relations among variables, with the purpose of explaining and predicting the phenomena” (p. 11). This definition provides us with the components and aims of a theory, which must initially be described and then evaluated for potential use in practice, education, and research in a discipline. Before moving to the components of a theory, we need to address three similar terms frequently associated with theory: model, framework, and conceptual framework or conceptual model. A model is a graphic representation of some phenomenon. It may be a mathematical model (A + B = C) or a diagrammatic model, linking words with symbols and lines. A theoretical model provides a visual description of the theory using limited wording and displaying parts and relationships symbolically. A framework is another means of providing a view of the concepts and relationships proposed in a theory. Again, use of words and narrative is limited, but the structure of the theory is illustrated and allows translation and interpretation of the narrative or text. A conceptual model or framework is similar to a theory in that it represents some phenomenon of interest and contains concepts and propositions. With a conceptual model or framework, however, the concepts and especially the propositions are broader, less defined, and less specific to the perceived reality than with a theory. As Fawcett (2006) noted, in professional nursing practice, conceptual models provide different ways to view practice and each model provides an alternative guide to the way nurses work with clients (p. 500). A theory can evolve from a conceptual model or framework as concepts are further defined, specified, tested, and interrelated to represent some aspect of reality. Then, a theory is “one or more relatively concrete and specific concepts that are derived from a conceptual model, the propositions that narrowly describe those concepts, and the propositions that state relatively concrete and specific relations between two or more of the concepts” (Fawcett, 2005, p. 18). Concepts become less abstract, and the population of interest is identified as more is known about some reality. As a more concrete explanation of a phenomenon is available, the information can be used in specific, meaningful nursing client applications. Chapter 3 l Theory 29

As knowledge about some phenomena increases, a theory is proposed to address phenomena or reality within the discipline. The components of a theory are the concepts, with their specific definitions, and the propositions that describe or link those concepts. At the simplest level, a concept is a view or idea that we hold about something. It can be something highly concrete, such as a pencil, or something highly abstract, such as quality. The more concrete the concept, the easier it is understood and consistently used. For instance, we are comfortable envisioning a pencil and can easily describe this to others. This ability to describe something directly in the concrete world shares the “concept.” But the concept of quality is more abstract, and individual definitions may vary. We strive to define a concept specifically, as to how it can be measured so that others know exactly what we mean. Think about a pencil, perhaps defined as a writing instrument, as we would read in a dictionary. But what do we truly mean by a pencil? It is a yellowpainted, wooden-covered instrument that we use to make marks on a paper. Does it have an eraser? Does a mechanical pencil fit into this definition? A specific, operational definition narrows the definition to precisely what we view and how it can be measured for use in practice or research for a comparable measurement. Definitions are provided to help us understand the nature and characteristics of each block in the construction. We then need to relate these building blocks to each other. Describing and stating the relationships between or among the concepts provides the propositions of a theory. These propositions explain relationships: how the concepts are linked in the theory and relate to one another and to the total theory. They define how the structure is held together. In nursing theory, propositions refer to how human beings are characterized with specific abilities, knowledge, values, and traits and how these interrelate with the characteristics of health, the environment, and nursing. In nursing, theory is further differentiated into levels that describe, explain, predict, and control. All levels may be present as a practice theory evolves, is subjected to further research, and is refined. In application, testing, and refinement, theory is a continuum as long as the content meets the intent of the discipline and metaparadigm. In addition, theories are classified according to their scope as grand, middle-range, or limited in scope or practice. This is the breadth of coverage of some phenomenon. General systems theory is an example of a grand theory, or one with a broad scope. Systems theory has been used in development, testing, and application in many scientific disciplines, including nursing. Middle-range theories are narrower in scope, with a limited view of a phenomenon, and contain concepts and propositions that are measurable and can be empirically tested. Middle-range theories are some of the developmental theories reviewed later in this chapter with which you may be familiar. Although these theories address individual development, they apply in interdisciplinary practice areas. Some of our traditional nursing theories meet the characteristics of a middle-range theory, as described later in Table 3–3. More limited nursing practice theories 30 Section 1 l Beginning Your Journey

are evolving as hypotheses are derived from middle-range theories. These practice theories are tested, revised, and made specific to certain practice areas or types of healthcare client. These limited practice theories focus on measurable variables and propositions that are based on research and are refined further, as to a specific population or group of individuals with a common characteristic.

Theories From Outside of Nursing Nursing and other healthcare disciplines have long used a variety of theories to guide practice. Some are discipline-specific whereas other theories have been applied from other disciplines. Although nursing leaders have stated that nurses must embrace knowledge specific to the discipline of nursing through our unique conceptual models and theories, borrowed or shared theories can address interdisciplinary practice. Recall the metaparadigm concepts (human beings, health, environment, and nursing). Borrowed theories may address the human beings, health, and the environment, but what of nursing? With collaborative practice, however, these theories provide a common ground and the opportunity for the application and sharing of middle-range theories. They also enable us to understand human nature, motivation, and development. Several classic theories have been applied in nursing to view the person, family, the community, and groups. We use Maslow’s (1970) hierarchy of needs to view the person and basic human needs. Developmental theories have been applied across the human life span as we seek to understand the complexity of human behavior. In looking at the person or group, we have applied systems theory to understand the interaction of person and environment. The following section briefly describes selected theories useful in nursing practice. MASLOW’S THEORY OF HUMAN MOTIVATION AND HIERARCHY OF BASIC NEEDS A theory widely used among disciplines is Maslow’s theory of human motivation. Human values are prevalent in this philosophy that looks at the complexity of human behavior. The theory of motivation is based on data but does not address specific nursing concerns except as they relate to human behavior, motivation, and environmental influences. Maslow’s theory includes a hierarchical structure for human needs. This hierarchy of needs is viewed as a pyramid (Fig. 3–1). At the base of the pyramid are the physiological drives. Higher needs progress upward as safety, love and belonging, esteem, and selfactualization needs. Maslow (1970) explained that the individual concentrates on the physiological drives first because they are considered the most powerful, but as physiological needs are satisfied, higher needs emerge on which the individual focuses. The pyramid is the general structure for the hierarchy. Individual differences are provided for in this theory. Some individuals have altered placement of needs in the hierarchy. For example, one person might meet the physiological drives at a 75 percent level, whereas another person’s level for satisfaction is 85 percent. Individual differences also apply to the emergence of higher needs. Levels of satisfaction and emergence of higher needs therefore occur at different points in different people, as do pain thresholds in different people. Looking again at the theoretical hierarchy, we see at the bottom level of the pyramid the physiological drives, including the need to maintain homeostasis and the needs of hunger and thirst, sleep and rest, activity and exercise, sexual gratification and sensory Chapter 3 l Theory 31

pleasure, and maternal responses (Maslow, 1970). Meeting the physioMeeting one's logical hunger drive is very different full potential from meeting one’s nutritional requireESTEEM ments. When the individual is truly Feeling competent, hungry or thirsty, all energies and strong self-worth thoughts are directed to satisfying that LOVE and BELONGINGNESS drive for food or water. The person Feeling worthy of affection and social support will focus all efforts on food to satisfy his hunger and survival need at SAFETY the required level of satisfaction Feeling free from danger and risk, secure in one's own environment while ignoring other needs, such as the next level of safety needs. When PHYSIOLOGIC the physiological drives and needs are Adequate oxygen, food, and water relatively satisfied, higher-level needs Figure 3–1 Maslow’s Hierarchy of Human Needs. emerge. From Kearney-Nunnery, R. (2008). Advancing your career: Concepts in professional Safety needs are the next level of nursing (4th ed.). Philadelphia: F.A. Davis, with permission. the hierarchy. Safety, both physical and emotional, must be achieved. Threats to a person’s safety can become all-consuming. Think of an isolated person in an inner-city apartment whose fear for his safety motivates him to place bars on his windows and multiple chains and dead-bolt locks on his door. This person fears for his physical safety from a real or imagined threat. This fear of bodily harm is the person’s main concern; not whether access is limited in the case of a fire or accident. All focus is placed on freedom from perceived danger. Once the person satisfies these safety needs, the focus turns to the need for love and belonging. Inclusion and affection are important needs, not the isolated sex act, which is a physiological drive. Maslow (1970) described the normal person as having a hunger and striving for affectionate relations and a place in a group (pp. 43–44). Love and affection are manifested in many ways and are individually defined. Satisfying the need for belonging and love brings us to the next level, esteem needs. Esteem needs involve a sense of dignity, worth, and usefulness in life. Satisfying the sense of self-worth and respect for others allows the next, and highest, level of basic needs to emerge. The need for self-actualization at the top of the pyramid is the desire for self-fulfillment. This is the sense of being able to do all that a person can to answer the “why” of his or her existence. Maslow (1970) defined self-actualization as “the full use and exploitation of talents, capacities, potentials, etc., such [that] people seem to be fulfilling themselves and . . . developing to the full stature of which they are capable” (p. 150). Maslow’s hierarchy of needs has endured, and its applications have been extended in healthcare, education, industry, and marketing to understand people and their motivators. Needs related to individual, environmental, and health concerns are applicable to the nursing discipline. However, this theory is still a grand theory and does not address the metaparadigm concept of nursing. SELFACTUALIZATION

DEVELOPMENTAL THEORIES A group of theories widely used in healthcare and education are the developmental theories. These middle-range theories address personality, cognitive, and moral development using a life span perspective. This perspective is based on progression and complexity in motor, 32 Section 1 l Beginning Your Journey

personal-social, cognitive, or moral behavior. Common to the developmental theories are predictable steps or stages through which the individual progresses during the life cycle as a building process. One of the classic developmental theories used in nursing looks at personality development. Erikson’s (1963) eight ages of man represents a theory of psychosocial personality development in which the individual proceeds through critical periods in a step-by-step process (Fig. 3–2). This theory continues to be used widely in healthcare and psychology. Each stage has positive and negative aspects that are defined and described. The basic goal is for the individual to develop a favorable ratio of the positive aspects for a healthy ego. Propositions are developed for each of the stages. Erikson’s theory has been used widely in nursing to foster positive ego development and empowerment in individuals. Although this theory does not specifically address the domain of nursing, common concerns include the human beings, the environment, and psychosocial health. In terms of cognitive development, Learn more about child development and Erikson’s we base many of our interventions Eight Ages at with children on the work of Jean http://webspace.ship.edu/cgboer/erikson.html Piaget. Piaget detailed the development of the intellect in children through observations, especially those of his own children. Piaget’s theory looks at the innate and environmental influences on the development of the intellect in four major periods of cognitive development: sensorimotor, preoperational thought, concrete operations, and formal operations (Table 3–1). Within his theory, Piaget provided us with the concepts of schema, object permanence, assimilation, and accommodation. Schema are patterns of thought or behavior that evolve into more complexity as more information is obtained through assimilation and accommodation. Object permanence, the knowledge that something still exists when it is out of sight, develops when the child is between 9 and 10 months of age. The classic example of this occurs in the game of Peek-a-Boo with children at this age. Assimilation is the acquisition and incorporation of new information into the individual’s existing cognitive and behavioral structures. Accommodation is the change in the individual’s cognitive and behavioral patterns based on the new information acquired. Piaget’s theory has been translated and applied worldwide and across disciplines. And further research and theory is still evolving from his theory of development. Piaget’s work concentrated on cognitive development and has provided major insight into working with children. Applications are seen in health teaching, but, as a

✳

AGES

STRENGTHS & VIRTUES

DEVELOPMENTAL STAGE

8. 7. 6. 5. 4. 3. 2. 1.

Figure 3–2 Erikson’s Eight Ages of Man. From Kearney-Nunnery, R. (2008). Advancing your career: Concepts in professional nursing (4th ed.). Philadelphia: F.A. Davis, with permission.

Chapter 3 l Theory 33

TABLE 3–1

Piaget’s Theory of Cognitive Development

Period of Cognitive Development Sensorimotor Stages • Reflexive

Age

Stage Description

Birth–1 month

• Primary circular reactions

1–4 months

• Secondary circular reactions

4–10 months

• Coordination of secondary schema • Tertiary circular reactions

10–12 months

• Representational thought begins Preoperational

18–24 months

Concrete operations

7–11 years

Formal operations

After 11 years

Use of primitive reflexes, such as sucking and rooting Repeating an event for the result, such as thumb in mouth Combining events for a result, such as kicking a mobile over crib Creating a behavior for some result, such as standing in crib to reach mobile Looking for similar results from varying behaviors, such as shaking crib and jumping to observe movements of mobile Symbolic representation in thought such as hanging objects to create mobile Making overgeneralizations, such as all cats are named Tiger; egocentric Focuses only on one concrete attribute Magical thought and symbolic play present Logical and reversible thought appears; conservation of matter and numbers Theoretical and hypothetical thinking now possible; higher-order mathematics and reasoning

12–18 months

2–7 years

borrowed theory, it can address only a portion of the metaparadigm concepts of nursing. Also in the area of development and following Piaget’s theory of cognitive development is Kohlberg’s theory of moral development. Kohlberg’s extensive work on moral development (Kohlberg, 1984; Kohlberg et al., 1987) is based on research with children given scenarios to describe reactions and make judgments. He initially studied boys 10 to 16 years old from Chicago, later adding research with children of both genders and different backgrounds. Kohlberg’s theory consists of six stages grouped into three major levels: preconventional, conventional, and postconventional (Kohlberg, 1984), illustrated in Table 3–2. Kohlberg’s theory confers major insight into moral development. He provided the theoretical structure, the supportive research, and applications in educational practice. The individual progresses through the levels and stages, not as a natural process, but through intellectual stimulation with a central focus on moral justice. This requires thinking about moral problems and issues. Consider the usefulness of this theory when you are working with a child or adolescent who was recently diagnosed with a terminal illness. However, as with Piaget’s theory, Kohlberg’s theory is limited to a specific area of development. The focus is on human beings, such as the child, with implications for adult life. Environmental factors provide insight for social and psychological health but the limitation to moral development addresses only a portion of the domain of concern to nursing. Many developmental models are used and applied in nursing. A life span, developmental, or life processes focus has major relevance for nursing, because we view human beings in the context of environment and effects on health status. Several nursing theories have a decidedly developmental focus as seen later in this chapter, whether as a main component, as in Watson’s theory, or with specific concepts included, defined, and built on, as in King’s model (see Table 3–3). 34 Section 1 l Beginning Your Journey

TABLE 3–2

Kohlberg’s Theory of Moral Development

Level Level I: Preconventional morality

Stage 1. Heteronomous morality

Level II: Conventional morality

3. Interpersonal expectations, relationships, and conformity

2. Individualism, purpose, and exchange

4. Social system and conscience

Level III: Postconventional morality

5. Social contract and individual rights

6. Universal ethical principles

Stage Description Follows rules from authorities (e.g., parents) to avoid punishment. Sees that different individuals have different rules (parents vs. teachers) but the rules followed are based on individual interests. Motives of other person are now realized when considering right and wrong. The good of society is now considered with the individual having a role and following rules. Believes in upholding laws and considers the greatest good for greatest number. Principles of justice and human rights are followed and upheld.

Source: Adapted from Kohlberg, L. (1984). Essays in moral development: Vol. II. The psychology of moral development (pp. 174–176). San Francisco: Harper & Row.

SYSTEMS THEORY Perhaps the most widely used theory in multiple disciplines is systems theory. Systems have been in existence for ages, but in the late 1930s, Bertalanffy introduced systems theory to represent an aspect of reality. This grand theory was incorporated in the paradigms of many scientific communities. Systems theory is concerned with interrelationships among the parts and the whole. A system generally contains the following basic components: input, output, boundary, environment, and feedback. Figure 3–3 illustrates a basic view of a simple system. Environmental influences are a major consideration in healthcare. Systems theory provides a useful framework to visualize some phenomenon (the system), focusing on the components, structure, and functions as the internal environment (throughputs), and influenced by (inputs and feedback) and influencing (outputs) the environment. It is important to analyze the system carefully for all component parts, structures, and functions. Recall that the basis for general system theory is that “the whole is greater than the sum of the parts.” This brings us to the need for a precise analysis of interrelationships among components and between the parts and the entire system. In addition, an open

Figure 3–3 General Systems Model: A Simple Open System. From Kearney-Nunnery, R. (2008). Advancing your career: Concepts in professional nursing (4th ed.). Philadelphia: F.A. Davis, with permission.


system has permeable boundaries receiving input and feedback from the environment. Problems occur when environmental factors are unknown, unclear, or ignored. Consider the broad health-service system. Since the reports on patient safety from the Institute of Medicine beginning in 1998, we have become greatly concerned about safety in healthcare. Systems issues have been a major focus, but moving from a culture of blaming individuals, the challenge became one of improving components in the system, input, feedback, and outputs. In addition, the broader healthcare environment and societal influences are included and visualized as crossing the system boundaries of an individual hospital setting. In nursing, systems theory and various applications have been used to explain organizations, nursing and healthcare delivery, and groups of people. Several nursing models are based on systems theory. For example, Johnson’s (1990) behavioral systems conceptual model views the person as a behavioral system and nursing as an external force. King’s (1981) theory of goal attainment is another example of a nursing theory based on a systems model.

Nursing Models Florence Nightingale was really our first nursing theorist and researcher. In her classic Notes on Nursing (1859) she detailed the role of the environment and hygiene for the health of the individual and the role of the nurse in the process. She actually did speak to our metaparadigm concepts in an earlier century. Recall these metaparadigm concepts: human beings, health, environment, and nursing. More than a hundred years later, Virginia Henderson defined the unique role of the professional nurse as: Assisting the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. (Henderson, 1966, p. 15) This concrete definition was a philosophy of nursing and was expanded and applied to practice, education, and research. Henderson’s philosophy of nursing was one of caring, assisting, and supporting the person. Notice, we are still focused on our metaparadigm concepts: human beings, health, environment, and nursing. Then, in the 1970s and 1980s models specific to nursing were developed and tested further as graduate programs in nursing grew throughout the country. Consider some of these conceptual models of nursing identified in Table 3–3 and how the models addressed the metaparadigm concepts of nursing. Some of the models are more concrete as with the human as a behavioral system. Other models are more complex when considering interactions and meaningfulness of patterns in one’s unique environment.


TABLE 3–3

Selected Conceptual Models and Theories of Nursing

Theorist Johnson (1990)

Model Behavioral System

King (1981)

Theory of Goal Attainment

Leininger (2006)

Culture Care Diversity & Universality

Human beings, families, clans, and collective groups that are valued and respected and often viewed as sacred.

Neuman (2002)

Systems Model

The person is the client or the client system and may be an individual, family, group, or a social issue composed of five interacting variables: • Physiological • Psychological • Sociocultural • Developmental • Spiritual (Neuman, 2002, pp. 15–17).

Human Beings The behavioral system composed of seven subsystems: • Achievement • Affiliative • Aggressive/ protective • Dependency • Eliminative • Ingestive • Restorative • Sexual King (1981) defines human beings as • Social • Sentient • Rational • Reacting • Perceiving • Controlling • Purposeful • Actionoriented • Time-oriented (p. 143).

Environment Internal to the human being including biological, cultural, familial, sociological, and ecological factors.

Health Equilibrium as balanced functioning of the person as the behavioral system.

Nursing An external regulatory force that intervenes to restore equilibrium.

Nurse-client interactions lead to goal attainment in natural environments with the theoretical concepts of • Interaction • Perception • Communication • Transaction • Role • Stress • Growth & Development • Time • Space The total geophysical situation(s) or the lived-in geographic and ecological settings of the culture.

The ability to function in social roles (King, 1981, p. 143).

“A process of human interactions between nurse and client whereby each perceives the other and the situation; and through communication, they set goals, explore means, and agree on means to achieve goals” (King, 1981, p. 144).

A state of well-being that is culturally defined. It is also a state to be maintained to perform daily role activities.

All internal and external influences on the client system and represented as three environments: Internal, external, and created.

Wellness and illness are viewed as opposite ends on a continuum with health equated with optimal system stability and wellness at any given time (Neuman, 2002, p. 23).

Three action-decision culture care modes: • Preservation and/or maintenance • Accommodation and/or negotiation • Repatterning and/or restructuring (Leininger, 2006, p. 8). The optimal goal of nursing is to maintain optimal wellness of the client system. “Nursing actions are initiated to best retain, attain, and maintain optimal client health or wellness using the three preventions as interventions to keep the system stable” (Neuman, 2002, p. 25). The three preventions in this model are primary, secondary, and tertiary interventions.

Continued


TABLE 3–3

Selected Conceptual Models and Theories of Nursing—Cont’d

Theorist Newman (1994, 2007)

Expanding Consciousness

Model

Orem (2001)

Self-care, a human regulatory function

Parse (1987, 1998, 1999)

Human Becoming

Pender (2006)

Health Promotion Model

Human Beings Centers of consciousness and open energy systems constantly interacting and evolving with each other and the environment (Newman, 1994).

Environment

Health

Human beings interact as patterns and with the patterns in the environment. And the patterns vary and are unique to the individual person in their unique environment.

As a pattern of the whole that includes both disease and non-disease (Newman, 1994). Health is described as expanding consciousness.

Human beings are viewed in various ways and have structural and functional differentiations with the following abilities: • Reflection of oneself and the environment • Use of symbols in thinking, communicating, and making things better (Orem, 2001, p. 182). Open beings who are free to choose meaning in their unique situation and cocreate personal health. Human beings are viewed as individuals, families, or groups.

Complex, lived experiences. Environmental features are interactive and evaluated as physical, chemical, biological, and social features (Orem, 2001, p. 79).

“A descriptor of living things with respect to their structural and functional wholeness and soundness” (Orem, 2001, p. 516). Human regulatory function is a process of self care to address health and normal functioning.

Environment is the context of the interaction of the person in their unique environment in interaction with others in the process of becoming. It may be a traditional healthcare setting or telephone or e-mail wherever people and nurses meet (Parse, 1999, p. 1384) The interpersonal and physical environment (Pender, Murdaugh, & Parsons, 2006).

A process of becoming as experienced by the person and with a set of lived value priorities (Parse, 1987).

The nurse-person, the nurse-family, or the nurse-group involves practice within the following methodologies: • Illuminating meaning • Synchronizing rhythms • Mobilizing transcendence

Holistic human functioning (Pender, Murdaugh, & Parsons, 2006, p. 50). Health is a subjective life span process only partially observable by traditional scientific

Interventions for health behavior change with a focus on the client’s autonomy and selfdetermination in lifestyle modification (Pender, Murdaugh, & Parsons, 2006, p. 65).

“Each person has unique personal characteristics and experiences that affect subsequent actions” (Pender,


Nursing Nursing is a dynamic and relational process that is moving, evolving, and transforming (Newman, 2007, p. 122). A human science with the process described as meeting, forming shared consciousness, and moving apart as caring in the human health experience (Newman, 1994). Nursing care is required when there are self-care or dependent-care deficits. Nursing is a direct human health service provided by a qualified person to help persons to continually meet therapeutic selfcare demands and exercise their self-care agency (Orem, 2001).

TABLE 3–3

Selected Conceptual Models and Theories of Nursing—Cont’d

Theorist

Model

Rogers (1989)

Science of Unitary Human Beings

Roy & Andrews (1991)

Adaptation

Watson (1999, 2002)

Caring

Human Beings Murdaugh, & Parsons, 2006, p. 51). In this model, prior related behavior and personal factors lead to behavior-specific cognitions and affect and then to the behavioral outcomes. The Unitary Human Being is the human energy field identified by pattern and manifests characteristics specific to the whole that cannot be predicted or reduced to specific parts and evolved along with the environmental field. The adaptive system with parts that function as a unity (Roy & Andrews, 1991, p. 4).

Environment

Experiencing subjects who co-participate with nurses in ongoing change (Watson, 1999).

Health

Nursing

methods (Pender, 2006, p. 152).

The environment is an interacting energy field with the human field and is also an irreducible fourdimensional energy field identified by pattern that changes continuously and innovatively.

Although not specifically defined since the interaction of the human and environmental energy fields is unique, homeo-dynamics is ongoing functioning under the principles of resonancy (change), helicy (diversity and innovation), and integrality (continuous interaction).

A learned profession that is both a science and an art with the purpose of helping people to achieve maximal well-being.

Focal and contextual stimuli present and confronting the person as the adaptive system.

“A state and process of being and becoming an integrated and whole person” (Roy & Andrews, 1991, p. 4).

Interhuman events, processes, and relationships (Watson, 1999). The context for viewing the person and the nurse is in the momentto-moment human encounters between the two people (Watson, 1999, p. 71).

Health or wellness is expressed as emotional/ spiritual well-being and as unity and harmony.

The goal of nursing is the promotion of adaptation of the person for health, quality of life, and dignity with dying within four adaptive modes: physiological, selfconcept, role function, and interdependence (Roy & Andrews, 1991). As both an art and a science, the expression of caring in nursing practice is demonstrated as: • Manifesting intention • Appreciating patterns • Attuning to dynamic flow • Experiencing the infinite • Inviting creative emergency (Watson, 2002).


The Impact of Theory on Practice Alligood (2006) proposes that “given our history and the challenges of today, utilization and application of nursing’s theoretical works are understood to be vital organizing structures for the critical thinking necessary in professional nursing practice” (p. 3). We use theory every day in our personal and professional lives, from the basic principles of asepsis in hygiene and standard precautions, to understanding the complex communication channels of the organizational system in which we practice. Theory, practice, and research are interrelated and interdependent. We need theory to guide practice predictably and effectively. We need research to support the significance and usefulness of the theory. Professional practice must provide the questions for study. Again, recall that nursing is a profession and a scientific community. We practice using principles provided by our metaparadigm and theoretical bases. This furnishes us with the tools for critical thinking, provision of care, education, administration, research, and interdisciplinary collaboration. Our paradigms and theories are designed to address problems and solutions in practice, or we need to shift to a new structure with different theories and paradigms to explain our concerns for people, environments, health, and nursing. Practice models are subject to change as new information is discovered and as client needs change. The paradigm concepts must be in a constant state of evaluation to ensure that the model of practice is current and based on nursing science. In the next chapter, we will focus on practice and on ethical dilemmas and decisions. Critical thinking and decision making again are important keys to professional nursing practice.

KEY POINTS • Metaparadigm concepts are the overall concerns to the discipline and include human beings, health, the environment, and nursing. 40 Section 1 l Beginning Your Journey

• Kuhn (1970) described a paradigm as “universally recognized scientific

•

•

• •

• •

•

•

achievements that for a time provide model problems and solutions to a community of practitioners” (p. vii). Kerlinger & Lee (2000) define a theory as “a set of interrelated constructs (concepts), definitions, and propositions that present a systematic view of phenomena by specifying relations among variables, with the purpose of explaining and predicting the phenomena” (p. 11). Theories are classified as grand, middle-range, or limited (practice) on the basis of their scope or breadth of coverage of phenomena. A theoretical model provides a visual description of the theory using limited narrative but displays components and relationships symbolically. A framework is another means of providing a structural view of the concepts and relationships proposed in a theory. A concept is a view or idea we hold about something, ranging from something highly concrete to a highly abstract construct. Propositions in a theory are the descriptions and relationships among the constructs (or concepts) that propose how the concepts are linked and relate to each other and to the total theoretical structure. Maslow’s theory and hierarchy of needs proposes a hierarchical structure for basic human needs. Developmental theories are widely used in nursing and other healthcare disciplines and include Erikson’s ages of psychosocial development, Piaget’s theory of cognitive development, and Kohlberg’s theory of moral development. A system generally contains the following basic component parts: input, output, boundary, environment, and feedback. Bertalanffy’s (1968) general systems theory is a grand theory applied to many disciplines. Theory, practice, and research are interrelated and interdependent. When we are selecting a nursing model or theory on which to base practice, the theory must be compatible and correspond to the phenomena of professional nursing practice.


1. Identify how the metaparadigm concepts apply in your practice setting. 2. Identify individuals who you think are self-actualized, and explain why. 3. Identify a theory used in your practice setting. Identify the concepts (constructs), how the component concepts are defined, the propositions that link the concepts, and the aims of this theory. 4. Describe how systems theory can be used in a healthcare setting. Identify the inputs and outputs of the system. Go to the Intranet site and complete the interactive exercises provided for this chapter.


REFERENCES Alligood, M. R. (2006). The nature of knowledge needed for nursing practice. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theory: Utilization and application (3rd ed. pp. 1–15). St. Louis: Mosby. Bertalanffy, L. V. (1968). General system theory: Foundations, development, applications. New York: George Braziller. Erikson, E. H. (1963). Childhood and society (2nd ed.). New York: W. W. Norton. Fawcett, J. (2005). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories. (2nd ed.). Philadelphia: F.A. Davis. Fawcett, J. (2006). Nursing philosophies, models, and theories: A focus on the future. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theory: Utilization and application (3rd ed., pp. 499–518). St. Louis: Mosby. Henderson, V. (1966). The nature of nursing: A definition and its implications for practice, education, and research. New York: Macmillan. Johnson, D. E. (1990). The behavioral system model for nursing. In M. E. Parker (Ed.), Nursing theories in practice (pp. 23–32). New York: National League for Nursing. Kerlinger, F. N., & Lee, H. B. (2000). Foundations of behavioral research (4th ed.). Belmont, CA: Wadsworth Thompson Learning. King, I. M. (1981). A theory for nursing: Systems, concepts, process. New York: John Wiley & Sons. Kohlberg, L. (1984). Essays in moral development: Vol. II. The psychology of moral development. San Francisco: Harper & Row. Kohlberg, L., DeVries, R., Fein, G., Hart, D., Mayer, R., Noam, G., Snarey, J., & Wertsch, J. (1987). Child psychology and childhood education: A cognitivedevelopmental view. New York: Longman. Kuhn, T. S. (1970). The structure of scientific revolutions (2nd ed.). Chicago: University of Chicago Press. Leininger, M. M. (2006). The culture care theory. In M. Leininger & M. R. McFarland (Eds.), Culture care diversity and universality: A worldwide nursing theory (2nd ed., pp. 1–41). Boston: Jones and Bartlett. Maslow, A. H. (1970). Motivation and personality (2nd ed.). New York: Harper & Row. Neuman, R. (2002). The Neuman Systems Model. In B. Neuman & J. Fawcett (Eds.), The Neuman systems model (4th ed., pp. 3–33). Upper Saddle River, NJ: Prentice Hall. Newman, M. A. (1994). Health as expanding consciousness (2nd ed.). New York: National League for Nursing. Newman, M. A., & Jones, D. A. (2007). Experiencing the whole: Health as expanding consciousness. In C. Roy & D. A. Jones (Eds.), Nursing knowledge development and clinical practice (pp. 119–128). New York: Springer. Nightingale, F. (1859). Notes on nursing: What it is, and what it is not. London: Harrison and Sons. [Commemorative edition printed 1992, Philadelphia: J. B. Lippincott.] Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.). St. Louis: Mosby. Parse, R. R. (1987). Nursing science: Major paradigms, theories, and critiques. Philadelphia: W.B. Saunders. Parse, R. R. (1998). The human becoming school of thought. Thousand Oaks, CA: Sage. Parse, R. R. (1999). Nursing science: The transformation of nursing practice. Journal of Advanced Nursing, 30(6), 1383–1387.


Pender, N. J. (2006). Expressing health through lifestyle patterns. In W. K. Cody (Ed.), Philosophical and theoretical perspectives for advanced nursing practice (4th ed., pp. 143–153). Boston: Jones and Bartlett. Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006). Health promotion in nursing practice (5th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Rogers, M. E. (1989). Nursing: A science of unitary human beings. In J. Riehl-Sisca (Ed.), Conceptual models for nursing practice (3rd ed., pp. 181–188). Norwalk, CT: Appleton & Lange. Roy, C., & Andrews, H. A. (1991). The Roy adaptation model: The definitive statement. Norwalk, CT: Appleton and Lange. Watson, J. (1999). Nursing: Human science and human care, a theory of nursing. Boston: Jones and Bartlett. Watson, J. (2002). Assessing and measuring caring in nursing and health science. New York: Springer.

BIBLIOGRAPHY Dickoff, J., & James, P. (1968). A theory of theories: A position paper. Nursing Research, 17, 197–203. Maslow, A. H. (1954). Motivation and personality. New York: Harper & Brothers. Roy, C., & Jones, D. A. (Eds.). (2006). Nursing knowledge development and clinical practice: Opportunities and directions. New York: Springer. Singer, D. G., & Revenson, T. A. (1998). A Piaget primer: How a child thinks (Rev. ed.). Madison, CT: International Universities Press. Tomey, A. M., & Alligood, M. R. (2002). Nursing theorists and their work (5th ed.). St. Louis: Mosby. Tourville, C., & Ingalls, K. (2003). The living tree of nursing theories. Nursing Forum, 38(3), 21–30, 36. Watson, J. (Ed.). (1994). Applying the art & science of human caring. New York: National League for Nursing. Watson, J. (2005). Caring as a sacred science. Philadelphia: F.A. Davis.

ONLINE RESOURCES Books by A.H. Maslow: http://www.maslow.com Jean Piaget Society: http://www.piaget.org Nursing Theories: http://www.nurses.info/nursing_theory.htm NurseScribe©: http://www.enursescribe.com Transcultural Nursing Society: http://www.tcns.org


CHAPTER 4

Ethics CHAPTER OBJECTIVES

Key Terms Rights Basic human rights Beneficence Nonmaleficence Justice Fidelity Selfdetermination (autonomy) Full disclosure Veracity Informed consent Privacy Confidentiality Utilitarianism Deontology Code of ethics Standards of care Advance directives Euthanasia Human genome

After completing this chapter, you will be able to: 1. Examine ethical principles in professional practice. 2. Define the terminology used in ethical decision making. 3. Analyze ethical dilemmas in contemporary healthcare situations. 4. Discuss the components of the ANA Code of Ethics for Nurses. 5. Identify ethical decision-making situations in the practice setting.

s a healthcare provider, you are confronted by ethical issues on a daily basis. But have you carefully considered all the implications? Are they ethical dilemmas? Dahnke and Dreher (2006) define an ethical dilemma as a problem with options that seem equally unfavorable (p. 4). Let’s look at some of the principles and issues in daily practice. Think about informed consent, advance directives, a persistent vegetative state, organ procurement and donation, and genomics. However, before looking at specific situations, consider the basis of ethical decision making.

A

Ethical Principles We hear a good deal about human rights. First, consider the concept of rights. A right is an agreed-upon entitlement. It is a constant and does not change with the circumstances. Husted and Husted (2001) warn that it is a grave ethical mistake to regard the term rights as a political term that can be an ever-changing product of legislation, rather than a more fundamental ethical term (p. 295). A right is an unchanging agreement rather than a modifiable law. Further, Catalano (2008) describes this blurring of ethical and political use of the term and differentiates among legal rights, ethical rights, and option rights. Legal rights are guaranteed by law, like freedom of speech. However, legal rights can be changed or modified through legislation. Moral rights are based on ethical principles such as self-determination and autonomy of the individual. Option rights allow some freedom of choice within certain parameters, such as choices with advance directives and not murder or active euthanasia. With this in mind, consider the following moral and basic human rights: ■ Beneficence ■ Justice and Fidelity ■ Self-determination and Autonomy


■ Full Disclosure and Veracity ■ Privacy and Confidentiality Beneficence is the principle of doing good with the person’s best interests as the goal of all actions. This includes the concept of nonmaleficence in that we “do not harm” the individual, family, or group. In healthcare, our role is to help but the person may be at risk of harm with the treatment. We must be vigilant to protect the person from avoidable harm or error. We will consider this further in our safety initiatives covered in a subsequent chapter, as with the use of bar-coding to reduce medication errors. Associated with the concept of beneficence is justice and fidelity. Justice is fairness to all and avoidance of favoritism. All clients deserve fair access to quality healthcare. Fidelity is loyalty to the person. If we tell a client we will be back to check on their pain relief in 10 minutes, we need to be true to that time frame. Full disclosure and self-determination are associated ethical principles. Self-determination is the sense of autonomy in which the person has the right to determine his or her fate. The development of a living will is one example of self-determination when the client makes decisions in advance of a critical situation. However, to make life decisions, the person must have complete information or full disclosure. The individual deserves all relevant information about their health status to make an informed decision. Full disclosure includes the principle of veracity or providing truthful information. Informed consent incorporates these ethical principles. Informed consent is when the individual has complete information on all sides of the issue and makes a decision for care (or not) freely and without constraint after careful consideration of both advantages and disadvantages of the action. Privacy and confidentiality also are closely associated concepts. Privacy means the person has the right to determine and control the amount of information to reveal about him- or herself. The professional relationship allows the person to provide this private

Chapter 4 l Ethics 45

information with the knowledge that it will be respected and remain private. This is confidentiality, in that the information that the person does reveal is respected and not revealed to others except as necessary as part of this professional relationship. This situation can be a delicate one, as in the example of a family history of mental illness. The client must have trust in the healthcare professional to feel comfortable to reveal such sensitive information. All of these ethical principles are guided by the way we look at the world. And with our expanding channels of information, including electronic information, the ANA (2006b) developed a Position Paper on Privacy and Confidentiality with nine principles that address client advocacy and trust in the professional relationship. Included in these principles are the client’s right to access her or his own information as well as limited access to others, except under defined circumstances. Of particular note is the issue of electronic health information and the required safeguards along with reporting requirements for violations to appropriate client privacy.

Systems of Ethical Decisions Ethics has been defined as the philosophical study of morality (Greipp, 1995, p. 51). There are two generally established systems of ethical decision making: utilitarianism and deontology. These two systems have been differentiated based on consequence or outcome (utilitarianism) or the obligation for action or inaction (Aumman, 1998). Utilitarianism is focused on the consequence or the outcome. It is based on two basic ideas: happiness and the greatest good for the greatest number. Decisions are made in this framework in terms of means that justify the way of getting there—for the greatest good in the end. Some ethicists further differentiate utilitarianism into rule and act utilitarianism. Rule utilitarianism draws on past experiences to formulate personal rules to determine what you consider is the “the greatest good” for the intended outcome. Act utilitarianism is based on the unique situation in the present circumstances for the determination of what is considered “right” and best to reach the intended consequence. As noted by Catalano (2008), this system is oriented toward the good of the population in general and rules and regulations are not necessarily followed to reach the intended outcome. Think about the times you may have been posed with the question of who should be in the lifeboat? Or, who should be saved? Using the system of utilitarianism focuses on the consequences for the greatest number and the greatest chance of happiness and success—regardless of the means of getting there. With our focus on the individual and their unique needs and characteristics, this system does pose limitations when making decisions. Do the “ends” really justify the “means?” Think about it! And who is the one to decide what is the “best” outcome in the situation? The second system, deontology, is based on obligations as rules and unchanging principles. Based on the German philosopher Kant (1724–1804), this system requires adherence to a set of established rules. The absolute rules are the means to reach the decision. These rules are absolute and unchanging, as is seen in some religious ethical decision-making systems. As with utilitarianism, deontology is divided into two subsets, rule versus act deontology. With rule deontology, the ethical standards or rules are made by people—past or present. These rules must be followed and do not change, regardless of the situation or individual factors. In act deontology, the highest value is placed on the moral values of the individual. You must make the same decision in any similar situation, regardless of the circumstances. As opposed to rule deontology, with act deontology, you are the one following rules, based on data you obtain about the situation. But, you make 46 Section 1 l Beginning Your Journey

the decision and act in a consistent manner, following those rules. You must arrive at the same decision in similar circumstances.

Code of Ethics A professional abides by a certain code of ethics applicable to the practice area. Developed within the profession, the code addresses general ethical practice issues. The Code of Ethics for Nurses developed by the American Nurses Association (ANA) is the ethical standard for professional nursing practice. As the ANA states, the “code makes explicit the primary goals, values, and obligations of the profession” through nine “nonnegotiable” provisions (Box 4–1) with interpretative statements (ANA, 2001, p. 5). The interpretative statements promote understanding for appropriate application of the code of ethics in professional practice. The ethical principles of human rights, self-determination, privacy and confidentiality, autonomy, and responsibility and obligations are specifically addressed in the code of ethics. The ANA Code also requires “duties to self,” as with professional growth and continued competence (Fowler, 2008, p. xi). Adherence to this specific code may be regulated in your state’s practice act. However, there are other ethical codes, including the International Council of Nurses (ICN) Code of Ethics for Nurses. The ANA is one of 128 countries that are members of ICN. The ICN Code of Ethics for Nurses presents four elements associated with nurses:

BOX 4–1

The Code of Ethics For Nurses

1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. 2. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community. 3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. 4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care. 5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. 6. The nurse participates in establishing, maintaining, and improving healthcare environments and conditions of employment conducive to the provision of quality healthcare and consistent with the values of the profession through individual and collective action. 7. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. 8. The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs. 9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy. Source: Reprinted with permission from the American Nurses Association, Code of Ethics for Nurses with Interpretive Statements, ©2001 Nursebooks.org, Washington, DC.


✳

people, practice, the profession, and coworkers (ICN, 2006). In addition, it illustrates for each of the elements, the roles of practitioners and managers, educators and researchers, and national nursing associations. Achieving professional status requires ethical standards for expected behaviors with clients, colleagues, and other professionals. Further information on these ethical codes can be found at their Web sites. Associated with a code of ethics is the concept of standard of care. Aiken (1998) defines standards of care as accepted practice and reasonable under the given circumstances with the sources of these standards from

ANA Code of Ethics for Nurses at http://nursingworld.org/MainMenuCategories/ ThePracticeofProfessionalNursing/EthicsStandards/ CodeofEthics.aspx ANA Position Statements at http://nursingworld.org/MainMenuCategories/ HealthcareandPolicyIssues/ANAPositionStatements/Ethic sandHumanRights.aspx ICN Code of Ethics for Nurses at http://www.icn.ch/icncode.pdf

■ ■ ■ ■ ■ ■

Laws and regulations Authoritative textbooks State practice acts and guidelines Facility manuals, equipment manuals, job descriptions, critical pathways Court decisions and administrative rulings Joint Commission on Accreditation of Healthcare Organization (JCAHO) standards (pp. 38–40)

Definition of practice and specific practice standards are further specified within the professional community through major nursing associations. The ANA has specified a variety of practice standards for the profession, both general and specific to certain practice areas. The ANA has prepared several specialty standards documents jointly with the particular specialty organization to reflect the expectations for specialized professional practice. These standards are described as “authoritative statements by which the nursing 48 Section 1 l Beginning Your Journey

profession describes the responsibilities for which its practitioners are accountable. . . . [S]tandards also define the nursing profession’s accountability to the public and the outcomes for which registered nurses are responsible” (ANA, 2004, p. 1). The publication Nursing: Scope and Standards of Practice (ANA, 2004), for example, prescribes standards of care and standards of professional performance. Recall that the standards of care address safe practice and use of the nursing process with the actions of assessment, diagnosis, outcome identification, planning, implementation, and evaluation (ANA, 2004). Standards of professional performance are expected professional roles and behaviors, including quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, resource utilization, and leadership (ANA, 2004, p. 3). Under the area of ethics, the registered nurse is required to adhere to the Code of Ethics for Nurses and “integrate ethical provisions in all areas of practice” (ANA, 2004, p. 39). Further standards of specialty practice are provided through the certification process with specialized education, testing, and ongoing learning requirements. Practice standards and expectations also have been developed by the applicable specialty organizations. Adherence to standards of practice is designed to promote safe and effective care, but there are still ethical dilemmas that nurses face on a daily basis.

Making Ethical Decisions Making ethical decisions is not an easy task. As described earlier, the choice may be between two equally unpleasant options. In the search for assisting with ethical dilemmas, several models for ethical decision making have been proposed and evaluated over the past years. A classic model by Leah Curtain (1978) provides the following steps for the ethical decision-making process: 1. Obtaining background information 2. Identifying the ethical components 3. Identifying the ethical agents or people involved 4. Identifying the options available 5. Applying ethical principles to the issues, like self-determination 6. Making a final resolution or decision to the ethical dilemma Think about an ethical dilemma that you have encountered in the past. Return to the basic information and ignore the resolution that was reached. Follow Curtain’s (1978) six steps and evaluate the resolution that did occur in that situation. Despite our code of ethics that provides direction or the ethical system of decision making we use, ethical dilemmas arise on a daily basis in healthcare situations. Consider the following issues in nursing practice and the ethical dilemmas. INFORMED CONSENT One of the most common ethical situations concerns selfdetermination with true informed consent. We are not looking at getting a form signed by the client. This is not a role for the nurse. The issue of informed consent contains many of the ethical principles we have reviewed: ■ Beneficence (doing good with the person’s best interests as the goal) ■ Justice (as avoidance of favoritism) ■ Fidelity (as loyalty to the person, rather than to what we may see as the reasonable treatment) Chapter 4 l Ethics 49

■ Full disclosure (with complete information on the risks, benefits, and options) ■ Self-determination (to decide for oneself and not for the sake of others), and without constraint after careful consideration of the situation knowing that one’s privacy is being protected in the confidentiality of the client-professional relationship This is what we would want for ourselves. So now, look back at the steps in the decisionmaking model. Can you identify the six steps of Curtain’s model? First, has all background information been obtained, including culturally appropriate information? Recall that some medical or surgical procedures are acceptable to certain people or cultures and not to others. So, has appropriate background information been obtained, assumed, discussed, or ignored with a focus on our healthcare model? Have all the ethical components of the procedure and the situation been considered? And have all the ethical agents or people involved been identified, including relevant extended family members? So what are the options available to the client and have these been explained and are they fully understood? Now is the time to apply the ethical principles to the issues, like self-determination. What do you think? And your final resolution to the informed consent—was it true to the ethical principle? Not as simple as completing a consent for treatment form! ADVANCE DIRECTIVES Most healthcare providers are familiar with the term advance directives in which individuals provide written and specific instructions for their wishes relative to their future healthcare in a time when they are able to specify their wishes in the event that they are unable to communicate these wishes at that time. The ethical principles of autonomy and self-determination are the basis for advance directives, which can take the form of a living will or healthcare proxy and a durable power of attorney. Advance directives have their basis in both law and ethics. Originally enacted in law and revised in the 1980s, the Uniform Rights of the Terminally Ill Act provides for the development of a living will specifying personal requests on care and life support in the case of a terminal illness or injury. A healthcare proxy also may be developed to appoint a person to make decisions on care in the event that person cannot make them. Making the decisions in advance of a critical situation allows the person self-determination of their fate. However, there are other ethical principles that also must be honored. When developing advance directives, the individual must understand his or her options and have full-disclosure and understanding of the terminology, especially when standard forms are used. They must understand their options for the different life-support equipment and hydration and nutrition. This also is the time to address the choice for organ donation. The documents must be witnessed and notarized and state requirements should be considered, especially if the individual travels or lives in multiple states. There are differences among states. In addition, the person must know that she or he can have a change of mind. However, if the person does want to make changes, a revised document must be developed. The individual also must be able to have full trust in the person identified as his or her proxy in the case that the individual is unable to make decisions. This is not a time for favoritism, but one of trust that a person’s wishes will be honored with judgment and fidelity. Privacy and confidentiality also are import concepts in that one’s advance directives are just that—not public information. Not even if the family members do not consider themselves as “the public.” It is the individual’s self-determination to make the advance decisions and have the documents available to appropriate healthcare providers, legal counsel, and family. Ultimately, it is the individual’s decision and autonomy. 50 Section 1 l Beginning Your Journey

However, recall the concept of option rights: the range of decisions for the individual to make in advance directives vary by state and nation. In the United States, there are differences among states such as Oregon and physician-assisted suicide. Many states have specific forms and language that must be included in order for an advance directive to be considered a legal and enforceable document. Active euthanasia or “mercy killing” is not a component of advance directives in this country but may be in other countries such as the Netherlands. The Code of Ethics for Nurses (ANA, 2001) dictates that “nurses may not act with the sole intent of ending a patient’s life, even though such action may be motivated by compassion, respect for patient autonomy and quality of life considerations” (p. 8). Some people feel that advance directives lessen the burden on the family in the case of a crisis. However, the focus here is on the person and his or her autonomy and wishes. Yet, families comprise individuals who may be facing the dilemmas of beneficence in adhering to the person’s best interests, justice in that all appropriate care is provided, and fidelity as loyalty to the person’s wishes. Although the family does not have to “second guess” the individual’s wishes because they have been specified in the advance directives, at an end-of-life event, many conflicting emotions may be apparent and healthcare professionals must be supportive to both the individual and the family while upholding legally enforceable directives. Check out some of the online information available to clients. But a word of caution, ensure that clients are accessing reputable and appropriate information.


So now, additional dilemmas involved with advance directives include: ■ The client and the family are not in agreement ■ The client/family is not in agreement with the healthcare provider(s) ■ The issues of • “Do-not-resuscitate” • Hydration versus nutrition • Ventilation • Dialysis • Pain management • Religious and cultural differences • End-of-life final requests and planning • Organ and tissue donation And what others can you identify?

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THE PERSISTENT VEGETATIVE STATE Another dilemma that has had major legal and ethical challenges over the past years is the identification of the persistent vegetative state. The pronouncement of “brain death” is well established and has objective data that must be met. However, the persistent vegetative state has recently been debated in the courts with specified criteria now proposed. But there is still much discussion and debate and media coverage. Perry, Churchill, and Kirshner (2005) have illustrated the issues and dilemmas involved in the case of Terri Schiavo, who was a young woman in a constant vegetative state and who persisted in this state beyond the limits of a normal period of recovery. As the authors reported, “no patient, even those with traumatic brain injury, has been reported to recover after a full year of being in a persistent vegetative state” and Terri Schiavo survived in this state for 15 years (p. 744). As a result of all the legal contests and ethical debates, Ms. Schiavo persisted in a vegetative state for these years. However, as a result of her condition and the plight of her family with debates in the legal and medical communities, specific criteria to understand the persistent vegetative state criteria were developed to address both traumatic and nontraumatic brain injuries. So, think about the dilemmas within the family and in the medical community:

AARP http://www.aarp.org/families/end_life/ a2003-12-02-endoflife-finalwishes.html FamilyDoctor.org http://familydoctor.org/online/famdocen/home/ pat-advocacy/endoflife/003.html MedlinePlus http://www.nlm.nih.gov/medlineplus/ advancedirectives.html National Alliance on Mental Illness http://www.nami.org/Content/ContentGroups/Legal/ Advance_Directives.htm National Cancer Institute http://www.cancer.gov/cancertopics/factsheet/support/ advance-directives Transplants/Donations http://www.nlm.nih.gov/medlineplus/ transplantationanddonation.html

■ ■ ■ ■ ■ ■

Would or could she recover? The criteria for brain death were not met. What would this young woman want (self-determination)? What does the family know, want, perceive, and interpret? What different perceptions and feelings exist in the family structure? What are the benefits and risks of each treatment to Terri, the family, and society?


■ What if you were Terri and reliant on a feeding tube for existence? ■ What about the use of healthcare resources and the chances of a meaningful life? And what others can you identify?

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ORGAN PROCUREMENT AND Terri Schinder Schiavo Foundation DONATION Although organ transhttp://www.terrisfight.org/ plants have become a common procedure, there are ethical concerns with harvesting organs and both sides of the donation situation. Consider the dilemma of “harvesting,” access, self-determination, and cultural beliefs—among others. In the case of procurement or harvesting organs, care must be given to the dignity and wishes of the donor. Family issues also are of concern with grief issues on the donor’s side and hopeful expectation for the other family. Access continues to be an issue with cost and accessibility to healthcare. Self-determination applies as the wishes of both the donor and the recipient. Cultural beliefs also are a consideration. As noted by Spector (2000), organ donation is permitted in many religious groups but not in the case of Jehovah’s Witness followers. Returning to Curtain’s steps in the decision-making process, obtaining background information is vital in the assessment process for both the donor and the recipient as the ethical components, ethical agents, and the available options are identified and the ethical principles are applied in the final decision. In addition to the numbers of individuals on waiting lists, there are other complex issues to confront with the type of donation (blood, tissue, organs, and stem cells) and the individuals involved (youth, aged, minorities, religious, and cultural groups). Consider the online information available to the donors and individuals in need and their families. Overall, respect for individuals is an issue. And how would you reply when renewing your driver’s license if you are asked whether you want your donor status indicated on your license? And, what about the response of a family member to this same question?

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GENOMICS The Human Genome Organ Donation—Government Site Project has been an outstanding scienhttp://www.organdonor.gov/ tific achievement that provided new Organ Procurement Network information on gene structure, function, http://optn.org/ and dysfunction. The DNA sequencing of the human body has been a breakthrough in modern science providing valuable information on the human genome or the complete set of the human DNA. We now know what gene is affected in specific genetic diseases like sickle cell anemia and cystic fibrosis. Current research also is ongoing on the genetic mutations that occur with various cancers. Use of individual DNA in the criminal justice system frequently makes news. And what about the individual’s right to privacy? But also consider individual responsibility as more information is known on certain conditions that can be affected by either heredity or environment. This balance of privacy and responsibility presents ethical dilemmas. Consider the rights of parents and children. Recall that a right is an agreed-upon entitlement. Genetic mapping “can offer firm evidence that a disease transmitted from parent to child is linked to one or more genes . . . and can be used to find the single gene responsible for relatively rare inherited disorders . . . or more common disorders, such as


asthma . . .” (National Human Genome Research Institute, 2007b, p. 1). So consider knowledge of transmission versus ignorance of a preexisting genetic trait—for both parents and child. We continue to gain much needed scientific information from research on human DNA but the ethical considerations cannot be ignored in the quest for knowledge or medical breakthroughs. Pang (2002) noted that advances in genomics are likely to alleviate infectious diseases and alleviate chronic disorders but that attention must be paid to complex ethical and social issues (p. 1077). And what about cloning beyond sheep? At the national level, the Ethical, Legal, and Social Implications (ELSI) Research Program has been established to address the ethical challenges with genomic research. One of the current research priorities includes ethical boundaries and the use of genetic information (National Human Genome Research Institute, 2007a). These issues are just a start to the future dilemmas that the scientific and the healthcare communities will confront.

The American Nurses Association (ANA) in collaboration with stakeholder groups has published essential competencies for nurses and for curriculum in the area of genetics and genomics. These competencies address practice standards for RNs. In the area of professional responsibilities, awareness of one’s own values, advocacy for clients, competency in the nursing role relative to genetics and genomics are minimum competencies. In the practice domain, the ANA (2006a) competencies focus on the following: nursing assessment; identification of clients, valid information, and ethical standards; referral activities, and the provision of education, care, and support (pp. 11–13). These competencies include the need for critical analysis, advocacy, and collaboration with clients and other healthcare providers. Awareness of the terminology, current developments, and ethical standards are vital. To demonstrate the effect of this area on current health priorities, federal agencies such as the Agency for Healthcare Research and Quality have included activities in their annual line item budgets related to 54 Section 1 l Beginning Your Journey

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genomics. Investigate some of the fact National Human Genome Research Institute sheets provided at the Web site of the http://www.genome.gov/ National Human Genome Project and American Nurses Association the expected professional competencies. http://nursingworld.org/MainMenuCategories/ You will encounter additional and ThePracticeofProfessionalNursing/EthicsStandards/ CEHR/Genetics_1/CompetenciesandCurriculafor different ethical dilemmas throughout GeneticsandGenomics.aspx practice. Adherence to ethical principles is a part of clinical judgment and professional practice. Your skills in assessment, critical analysis, and nursing process will be invaluable as you confront the situations as they arise.

KEY POINTS • Rights are agreements that may be legal rights (based on laws that may

• •

• •

•

•

•

•

• •

be revised), moral rights (based on an ethical system or rules of conduct), and option rights (with differences within the overall legal parameters). Basic human rights include beneficence, full disclosure, self-determination, and privacy and confidentiality. Beneficence is the principle of doing good with the person’s best interests as the goal of all actions. Associated ethical principles include justice (fairness) and fidelity (loyalty). Self-determination is the sense of autonomy in which the person has the right to determine his or her fate. Full disclosure is when the individual has complete and relevant information to make an informed decision and includes the principle of veracity or providing truthful information. Informed consent is when the individual has complete information from all sides of the issue and makes a decision for care (or not) freely and without constraint given careful consideration on both advantages and disadvantages of the action. Privacy means the person has the right to determine and control the amount of information to reveal about him- or herself whereas confidentiality means the information that the person does reveal is respected and not revealed to others except as necessary as part of this professional relationship. The two generally established systems of ethical decision making are utilitarianism (based on the consequence) and deontology (based on the consistent obligations as rules and unchanging principles). The Code of Ethics for Nurses developed by the American Nurses Association (ANA) is the ethical standard for professional nursing practice. Standards of care are the accepted practice that is reasonable under a given set of circumstances for a specific profession. There are various ethical decision-making models. A classic model includes the following considerations: obtaining background information, Chapter 4 l Ethics 55

identifying the ethical components, identifying the ethical agents or people involved, identifying the options available, applying ethical principles, and making a final decision on the dilemma (Curtain, 1978). • Advance directives are legal documents (living will and durable power of attorney) that provide written and specific instructions for an individual’s wishes relative to his or her future healthcare in a time when the individual is able to specify those wishes in the event of endof-life decisions. • Active euthanasia is also called “mercy killing” with an active role in the person’s death and is not allowable in the Code of Ethics for Nurses (ANA, 2001, p. 8). • The Human Genome Project has been an outstanding scientific achievement that provided new information on gene structure, function, and dysfunction for the human genome (the complete set of the human DNA).


1. Reflect carefully and identify an ethical dilemma and debate each side with a colleague, one of you using the utilitarianism philosophy and the other using deontology. 2. Identify the basic human rights reflected in the ANA Code of Ethics for Nurses (2001). 3. What commonalities can you identify in the ANA Code of Ethics for Nurses (2001) and the ICN Code of Ethics for Nurses (2006)? 4. Review one standard of care from your facility’s policy and procedure manual and investigate its basis in the professional literature. 5. Find a peer from a different ethnic or cultural background and share your values on an ethical topic of your choice. Go to the Intranet site to complete the interactive exercises provided for this chapter.

REFERENCES Aiken, T. D. (1998). Standards of care. In J. B. Bogart, S. C. Davis, D. H. Dlugose, J. D. Holmes, P. W. Iyler, B. O. Blake, & D. J. Wise (Eds.), Legal nurse consulting principles and practice (pp. 37–45). Boca Raton, FL: American Association of Legal Nurse Consultants CRC Press. American Nurses Association. (2001). Code of ethics for nurses with interpretative statements (Publication No. CEN21 10M 08/01). Washington, DC: American Nurses Publishing. American Nurses Association. (2004). Nursing: Scope and standards of practice (Publication No. 03SSNP). Washington, DC: American Nurses Publishing. American Nurses Association. (2006a). The essential nursing competencies and curricula guidelines for genetics and genomics. Retrieved November 24, 2007, from http://nursingworld.org/MainMenuCategories/ThePracticeofProfessional Nursing/EthicsStandards/CEHR/Genetics_1/CompetenciesandCurriculafor GeneticsandGenomics.aspx


American Nurses Association. (2006b). Position statement: Privacy and confidentiality–12/08/06. Retrieved May 11, 2008 from, http://www.nursingworld.org/MainMenuCategories/ HealthcareandPolicyIssues/ANAPositionStatements/ EthicsandHumanRights/PrivacyandConfidentiality.aspx Aumman, G. (1998). Ethics and the legal nurse consultant. In J. B. Bogart, S. C. Davis, D. H. Dlugose, J. D. Holmes, P. W. Iyler, B. O. Blake, & D. J. Wise (Eds.), Legal nurse consulting principles and practice (pp. 175–191). Boca Raton, FL: American Association of Legal Nurse Consultants CRC Press. Catalano, J. T. (2008). Professional ethics. In R. Kearney-Nunnery (Ed.), Advancing your career: Concepts of professional nursing (4th ed., pp. 250–267). Philadelphia: F.A. Davis. Curtain, L. L. (1978). A proposed model for critical ethical analysis. Nursing Forum, 17(1), 12–17. Dahnke, M., & Dreher, H. M. (2006). Defining ethics and applying the theories. In V. D. Lachman (Ed.), Applied ethics in nursing (pp. 3–13). New York: Springer. Fowler, D. M. (Ed.). (2008). A guide to the code of ethics for nurses: Interpretation and application. Silver Springs, MD: American Nurses Association. Greipp, M. E. (1995). A survey of ethical decision making models in nursing. Journal of Nursing Scholarship, 1(1–2), 51–60. Husted, G. L., & Husted, J. H. (2001). Ethical decision making in nursing and health care: The symphonological approach (2nd ed.). New York: Springer. International Council of Nurses. (2006). The ICN code of ethics for nurses. Retrieved May 11, 2008, from http://www.icn.ch/icncode.pdf National Human Genome Research Institute. (2007a). ELSI research program. Retrieved December 2, 2007, from http://www.genome.gov/10001618 National Human Genome Research Institute. (2007b). Genetic mapping. Retrieved December 2, 2007, from http://www.genome.gov/10000715 Pang, T. (2002). Health policy and ethics forum: The impact of genomics on global health. American Journal of Public Health, 97(7), 1077–1079. Retrieved November 26, 2007, from CINAHL Plus with Full Text Database. Perry, J. E., Churchill, L. R., & Kirshner, H. S. (2005). The Terri Schiavo case: Legal, ethical, and medical perspectives. Annals of Internal Medicine, 143, 744–748. Spector, R. E. (2000). Cultural diversity in health and illness (5th ed.). Upper Saddle River, NJ: Prentice Hall Health.

BIBLIOGRAPHY American Nurses Association. (2003). Nursing’s social policy statement (2nd ed.) (Publication No. 03NSPS 15M 09/03). Washington, DC: American Nurses Publishing. Cameron, B. L. (2004). Ethical moments in practice: The nursing ‘how are you?’ revisited. Nursing Ethics 2004, 11(1), 53–62. Catalano, J. T. (2006). Nursing now! Today’s issues, tomorrow’s trends (4th ed.). Philadelphia: F.A. Davis. Collins, F., & Barker, A. (2007, March). Mapping the cancer genome: Pinpointing the genes involved in cancer will help chart a new course across the complex landscape of human malignancies. Scientific American, 296(3), 50–57. Retrieved November 26, 2007, from CINAHL Plus with Full Text database.


Collins, F. S., Green, E. D., Guttmacher, A. E., & Guyer, M. S. (2003). A vision for the future of genomics research: A blueprint for the genomic era. Nature, 422 (6934), 835–847. Retrieved December 1, 2007, from http://www.genome.gov/11007524 Fry, S. T., & Veatch, R. M. (2006). Case studies in nursing ethics (3rd ed.). Sudbury, MA: Jones and Bartlett. Garcia, J. G., Winston, S. M., Borzuchowska, B., & McGuire-Kuletz, M. (2004). Evaluating the integrative model of ethical decision-making. Rehabilitative Education, 18, 147–164. Ogden, V. (2005). Legal and ethical frameworks for healthcare practice. Journal of Community Nursing, 19(6), 16–18. Retrieved November 16, 2007, from CINAHL Plus with Full Text database. Racine, E. (2003). Discourse ethics as an ethics of responsibility. Journal of Law, Medicine and Ethics, 31, 390–397. Salladay, S. A. (2007). Placebo use: Deceptive practices. Nursing 2007, 10–11. Salladay, S. A. (2007). Ethical problems. Nursing 2007, 27–28. Savage, T. A., & Milton, C. B. (1989). Ethical decision-making models for nurses. Chart, 86(4), 2–5.

ONLINE RESOURCES Agency for Healthcare Research and Quality: http://www.ahrq.gov AARP: http://www.aarp.org/families/end_life/ a2003-12-02-endoflife-finalwishes.html American Nurses Association: http://www.nursingworld.org Bioethics Databases: http://www.nlm.nih.gov/bsd/bioethics.html Familydoctor.org: http://familydoctor.org/online/famdocen/home.html MedlinePlus: http://www.nlm.nih.gov/medlineplus/medlineplus.html National Alliance on Mental Illness: http://www.nami.org National Cancer Institute: http://www.cancer.gov/cancertopics/factsheet/support/ advance-directives National Human Genome Research Institute: http://www.genome.gov/ Organ Donation—Government Site: http://www.organdonor.gov/ Organ Procurement Network: http://optn.org/ Terri Schinder Schiavo Foundation: http://www.terrisfight.org/ Transplants/Donations: http://www.nlm.nih.gov/medlineplus/ transplantationanddonation.html


Section 2

Clinical Judgment and the Nursing Process

There are risks and costs to a program of action, but they are far less than the long-range risks and costs of comfortable inaction. John F. Kennedy, Jr. (1917–1963)

I

n this section, we concentrate on critical thinking, clinical judgment, and the nursing process. We will look at both the dependent and the independent roles of the professional nurse. In Chapter 5, we look to refinement of communication skills and the skills of critical thinking necessary for implementation of the nursing process. In Chapter 6, we focus on the imperatives for client safety that require attention and diligence in the healthcare setting and within the nursing process. In addition to safety, health promotion and disease prevention are important considerations. 59

Section 2

(continued)

In each step of the nursing process, critical thinking is a necessary behavior. Further attention to the steps of the nursing process is provided in subsequent chapters. In Chapter 7, we focus on assessment. More than gathering data, now we focus on the analysis of objective and subjective data obtained from multiple sources in the health history and physical assessment activities that are prerequisites for working with the client in the development of a plan of care. The assessment process also requires a frame of reference and we will organize assessment data according to Gordon’s (2006) eleven functional health patterns. Once analysis of the initial data has occurred, we move to developing and prioritizing nursing diagnoses and a mutually agreeable plan of care for the client. In Chapter 8, Teresa Burckhalter takes a unique approach to developing nursing diagnoses in accordance with NANDA criteria. The focus is on both actual and risk diagnoses with the identification of the problem, the etiology, and in the case of actual diagnoses, the signs and symptoms. Chapter 9 looks at clinical decision making and implementing the nursing process. Techniques along with the importance of client teaching are highlighted. Chapter 10 covers evaluation, which is vital to the success of a plan of care for a client. Section II concludes with a focus on outcomes. Evaluation of outcomes and revisions to a plan of care are a professional obligation. An important component of evaluation is leadership. Leadership is a vital role for the professional nurse to drive changes in the care of plan or to direct the plan of care in accordance with the wishes of the client/family.

REFERENCE Gordon, M. (2006). Manual of nursing diagnosis (11th ed.). Sudbury, MA: Jones and Bartlett.

60 Section 2 l Clinical Judgment and the Nursing Process

CHAPTER 5

Decisions and Approaches: Effective Communication Skills CHAPTER OBJECTIVES After completing this chapter, you will be able to: 1. Describe verbal and nonverbal communication techniques. 2. Identify therapeutic and nontherapeutic communication techniques. 3. Identify barriers to effective communication. 4. Examine cultural variations in communication patterns. 5. Examine the components of critical thinking and the attributes for effective communication skills and clinical judgment.

killful communication techniques are critical for effective care of clients. In addition, effective communication is vital to successful working relations among healthcare providers across the various disciplines. It is no surprise that collaboration between nurses and physicians improves quality of care (Coeling & Cukr, 2000, p. 63). However, a prerequisite for collaboration is effective communication. Let’s begin by examining the communication process for decisions and effective care of clients.

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The Communication Process We constantly strive for effective communication. Communication has been defined as “the process of sharing information using a common set of rules (Northouse and Northouse, 1998, p.2). But what is this common set of rules? If we consistently used some common set of rules, would we have miscommunication and nontherapeutic communication between two individuals? Also consider communication in groups and in organizations. Communication becomes more complex when electronic and cultural differences are considered. However, look back a bit.

Key Terms Communication Sender Channel Message Receiver Noise Relationship Metacommunication Verbal communication Nonverbal communication Barriers to communication Therapeutic communication Cultural competence Critical thinking

Chapter 5 l Decisions and Approaches: Effective Communication Skills 61

The classic communication model was developed by Claude Shannon in the 1940s. He was a researcher at Bell Telephone and proposed a simple mathematical model as the communication channel. His model was further developed with a colleague into a classic linear model for general communication. The communication channel required that the sender (or the source of the information) use some channel (transmission medium) to provide the message (purpose of the information) to the receiver (who must effectively encode/understand the information). However, during the transmission process the noise, distortion, and amount of information in the message also has to be considered. Noise is defined as the extraneous information or distraction added to the message (and not by the sender). Now, remember this was years ago when the technology was evolving. This linear model does not capture all the aspects of nurse and client interactions. Modern communication theory evolved with Berlo’s (1960) consideration of human and interpersonal relationships. He looked at many human factors including psychological, sociological, and linguistic considerations. Berlo (1960) observed that 70% of our daily active hours are spent in communication—performing, as well as listening and reading (p. 1). This statistic does not even include time spent on the Internet and text messaging! He further considered Shannon’s model and identified three purposes of communication: to inform, to persuade, and to entertain (p. 9). Berlo’s communication process contains the following components:

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Source-Encoder Message Channel Decoder-Receiver

On first glance, this may seem similar to Shannon’s model. However, by viewing the separate steps, we see further applicability to today’s world and the complexity of the communication process. Look at all the sources or senders and encoders of messages to a client in the healthcare setting. Berlo (1960) describes the sender as encoding the information 62 Section 2 l Clinical Judgment and the Nursing Process

after determining the way in to affect the receiver to produce a desired response (p. 41). Consider how we may send the same message in a different way to two different individuals in order to produce the desired response. Identify the variety of influences that can add noise or distortion to the information, especially with multiple decoders and receivers. Think about the potential for adverse incidents that could occur in a healthcare setting with additional “hand-offs” and the chance for distortion of information. These hand-offs are communication lapses and missing information that can occur with multiple healthcare providers in a hectic environment. The decoder-receiver also must be able to understand the message that was intended from the source. Consider the scenario with someone whose native language is not yours and the external and internal translation and interpretation that occurs. In the source-receiver sequence, Berlo (1960) posed four factors that affect the way messages are received and interpreted: ■ ■ ■ ■

Communication skills Attitudes Knowledge-level Social-cultural system (p. 50)

In nursing, communication becomes more complex with our metaparadigm concepts of human beings, health, environment, and nursing. Communication has also been incorporated into nursing models, as in King’s (1981) conceptual model and theory of goal attainment in which communication is defined as “an interchange of thoughts and opinions among individuals” (p. 62). This idea demonstrates more complexity than the simple transmission of a message. The Health Communication Model (Northhouse & Northouse, 1998) begins to address this complexity through relationships in the healthcare context. Northouse and Northouse (1998) look at strategies for health professionals in the communication process and incorporate the following concepts in their model: relationships, transactions, and contexts. According to this model, health communication is multidimensional, involving both the content of the message (language and information) and the relationship, or how the individuals in the interaction are “connected” to each other (Northouse & Northouse, 1998, p. 6). They further identify four distinct relationships in health communications: professional-professional, professional-client, professional-significant other, and client-significant other (Northouse & Northouse, 1998, p. 17). These relationships become more complex when more than two individuals are involved in the communication, as is usual in the healthcare setting. Think about the client who is describing his current illness with his spouse present who prompts the client to describe his symptoms further. Now consider the client whose spouse adds additional information, interrupting the client. These relationships may be acceptable to and desired by these clients. However, now add in the interpersonal relationships with each of these and the healthcare providers involved in the communication and where this interview is taking place. Relationships affect transactions (verbal and nonverbal interactions) and also are affected by the environment or the context in which the health communication is occurring. The Health Communications Model is more aligned with our nursing metaparadigm concepts and professional practice. As observed by Favret (2008), this model incorporates all the thoughts, feelings, attitudes, and roles of the participants, which can greatly influence the accuracy of the communication (p. 128). This complexity with human relationships and interactions within a unique environment presents a challenge for effective interpretation of information and decision making. Chapter 5 l Decisions and Approaches: Effective Communication Skills 63

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Arnold and Boggs (2007) identify these complex factors as metacommunication, to describe the multiple influences on how communication is perceived, both verbal communication (including culture, native language, gender, and pitch) and nonverbal communication (including body language, culture, gender, and appearance) (p. 186). Notice that culture and gender are important components of both verbal and nonverbal communication. Individuals from some cultures more readily share health information than others. And we often recognize that women are frequently the care providers in the family and may readily share information about themselves or others in the family. Communication may be verbal or nonverbal. Verbal communication includes oral, written, and electronic communication. Now let’s consider the influences in oral communication, including vocalizations, differences among vocabulary or word selection, pacing, intonation (pitch), emphasis, and accent. Both the sender and the receiver are sensitive to individual variations. Written and electronic communications are similarly evaluated based on spelling, grammar, appropriate vocabulary and punctuation, emphasis, and overall appearance. Receivers of messages evaluate the sender of the message by the perceived verbal content as well as by the presentation of the content. Nonverbal communication includes messages sent and received Check out the free resources for giving a speech through gestures, body position and at Toastmasters International Resources for Oral language, and facial expressions. Presentations http://www.toastmasters.org/MainMenuCategories/ Physical space between the sender and FreeResources.aspx the receiver is another consideration for personal comfort, ease for interpretation, acceptability of content, and varies among cultures. Kinesics refers to body position and actions used in communication, or body language. Some people feel that body language may betray the verbal expression and that it is more difficult to deceive nonverbally in communication. Be aware of your nonverbal mannerisms the next time you are waiting in a supermarket line. You may not be verbalizing your impatience, but you may be communicating a message to the cashier that causes even more delay. In the acute care setting, consider the messages that family members interpret while waiting at the nurses’ station. Do they feel ignored or intimidated? The problem becomes one of interpretation. In addition, cultural differences should be accounted for rather than assumed differently. Now, you are probably thinking that this is not “rocket science.” True, but do we consciously consider these factors in our routine communication with clients and colleagues? Northouse and Northouse (1998) further categorize communication as either human communication (between people) or health communication (human communication specific to health issues). They also refer to these forms of communication as transactional in nature. These differences add more complexity to the simple sender, message, channel, and receiver model. The mere complexity of interpersonal communication requires constant skill and continued refinement. Have you ever caught yourself thinking, “Why did I say that?” In contrast, what about the times when you missed that thought—a missed communication or miscommunication. In daily life, we may have times to re-visit a conversation with another to correct misinterpretations. But consider the time factor in the clinical setting and the multiple interpersonal encounters experienced in a short time span. Look further at health communication.


Northouse and Northouse (1998) have identified the following variables relative to health communication: ■ ■ ■ ■ ■

Empathy Control or influence Trust Self-disclosure Confirmation

Think about these variables from a practice perspective. To quote an old Native American proverb, empathy is “walking in the other person’s moccasins.” Do you truly understand the person in the health communication encounter or are you interpreting from your own frame of reference? Have you found yourself using jargon or medical terms that they may not know, perhaps one as simple as NPO? Let’s consider the control variable. The health professional may be attempting to control the information from two sides: controlling the actual content of the message and attempting to control the receiver into accepting the information. Is the client receiving only some (or “filtered”) information? If so, consider who is imposing this filter and recall the four relationships: ■ ■ ■ ■

Professional-professional Professional-client Professional-significant-other Client-significant other (Northouse & Northouse, 1998, p. 17)

Attempting to have the other person accept information is often ineffective without a good relationship, which must include acceptance and trust on the part of the client. The client may also attempt to “control” communication by limiting the amount of information divulged to the healthcare provider. Recall the content on privacy and confidentiality related to self-disclosure discussed in Chapter 4, discussing the information that the client is willing to share with the healthcare provider. Confirmation is validation of the information, and this can occur through both subjective and objective data. However, a note of caution, in that the client should be aware that you are confirming your understanding of the information. Often, clients feel like they are Chapter 5 l Decisions and Approaches: Effective Communication Skills 65

being asked the same question by many providers. They also may feel like the providers do not believe them. An understanding of the subjective data and aligning it with objective data provides a more complete picture. And sharing this complete picture with the client involves him or her in the process. It also demonstrates respect for the client in the process and involves the client in his or her care. Another important component of communication is listening. Listening has been described as both a commitment and a complement as we attempt to view how others see their world and put aside our view to see the situation from the eyes of the other person (McKay, Davis, & Fanning, 1995). Active listening requires astute verbal and nonverbal communication. There are specific techniques that have been shown to be effective in human communication and those that are barriers. Arnold and Boggs (2007) have identified bridges and barriers in the nurse-client therapeutic relationship (Table 5–1). The effective techniques act to enhance interpersonal communication but require diligence in daily encounters with competing directives and personalities. Barriers to communication are nontherapeutic communication techniques or communication breakdowns. These barriers result in failure to send or receive an accurate message or result in misinterpretation of the message. Barriers diminish the interpersonal relationship, but again, may be unintentional in a busy and overburdened healthcare environment. We must constantly attempt to foster the bridges and incorporate warning lights in our professional thought when barriers start to emerge in the interpersonal relationship with clients.

Therapeutic Nurse-Client Communication Therapeutic communication does not just happen instantly. It develops gradually and includes three phases: initial, working, and termination. As with any communication, trust and respect are important goals for the initial phase. During the working stage, emphasis in placed on understanding the issues to be addressed and mutually developing strategies to meet client needs. The working phase is the longest, because this is the reason for the health communication—to address the client’s health and care needs. The termination phase prepares for the end of the relationship. In healthcare communication, the termination phase includes evaluation of the objectives and goals that were developed in the working phase. It also includes plans for separation, with the client taking on more independence in their role. Keep in mind that trust must be maintained and respect shared throughout all phases. Therapeutic nurse-client communication is directed at the goals of the TABLE 5–1 Bridges and Barriers in Therapeutic helping relationship. Tamparo and Relationships Lindh (2007) describe therapeutic communication as meeting the need or Bridges Barriers addressing a problem of a person in Caring Anxiety need of healthcare by a healthcare proTrust Stereotyping/bias fessional who is skilled in communiMutuality Overinvolvement Respect Violation of personal space cation techniques to diminish that Empowerment Violation of confidentiality problem (p. 6). Specific communicaEmpathy Cultural barriers tion techniques must be authentic and Ethical principles Gender practiced on a regular basis for the natural skill of the healthcare profesFrom: Arnold, E., & Boggs, K. (2007). Interpersonal relationships: Professional communication sional (see Tables 5–2 and 5–3). skills for nurses (5th ed.). Philadelphia: Saunders/Elsevier, p. 117 with permission. 66 Section 2 l Clinical Judgment and the Nursing Process

TABLE 5–2

Therapeutic Communication Techniques

Therapeutic Techniques Active listening Restatement Reflection Focusing Encouraging elaboration Looking at alternatives

Use of silence

Appropriate questions

TABLE 5–3

Examples Leaning forward, making eye contact, and nodding your head while expression, “what else?” You mentioned that this is the worst pain that you have ever experienced. So you feel that you have had less pain management in the past 2 weeks and are missing more work and family activities? Tell me more about the pain sensation you are having now in your lower back. When you consider your back pain, tell me more about the sensations. Since operating an automobile is dangerous while taking Hydrocodone, what options do you have for getting to the doctor and to the supermarket? Do you have a neighbor or a friend who could help when your children are not in town? Which could work for your different activities? Sitting quietly while the client decides what information they wish to provide but leaning forward and making eye contact, looking interested in the person. What do you expect with your attendance at this pain management clinic? Tell me about which of your daily activities is most limited with your back pain.

Nontherapeutic Communication Techniques

Nontherapeutic Techniques False reassurance Giving advice Probing Stereotyping Social comment Changing the subject Use of jargon

Examples Now, you just had a scare. It will be okay just like the last time. Now, why don’t you try acupuncture? It worked for me when I had back pain. Are you sure there is no incidence of mental breakdowns in your family? I am sure you have a high pain threshold since Native Americans are so stoic. Medicare and Social Security just don’t help enough. What do you think they will bring you for lunch today? Now, we have to get you up to get an MRI and to PT.

Developmental Considerations Recall our consideration of the developmental theories discussed in Chapter 3. Effective, therapeutic communication must be directed at the appropriate developmental level of the client. It also should incorporate the client’s personality, cognitive, and moral development using a life span perspective. Remember the steps or stages through which the individual progresses during the life cycle. Think about the importance of promoting trust rather than mistrust in an infant. Now, consider how this trust could be developed between the infant and caregiver through nonverbal communication such as touch and through the character of the verbal communication as opposed to the content. These same communication techniques may be useful for the elder with dementia but would not be the best style for the adolescent or young adult. Erikson’s theory of psychosocial development reviewed in Chapter 3 provides valuable clues for communication techniques. Remember, with Chapter 5 l Decisions and Approaches: Effective Communication Skills 67

illness, lower level needs may predominate but we still must focus on developmentally appropriate communication. Nonverbal communication also is an important consideration for children. For example, when communicating with a child you should be at their eye level so that you are not “talking down” to the child, which may be interpreted as a threat. This also relates to the person in bed who does not want to be towered over, talked to from the door or over the intercom, or called a familiar name rather than a respectful one. A child may be called “sweetie” by a family member, but should be allowed to decide how to be addressed. This means of address is even more important for the older individual who may be feeling powerlessness and who does not want or need to be called by a familiar name or nickname. The individual’s cognitive level is another developmental consideration. Piaget’s theory of cognitive development is useful with toddlers and preschoolers who overgeneralize and have magical thought requiring care in wording and examples. For example, the young child may fear “going to sleep” and equate that with death after the demise of a favorite pet. Logical reasoning does not emerge until after 11 years old. And the affects of illness, pharmacological agents, and fear may interfere with cognition and logical reasoning. Kohlberg’s theory of moral development and the application of rules and principles of justice are further consideratons in truly therapeutic communication. However, beyond personality, cognitive and moral development are additional environmental and cultural considerations that must be assessed and incorporated for effective communication.

Cultural Considerations When people speak of ethnicity and race, they generally refer to a group, tribe, or nation of people united by some common characteristics, whether biological, environmental, or social. In the United States, we tend to classify people into five ethnic groups: African Americans, Asian Americans and Pacific Islanders, Hispanic Americans, Native Americans, and white Americans. But this tendency does little to help us understand their unique communication patterns, let alone their health beliefs, practices, needs, or diversity represented within each of these population classifications. It may, in fact, encourage us to impose stereotypical judgments on persons within these groups. Recall that stereotyping was identified as a barrier to the therapeutic relationship. This point leads us to the concept of culture as a way of life and the increasing focus on cultural competence. Betancourt, Green, and Carrillo (2002) describe three components of cultural competence—organizational, systemic, and clinical—with clinical cultural competence as “health professionals’ awareness of cultural issues and health beliefs while providing methods to elicit, negotiate, and manage the information once it is obtained” “(Betancourt et al., 2002, p. 17). Our cultural inheritance has a powerful influence on our behaviors, both conscious and unconscious. We bring into our personal and professional lives the influences from our ancestors, family, peers, and colleagues. We are affected by history, genetics, social customs, religion, language, politics, law, economics, education, and many other factors. We mutually influence and are influenced by others because of these endowments. When we talk about cultural diversity, we mean more than an inherited background. “Culture” implies social, familial, religious, national, and professional characteristics that affect the way we think and act; it is a combination of all these things. It is important to consider the characteristics of both the client and the health professional. The values for cultural diversity and culturally sensitive care are necessary for a therapeutic 68 Section 2 l Clinical Judgment and the Nursing Process

nurse-client relationship. As Andrews and Boyle (2003) indicates, however, “health professionals must have positive experiences with members of other cultures and learn to value genuinely the contributions all cultures make to our multicultural society” (p. 9).

In our healthcare system, we generally view the roles of healthcare providers and those of consumers in traditional ways. We consider the disease or illness, including all the pathophysiology and treatment modalities with the healthcare provider as the authority figure. We are aware of healthcare and health promotion services in both the hospital and community setting. We usually present them through our words and behaviors as norms to which clients must adhere. Otherwise, they are termed “bad patients,” “noncompliant,” or even “problem cases.” As noted by Spector (2000), the scientific or medical model has a dualistic view of body and mind and adherence to scientific and technological norms of the system for acute care, chronic care, rehabilitation, psychiatric/mental health, and community/ public health—and is a culture onto itself (pp. 110–111). The holistic model sees health as a balance of the physical, mental, and spiritual whole and includes both alternative and complementary therapies (e.g., aroma or massage therapy) and ethnocultural practices (e.g., herbals or voodoo) (Spector, 2000). The holistic aim is for a sense of harmony and treatment is to correct an imbalance. These cultural differences can exist as competing health beliefs and roles between the client and the healthcare provider, and can also become a barrier to the therapeutic relationship. For example, the healthcare community carefully conducts research to identify factors to treat, manage, or cure a disease. But our clients may not adhere to the scientific model and believe in holistic, religious, or supernatural influences. Faced with clients whose belief system includes the “hot/cold” theory of disease causation and treatment—which holds that imbalance of the body humors resulting in a “hot” infectious condition must be treated with appropriate foods or herbs—we may ignore or patronize the client. Many scientific minds reject this theory, creating conflict and failure to provide healthcare. The movement for culturally competent care is an imperative for an effective nurseclient relationship. Difficulties arise when significant values are unknown, in conflict, or Chapter 5 l Decisions and Approaches: Effective Communication Skills 69

poorly understood. The client’s cultural values can be quite different from those of the healthcare provider. Consider the importance of religious or dominant spiritual influence in many subgroups in our environment. Time, openness, and a growing understanding are critical components of a nurses’s development of higher levels of cultural competence and effective communication. Purnell and Paulanka (2005) describes cultural competence as a conscious process, one that is not necessarily linear in nature, and one with many definitions and terminology (p. 7). The Purnell Model for Cultural Competence was originally designed as an organizing framework, as a wheel with four rims representing the society, community, family, and the person, and spokes as 12 wedges representing cultural constructs, to the unknown dark core at the center as illustrated in Figure 5–1. Seven primary concepts (e.g., age and gender) and 13 secondary concepts (e.g., marital status) of culture are identified with cultural competence as a nonlinear process as the road below the wheel. The development of cultural competence is implicit as noted in one of 21 assumptions upon which the model is based, “when individuals of dissimilar cultural orientations meet in a work or therapeutic environment, the likelihood for developing a mutually satisfying relationship is improved if both parties in the relationship attempt to learn about each other’s culture” (p. 12). Cultural competence is a directive to actively understand the uniqueness of human beings in their environment. In doing this, therapeutic relationships are possible to effectively care for individuals, families, and groups with positive outcomes. We need to remind ourselves that individuals within a selected culture are different. As we seek to understand different cultures and heritages, we must still focus on the individual and families. Consider the following variables for culturally competent care: ■ Time with clients to become accepted and gain an understanding of their belief system ■ Differences in belief systems among generations and geographic origin ■ Past experiences and current situation ■ Religious influences ■ Familial influences ■ Understanding of advance directives ■ Acceptance of the healthcare services, systems, and practitioners ■ Linguistic issues

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All of these variables require the use of critical thinking skills on the part of the nurse as a component of cultural competence and clinical judgment. The Center for Cross-Cultural Health at www.crosshealth.com Transcultural C.A.R.E. Associates at http://www.transculturalcare.net

Critical Thinking

You will hear a good deal about critical thinking throughout your nursing program. Nurses cannot successfully care for clients with only remembered facts. Nurses practice based on concepts that are in constant evaluation and applied to the situation at hand based on careful analysis and evaluation. In fact, critical thinking is a requirement for accreditation of nursing programs—how they promote, measure, and evaluate critical thinking skills. Based on the results of a consensus panel, Faccione (2007) described six core critical thinking skills and additional personal attributes for critical thinking (Box 5–1).


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BOX 5–1

Critical Thinking Skills and Dispositions

Core Cognitive Skills ✻ Interpretation ✻ Analysis ✻ Evaluation ✻ Inference ✻ Explanation ✻ Self-regulation

Personal Attributes ✻ Inquisitive ✻ Systematic ✻ Judicious ✻ Truthseeking ✻ Analytical ✻ Open-minded ✻ Confident in reasoning

Source: Faccione, P. (2007). Critical thinking: What it is and why it counts. 2007 Update. Insight Assessment. Retrieved December 2, 2007, from http://www.insightassessment.com/pdf_files/what&why2007.pdf

These identified core cognitive skills are necessary in daily life but especially in professional practice. As new information becomes available, it must be considered in light of contextual factors for the individual client in his or her unique environment. Particular to defining critical thinking in nursing, Scheffer and Rubenfeld (2000) conducted research to develop a consensus statement. Again cognitive and affective behaviors and traits were identified (Box 5–2). The authors described these affective components as habits of the mind (Scheffer & Rubenfeld, 2000). Recall from Chapter 1 that adults learn by (1) elaborating existing frames of reference, (2) learning new frames of reference, (3) transforming points of view, or (4) transforming habits of mind (Mezirow, 2000, p. 19). These habits of mind provide the values and abilities within the person to allow for critical thinking in daily life and in clinical practice. But practice and constant refinement allow for ease and skill in the process. When considering these skills and attributes, parallels have been made with the nursing process, in the steps of assessment, diagnosis, planning, implementation and evaluation, and the decision-making process. However, as Staib (2003) has observed, “. . . critical thinking is more than the nursing process” (p. 506). Critical thinking is a requirement for effective use of the nursing process. The cognitive skills must be used for understanding and acting on the data. But the individual nurse must also have the personal attributes listed for application of the needed skills. These cognitive and affective skills are apparent in the work from both of these critical thinking consensus groups

BOX 5–2

Critical Thinking Components in Nursing

Cognitive Components

Affective Components

✻ Analyzing ✻ Applying standards ✻ Discriminating ✻ Information seeking ✻ Logical reasoning ✻ Predicting ✻ Transforming knowledge

✻ Confidence ✻ Contextual perspective ✻ Creativity ✻ Flexibility ✻ Inquisitiveness ✻ Intellectual integrity ✻ Intuition ✻ Open-mindedness ✻ Perseverance ✻ Reflection

Source: From: Scheffer, R. K., & Rubenfeld, M. G. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, 39, 352–359, p. 358.


and support this multifaceted process. Think about it. Are you inquisitive, intuitive, reflective, creative, and open-minded both in and away from the practice setting? Consider how you perform in a hectic environment versus during a favorite leisure time activity. Most nurses are systematic through their attention to procedural steps, but what about in the thinking process. As observed by Riddell (2007), both knowledge and experience influence critical thinking and this leads to sound clinical decision making (p. 125). Think about how you demonstrate the critical thinking components in practice. Analyzing a situation is more than performing a procedure. For example, it includes consideration of individual factors including the diabetic client’s home environment where he will be administering his own insulin. Standards would include principles of effective medication administration and monitoring as well as using and teaching principles of asepsis and good hygiene. Being discriminating in this case requires consideration of the client’s uniqueness and matching this information with appropriate care techniques. Critical reflection and logical reasoning is crucial for effectiveness and efficiency in meeting the individual’s healthcare needs. You would be looking to promote health and positive outcomes and for discovery of a better way to do it and incorporating this in your cognitive, psychomotor, and affective skill set. And speaking of the affective components, practice and conscious effort to develop these habits of mind come with expertise in the registered nurse role in the competency process, moving from novice to expert.

COMMUNICATING WITH COLLEAGUES Recall that Northouse and Northouse (1998) identified four relationships in their health communications model. One of these was the professional-to-professional communication required among healthcare providers. Just as ongoing attention and refinement of communication skill is needed with clients, so it is with colleagues. This ongoing attention to Chapter 5 l Decisions and Approaches: Effective Communication Skills 73

teamwork and communication is essential for client safety and efficacy of care, especially given a national study that found that nurses and physicians have different interaction styles and clinical vocabularies (McCarthy & Blumenthal, 2006, p. 16). The registered nurse may be the case manager for the client and be required to participate in many different relationships and health communications. The three phases of the communication process also are applicable. For example, in the initial phase the establishment of trust and mutual respect are critical. Trust and respect also are important in the professional communication process to achieve an effective working phase to meet the client’s healthcare needs. Careful attention should be paid to both verbal and nonverbal techniques for effective communication among professionals. The healthcare agency is also a culture in itself. We have our own language, jargon, and values in the healthcare environment. Recall that this culture must also be considered as well as the client’s. Also consider any cultural differences that may exist among the different health professionals involved in the communication process. This multifaceted process requires continual use of critical thinking and therapeutic techniques. In addition to the usual verbal and nonverbal interpersonal communication techniques, additional technologies are used in organizations. We have computer networks, fiber optics, satellite, and teleconferencing technology. Computers manage information storage, inventory, rapid retrieval, data processing, data analysis, and report generation. The information we compile and the method we use to transmit it vary by the nature of the communication channel we are using. For example, a general rule in an organization is to limit memos to one page or less and disperse them to the appropriate parties; however, the sender needs to consider the available and appropriate technology, such as interoffice paper copies or electronic mail. Considering the purpose of the message is indispensable. Whether we are involved in obtaining orders or transmitting assessment or laboratory findings, the method and receiver of the information are important. Clear, concise, and timely information is necessary for an effective process. Recall the concept of noise as the inclusion of extraneous information. In professional communication, attention to both the purpose of the information and the nature of the information are vital. The time frame and ongoing evaluation also are factors in the initial communication phase, as well as in the feedback phase of the process. Information can be sent or received by telephone, fax, text messaging, or electronic mail, depending on sender’s and receiver’s access to and skill with the available technology. This involves not only the channels, technology, and purpose of the information, but also the person, as the receiver of the information. Consider the use of electronic mail in organizations. The intent is to efficiently and rapidly deliver information to other professionals in the sender’s network while reducing paper and administrative costs. If the information is not sent correctly or received appropriately, the message is not communicated and the process is ineffective. Personal skills in verbal and written communication through specific technologies must be continually developed. For example, it must be remembered that electronic mail can be easily forwarded to others and the original sender’s message will be evaluated on the appropriateness of content, format, and presentation (including grammar and appearance). Selecting the proper channels and preparing the information in the correct format are vital for effective communication.


CLINICAL DECISION MAKING The communication process is just that, a process requiring ongoing attention and development for effectiveness, whether communicating with clients, family, or professionals. Critical thinking and the cognitive skills and personal abilities are interwoven in the process to make it effective. Effective clinical decisions are dependent on valid information and good communication. Remember, communication occurs regardless. However, reflect on the effectiveness of the process and whether therapeutic techniques were used. Now, critically think about your next encounter with a client.

KEY POINTS • Communication has been defined as “the process of sharing information using a common set of rules (Northouse & Northouse, 1998, p. 2). • The communication channel required that the sender (or the source of the information) use some channel (transmission medium) to provide the message (purpose or the information) to the receiver who must encode (understand) the information.

• In the communication process, noise is the something added to the message as extraneous information or distraction.

• According to the health communication model, communication is

• •

• •

•

•

multidimensional involving both the content of the message (language and information) and the relationship, or how the individuals in the interaction are “connected” to each other (Northouse & Northouse, 1998, p. 6). Metacommunication is the way in which the multiple and complex factors in the communication process are perceived by the receiver. Verbal communication includes oral as well as written and electronic communication. Some factors to consider with oral communication include vocalizations (vocabulary, pacing, intonation, emphasis, accent) along with written and electronic communication similarly evaluated based on spelling, grammar, appropriate vocabulary, punctuation, emphasis, and overall appearance. Nonverbal communication includes messages sent and received through gestures, body position and language, and facial expressions. Barriers to therapeutic communication include false reassurance, giving advice, probing, stereotyping, social comment, changing the subject, and the use of jargon. Therapeutic communication considers individual factors including developmental level and the unique culture using techniques of active listening, restatement, reflection, focusing, encouraging elaboration, looking at alternatives, silence, and appropriate questions. Cultural competence is a directive to actively understand the uniqueness of human beings in their environment and requires time, understanding, sharing and acceptance of different value systems, and effective communication skills.


• Critical thinking has been described as including both cognitive skills and personal abilities to truly seek to understand a situation, whether in personal life or professional practice.


1. Conduct a 5 minute interview of a colleague. At the conclusion, compare your observations of the verbal and nonverbal communication techniques used by both of you. Identify both therapeutic and nontherapeutic techniques. 2. Identify barriers to effective communication in the following situations: a. 79-year-old male the day following hip replacement. b. 58-year-old female with early stage Alzheimer’s disease. c. 6-year-old female visiting her mother following a hysterectomy. d. 38-year-old Hispanic migrant worker in a health clinic for a tetanus immunization. e. 18-year-old male admitted to the ICU who is unconscious following a motor vehicle accident and identified as a member of a local gang. f. 28-year-old just diagnosed with HIV-AIDS. 3. Examine the components of critical thinking and the attributes for effective communication skills and clinical judgment. Go to the Intranet site and complete the interactive exercises provided for this chapter.

REFERENCES Andrews, M., & Boyle, J. (2003). Transcultural concepts in nursing care (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. Arnold, E., & Boggs, K. (2007). Interpersonal relationships: Professional communication skills for nurses (5th ed.). Philadelphia: Saunders/Elsevier. Berlo, D. K. (1960). The process of communication: An introduction to theory and practice. New York: Holt, Rinehart & Winston. Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002, October). Cultural competence in health care: Emerging frameworks and practical approaches (Field Report, Publication No. 576). New York: The Commonwealth Fund. Coeling, H. V. E., & Cukr, P. L. (2000). Communication styles that promote perceptions of collaboration, quality, and nurse satisfaction. Journal of Nursing Care Quality, 14(2), 63–74. Faccione, P. (2007). Critical thinking: What it is and why it counts. 2007 Update. Insight Assessment. Retrieved December 2, 2007, from http://www.insightassessment.com/pdf_files/what&why2007.pdf Favret, J. O. (2008). Effective Communication. In R. Kearney-Nunnery (Ed.), Advancing your career: Concepts of professional nursing (4th ed., pp. 123–139). Philadelphia: F.A. Davis. King, I. M. (1981). A theory for nursing: Systems, concepts, process. New York: John Wiley & Sons. McCarthy, D., & Blumenthal, D. (2006). Committed to safety: Ten case studies on reducing harm to patients. New York: The Commonwealth Fund. Retrieved January 13, 2008, from http://www.commonwealthfund.org/publications/ publications_show.htm?doc_id=368995& McKay, M., Davis, M., & Fanning, P. (1995). Messages: The communication skills book (2nd ed.). Oakland, CA: New Harbinger Publications.


Mezirow, J. (2000). Learning to think like an adult: Core concepts of transformation theory. In J. Mezirow and Associates, Learning as transformation: Critical perspectives on a theory in progress (pp. 3–33). San Francisco: Jossey-Bass. Northouse, P. G., & Northouse, L. L. (1998). Health communication strategies for health professionals (2nd ed.). Norwalk, CT: Appleton & Lange. Purnell, L. D, & Paulanka, B. J. (2005). Transcultural health care: A culturally competent approach (2nd ed.). Philadelphia: F.A. Davis. Riddell, T. (Mar 2007). Critical assumptions: Thinking critically about critical thinking. Journal of Nursing Education, 46(3), 121–126. Retrieved November 26, 2007, from CINAHL Plus with Full Text database. Scheffer, R. K., & Rubenfeld, M. G. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, 39, 352–359. Spector, R. E. (2000). Cultural diversity in health & illness (5th ed.). Upper Saddle River, NJ: Prentice Hall Health. Staib, S. (2003). Teaching and measuring critical thinking. Journal of Nursing Education, 42(11), 498–508. Retrieved November 26, 2007, from CINAHL Plus with Full Text database. Tamparo, C. D., & Lindh, W. Q. (2007). Therapeutic communications for health care (3rd ed.). Cliffton Park, NY: Thompson Delmar Learning.

BIBLIOGRAPHY Banning, M. (2006). Nursing research: Perspectives on critical thinking. British Journal of Nursing, 15(8), 458–461. Retrieved November 26, 2007, from CINAHL Plus with Full Text database. Beistle, K., Smith, D., & Nagel, G. (2006). Critical thinking underlies evidencebased decision making. RDH, 26(6), 74–75. Retrieved November 26, 2007, from CINAHL Plus with Full Text database. Chabeli, M. (Aug 2006). Higher order thinking skills competencies required by outcomes-based education from learners. Curationis, 29(3), 78–86. Retrieved November 26, 2007, from CINAHL Plus with Full Text database. Dickerson, P. S. (2005). Nurturing critical thinkers. The Journal of Continuing Education in Nursing, 26(2), 68–72. Edwards, S. (2003). Critical thinking at the bedside: A practical perspective. British Journal of Nursing, 12(19), 1142–1149. Erikson, E. H. (1963). Childhood and society (2nd ed.). New York: W. W. Norton. Kohlberg, L. (1984). Essays in moral development: Vol. II. The psychology of moral development. San Francisco: Harper & Row. Kostovich, C., Poradzisz, M., Wood, K., & O’Brien, K. (2007). Learning style preference and student aptitude for concept maps. Journal of Nursing Education, 46(5), 225–231. Retrieved November 26, 2007, from CINAHL Plus with Full Text database. Walsh, C., & Seldomridge, L. (2006). Critical thinking: back to square two. Journal of Nursing Education, 45(6), 212–219. Retrieved November 26, 2007, from CINAHL Plus with Full Text database. Ward, C. (Sep/Oct 2006). Developing critical thinking in nursing. Med-Surg Matters, 15(5), 1. Retrieved November 26, 2007, from CINAHL Plus with Full Text database.

ONLINE RESOURCES The Center for Cross-Cultural Health: www.crosshealth.com Toastmasters International: http://www.toastmasters.org/ Transcultural C.A.R.E. Associates: http://www.transculturalcare.net


CHAPTER 6

The Imperative for Safe Nursing Care and Use of the Nursing Process CHAPTER OBJECTIVES

Key Terms Culture of blame Culture of safety Sentinel event Root cause analysis Primary prevention Secondary prevention Tertiary prevention Nursing process NANDA NIC NOC

After completing this chapter, you will be able to: 1. Discuss the imperative for safety in the healthcare setting. 2. Differentiate between the cultures of safety and blame. 3. Explain the use of a root cause analysis for a sentinel event. 4. Review current safety initiatives in the context of the nursing process. 5. Differentiate activities designed for primary, secondary, and tertiary health promotion. 6. Discuss the history and application of the nursing process in the practice setting.

e have seen nursing and healthcare change radically in recent years. With restructuring of healthcare, nursing professionals have responded with refinements, advancements, and innovations. Nursing has moved from the functional service mode of the mid-1900s to an effective, outcomes, and consumer-focused orientation. It is no longer the nursing care plan for the patient, but now is the collaborative care plan of the client. This care must be framed in the context of safety and client involvement. This imperative requires acute attention to safety and increasing refinement of skills in the nursing process.

W

Building a Culture of Safety THE INSTITUTE OF MEDICINE QUALITY CHASM Health professions and consumers of healthcare were alarmed with the release of reports from the Institute of Medicine (IOM) of the National Academies on the high 78 Section 2 l Clinical Judgment and the Nursing Process

incidence of medical errors. There was a definite call to improve safety to clients. The IOM is a nonprofit organization designed to provide science-based advice as a public service. The 2001 report from the IOM, Crossing the Quality Chasm, proposed rules for the health system in the 21st century for quality healthcare (Box 6–1). The six overall aims—that care should be safe, effective, patient-centered, timely, efficient, and equitable—underlie the ten rules (IOM, 2006, p. 1). A further report after a Health Professions Education Summit led to the identification of the five core competencies for all health professionals: ■ ■ ■ ■ ■

Provide patient-centered care Work in interdisciplinary teams Employ evidence-based practice Apply quality improvement Utilize informatics (Greiner & Knebel, 2003)

BOX 6–1

Rules for the 21st Century Health System

✻ Care is based on continuous healing relationships. ✻ Care is customized according to patient needs and values. ✻ The patient is the source of control. ✻ Knowledge is shared and information flows freely. ✻ Decision making is evidence-based. ✻ Safety is a system property. ✻ Transparency is necessary. ✻ Needs are anticipated. ✻ Waste is continuously decreased. ✻ Cooperation among clinicians is a priority. Source: Greiner, A. C., & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: Institute of Medicine, (p. 48).

Chapter 6 l The Imperative for Safe Nursing Care and Use of the Nursing Process 79

Client safety and effectiveness of outcomes became major national objectives and directed additional attention to nursing. Research by the Agency for Healthcare Research and Quality (AHRQ) and other national leaders for client safety focused on expanding the knowledge base on how the quality of the healthcare workplace affects the quality of healthcare provided, especially in the areas of workload and working conditions, effects of stress and fatigue, reducing adverse events, and the organizational climate and culture. Client outcomes were now being investigated, along with nursing-sensitive indicators and factors that promote safe and effective practice. In late 2003, nursing itself was the focus of the IOM in their report, Keeping Patients Safe: Transforming the Work Environment of Nurses. The IOM’s Committee on the Work Environment and Patient Safety provided specific recommendations to both acute care and long-term care organizations on issues of management practices, workforce capability, work design, and the organizational safety culture (Page, 2004, p. 3). The following risk factors were identified for patient safety in nursing work environments: ■ ■ ■ ■ ■ ■ ■ ■

More acutely ill patients Shorter hospital stays Redesigned work Frequent patient turnover High staff turnover Long work hours Rapid increases in new knowledge and technology Increased interruptions and demands on nurses’ time (Page, 2004, pp. 37–45)

Although these facts were no surprise, their identification as risk factors to clients was significant. Nurses have been reporting these factors but now they were included in a major national report. This committee also documented the national shortages of both nurses and nursing assistants. Recommendations to nursing leadership and management on how to address the deficiencies in the documented work environments called attention to leadership, communication and collaborative skills, evidence-based practices, adequacy of resources, and an emphasis on safety. At the staff level, the committee found “strong evidence that nurse staffing levels, the knowledge and skills level of nursing staff, and the extent to which workers collaborate in sharing their knowledge and skills affect patient outcomes and safety” (Page, 2004, p. 161). This finding provides further support for the need to incorporate the five core competencies (see Chapter 2, Box 2–2) into professional nursing practice on a consistent basis. Nurses consistently strive to provide client-centered care, but for safe and positive client outcomes this must also be done in light of the other core competencies. Evolving technologies, evidence-based collaborative practice, and continued competence are essential components for safety and quality improvement in the delivery of healthcare to consumers. In subsequent years, the IOM investigated health disparities, the role of the government including Medicare, rural health, healthcare reimbursement practices, and mental health conditions among other quality improvement initiatives. Of particular note was a study mandated by the United States Congress on preventing medication errors. In July 2006, the IOM report released on Preventing Medication Errors presented information available on the incidence of medication errors in acute care settings, long-term care, and in ambulatory care—including errors in the homes of consumers—in an effort to develop an agenda for the nation to reduce preventable errors and adverse drug events and enhance


medication safety. Although the incidence rates were approximated based on the data, the report did emphasize that these rates were most likely underestimates, based on available and reportable data and the incidence of adverse events. It was reported, however, that at least 25 percent of all harmful adverse drug events are preventable (Aspden,Wolcott, Bootman, and Cronenwett, 2006, p. 4). Based on the ten rules from the earlier Quality Chasm Report in 2001, the IOM (Aspden, et al., 2006) recommended the transformation of the entire system to a patient-centered, integrated-use system with specific action agendas to support the consumer-provider partnership for: ■ ■ ■ ■

Healthcare organizations The pharmaceutical, medical device, and health information technology industries Research on safe medication use Oversight, regulation, and payment

Seven recommendations provided by the IOM (Aspden, et al., 2006) focused further on: ■ ■ ■ ■ ■ ■

Consumer empowerment for self-medication management Improvement and standardization of resources by governmental agencies Implementation of client-information and decision-support technologies nationwide Improved labeling, packaging, and distribution including studies on use of samples Standards for drug information technologies including design and alert systems Funded research on safe and appropriate medication use across settings, especially on error prevention ■ Adoption of broad practices, technologies, and professional behaviors focused on safety and error reduction In the past, errors resulted in incident reports and someone being identified as the cause. This finger pointing at an individual or individuals was the culture of blame. This culture and associated practices did not generally yield improvements, rather loss of opportunities to make improvements and at times, secretive practices. Consumers, insurers, and the media became concerned for safety and often questioned too much or too little care and testing. Systemic issues in the healthcare environment were now questioned and targeted for improvement. We have entered the culture of safety in which the environment and the entire system is the focus to allow healthcare providers and consumers to address quality improvement. These recent reports demonstrated the change of focus on an individual causative agent to an environmental practice that needed to change. Concerted efforts must now be collaborative among professionals, governmental agencies, suppliers, educators, and regulators with the consumer involved in the process. Evidence-based practice is the standard with a focus on safety, positive client outcomes, and the use of known and evolving technologies.

Healthcare Safety Goals A national study on safety concluded that “the environment along with the social support, organizational culture, and technology can play an important role in improving health, safety, effectiveness and satisfaction of the health care team” (Joseph, 2006, p. 1). Quality assurance programs have been in place for years. However, our failure as documented in the IOM report To Err is Human: Building a Safer Health System (Kohn, Corrigan, &


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Donaldson, 1999) estimated that 98,000 Americans die annually because of adverse events in hospitals. Renewed efforts have been mandated to provide a safer healthcare environment. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2007a) accredits healthcare organizations every 3 years and, for almost 60 years, has “maintained state-of the-art standards that focus on improving the quality and safety of care provided . . .” especially with performance expectations that focus on safety and the quality of patient care (pp. 1–2). Performance of the entire agency and system are appraised. In addition to the periodic onsite reviews, annual reports and safety statistics are reported. We also have seen the implementation of various safety initiatives including physician order entry, bar-coding, intensivists, and limitations on abbreviations that lead to errors. In 2004, the JCAHO (2007b) published an official “DO NOT USE” List. Also, as part of the safety movement, annual healthcare safety goals Refer to the Official JCAHO Do Not Use List at for the various healthcare agencies http://www.jointcommission.org/PatientSafety/ DoNotUseList/ have been specified. For example, in 2008 the goals for acute care hospitals focused on accurate client identification, effective communication among caregivers, safe medication practices, reduction in infections, risk reduction associated with patient falls, client involvement in their care, and the availability of rapid response teams (JCAHO, 2008). The JCAHO (2007c) defines a sentinel event as “an unexpected Check out the Current JCAHO National Patient occurrence involving death or serious Safety Goals for the Year at physical or psychological injury, or http://jointcommission.org/PatientSafety/ the risk thereof . . . [and] signals the NationalPatientSafetyGoals/ need for immediate investigation and response” (p. 1). (See Box 6-2). This investigation in the case of a sentinel event takes the form of a special analysis. A root cause analysis is an intensive questioning into the cause of a problem with the goals of providing corrective action, eliminating the problem from recurrence, and instilling quality improvements. This type of intensive analysis considers the entire system, not just individuals. It considers what happened, why it happened, and the causative factors, including factors relating to the following: ■ Human beings, including communication, leadership, and management practices ■ Equipment, both in terms of proper operation and as contributor to the problem ■ Environment, especially those that can be controlled To assist in the process, special teams are involved, software and consultants may be used, and forms and matrices to assist in the analysis are available on the JCAHO Web site. The end result is the development of an action plan to prevent recurrence of the sentinel event. Notice that the effort is on problem-solving and finding solutions rather than blaming individuals. Recall that a system has inputs, throughputs, and outputs. In this case, the sentinel event was an output from the system as an adverse event. The people involved, the processes that took place, and the equipment and environmental factors are scrutinized.


BOX 6–2

Types of Sentinel Events

✻ Anesthesia-related ✻ Assault, rape, homicide ✻ Delay in treatment ✻ Elopement ✻ Home care fires ✻ Infection-related ✻ Maternal deaths ✻ Medical equipment ✻ Medication error ✻ Op/post-op

✻ Patient abductions ✻ Patient falls ✻ Perinatal death/injury ✻ Potassium chloride ✻ Restraint deaths ✻ Suicide ✻ Transfusion ✻ Ventilator ✻ Wrong-site surgery

Source: Joint Commission on the Accreditation of Healthcare Organizations. (JCAHO). (2007c). Root causes of sentinel events: 2006.

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The JCAHO is one of many See further details on sentinel events from the organizations that actively promote JCAHO at client safety. The American Nurses http://www.jointcommission.org/SentinelEvents/ Association (ANA) is the professional organization for registered nurses and has long focused on safety and quality improvement for the profession and for consumers. The ANA’s (2008) Center for Nursing Quality Association’s National Center for Nursing Quality (NCNQ®) addresses both the safety and quality of nursing care for clients and the quality of the nurses’ work environments. In the mid 1990s, the ANA, as part of a safety and quality initiative, began research on nursing-sensitive indicators that looks at care and client outcomes most affected by nursing care. Research continues as a database has been developed and continues to be tested nationwide on these nursing-sensitive indicators. The ANA (2006) has also developed a position paper on the association between patient safety and healthy nursing work hours to ensure that Chapter 6 l The Imperative for Safe Nursing Care and Use of the Nursing Process 83

nurses have adequate resources especially in terms of scheduling, sufficient compensation, and appropriate staffing. A notable leader for quality and safety in healthcare is the Leapfrog group, formally established after the IOM report on patient safety. This organization comprises major corporate leaders and employers (like Aetna, Dow Chemical, FedEx, Toyota, Verizon, and many others) who want the most for their employees, both in terms of safety and purchasing power. They reward best practices and publish “report cards” on provider performance. The Leapfrog Group (2008) has identified four basic quality practices, called “leaps,” based on the safety research: ■ ■ ■ ■

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Computer physician order entry (CPOE) systems Staffing ICUs with intensivists Referrals to hospitals with the best results for treating certain high-risk conditions Implementation of The National Quality Forum–endorsed Leapfrog Safe Practices

Hospitals are scored on their safety records and the implementation of these proven safe practices. The major corporate members are also the purchasers for healthcare and they want the best for their purchasing power. As noted by the Leapfrog Group, the National Quality Forum (NQF) has endorsed selected safe practices in healthcare as they address the quality of healthcare of the nation. With a broader composition of both public and private partners including organizations and national, state, and local governmental agencies, the NQF (2006) describes the goals of “setting national priorities and goals for performance improvement, endorsing national consensus standards for measuring and publicly reporting on performance, and promoting the attainment of national goals through education and outreach programs” (p. 2). Current topics they are focusing on include the electronic health record, pay for performance, personal health records, and client safety. The Institute for Healthcare Improvement is a not-for-profit organization focused on client safety and quality improvement worldwide. This organization strives to build awareness through education, collaborative improvement, and system redesign to promote quality improvement for the worldwide healthcare community. They focus on best practices and sharing the information and unifying the healthcare industry on quality improvement (IHI, 2007). As an example of the impact of this organization, a national campaign to save 100,000 Lives was launched in 2004 through the use of rapid response teams, evidence-based care for clients with acute MIs, and the prevention of adverse drug events, infections, and ventilator-associated pneumonia (IHI, 2008). The success was so great, that in 2006, this initiative became the Five Million Lives Agency for Healthcare Research & Quality Campaign spanning from December http://www.ahrq.gov/qual/ 2006 through December 2008. The American Nurses Association focus was on clients, safety, quality http://www.nursingworld.org improvement, and building the culInstitute for Healthcare Improvement ture of safety. http://www.ihi.org/ihi JCAHO Many more organizations, groups, http://www.jointcommission.org/PatientSafety/ and individuals are actively pursing The Leapfrog Group client safety at the local, state, national, http://www.leapfroggroup.org and international levels. Only a few National Patient Safety Foundation have been described here that will lead http://www.npsf.org to other collaborations and initiatives


focused on the Culture of Safety for all clients of healthcare. See how your local agencies score and which initiatives are in place or planned.

Levels of Prevention An important safety consideration is the prevention of adverse events. However, safety also concerns health promotion activities. When considering health promotion activities, we frequently refer to illness and disability prevention. But in healthcare, we must address the three levels of prevention: primary, secondary, and tertiary. Health promotion activities require clients actively involved in all levels of prevention for optimum health and safety. Primary prevention refers to healthy actions taken to avoid illness, injury, or disease. Examples are healthy nutrition, smoking cessation, home and environmental safety equipment, exercise programs, parenting classes, community awareness programs, and mental health programs and activities. Primary prevention refers to individual lifestyle health promotion strategies. These are becoming more popular and prevalent as people take responsibility for their own health. We have seen a growing number of health food and holistic health stores, “healthy” fast food options, Web sites, and educational programs for the general public. Secondary prevention involves screening for early detection and treatment of health problems. With secondary prevention, the individual is seeking healthcare not for a specific problem but, rather, for early detection of a potential problem, to mobilize resources, and reduce the intensity or severity of a problem if it is identified. Secondary prevention usually involves use of some procedure or measurement tool in addition to the health history and physical assessment. Examples of secondary prevention are screening procedures used by healthcare consumers or healthcare professionals for physiological, developmental, or environmental problems. Physiological procedures include screening for hypertension or specific forms of cancer. Mental health screening procedures range from simple tests for orientation to more elaborate instruments such as mental status questionnaires for aging clients. In young children, examples of secondary prevention activities are use of growth charts to assess growth along established percentiles and developmental screening tests to detect problems in the areas of personal-social skills, motor activities, and language. Note the difference between using parenting classes as primary prevention for developmental stimulation versus screening for developmental problems as secondary prevention. Environmental screening procedures include testing air and water quality and home safety assessments. If a problem is detected, a referral is made for a differential diagnosis and early treatment. Tertiary prevention occurs during the rehabilitative phase of an illness to prevent complications or further disability. The individual has already entered the healthcare system and is recovering from or learning to cope with a health deficit. Tertiary prevention builds on this care to prevent further deficits, as with physical therapy for the elder following a fall. Examples of tertiary prevention include counseling and teaching after recovery from a cardiovascular event, an accident or injury, an abusive situation, or any other physical, psychosocial, mental, or environmental disruption from usual health and functioning. Support from self-help groups is a large component of tertiary prevention. An example of tertiary prevention is family counseling after identification of a child in an abusive situation.


Professional nursing practice involves not only health and safety promotion but also all three levels of preventive activities. Because the health of individuals, families, communities, and groups is a major concern in nursing, professional skill and expertise in the area of prevention activities are presumed in practice, education, research, and administrative functions. In nursing practice, use of the nursing process allows a systematic means for applying critical thinking skills for healthcare and health promotion activities.

Nursing Process Nursing process is the systematic use of the skills of critical thinking in the professional nursing role using the steps of assessment, diagnosis, planning, implementation, and evaluation. The American Nurses Association (2007) describes the nursing process as “the essential core of practice for the registered nurse to deliver holistic client-focused care” (p. 1). Detailed discussion of these steps will follow in the next four chapters. Nursing process is not a new invention, but one that has evolved from the problem-solving process specific to the domain of nursing. This evolution of the nursing process has taken place for more than 50 years as we refine our skills and address the specific domain of nursing. In the 1960s, Yura and Walsh (1967) described this process to plan nursing care activities. They subsequently defined the nursing process in all client care settings as follows: an orderly, systematic manner of determining the client’s problems, making plans to solve them, initiating the plan or assigning others to implement it, and evaluating the extent to which the plan was effective in resolving the problems identified (Yura & Walsh, 1978, p. 20). This occurred at the time of the development of skills in physical assessment by nurses and at the onset of the identification of nursing diagnoses as a classification system. At that time, they proposed the use of a four column format to plan nursing care, assessment, planning, implementation, and evaluation. Scientific principles for each of the assessment findings were required, because at that time, many of the assessment data were physical findings and dependent data from other disciplines, especially medicine. However, nursing as an art and a science matured and the nursing process was expanded to five steps: assessment, diagnosis, planning, intervention, and evaluation. Since then, ANA (2004) has defined the science of nursing as “based on a critical thinking framework, known as the nursing process, composed of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation” (p. 11). In the initial stage of the nursing process, client assessment for potential and actual health needs and problems is the focus. As will be seen in Chapter 7, data is collected in a systematic and organized manner. The organizing framework for the assessment may be based on body systems, functional health patterns, basic needs, or a specific nursing theory. The nurse’s critical thinking, interpersonal, and technical skills are essential for a comprehensive assessment of the client’s needs.


Before planning care to address the client’s needs, however, these needs must be identified and classified through a careful analysis of the assessment data. Alfaro-LeFevre (2005) describes this interpretation of assessment data the pivotal point in the nursing process; making a nursing diagnosis. The ANA (2004) has further defined a nursing diagnosis as “a clinical judgment about the client’s response to actual or potential health conditions or needs . . . [and] the basis for determination of a plan of care to achieve expected outcomes” (p. 114). Notice the focus of a nursing diagnosis is on clinical judgment and outcomes identification. A nursing diagnosis is in the domain of nursing, not medicine or another health profession. The profession is now focused on the domain of nursing and how clients’ needs were influenced specific to nursing care. The specification of the domain of nursing addresses client safety and efficacy of care but requires a consistent and standardized terminology. This standardized terminology for the discipline was a goal of the development of a classification system for nursing diagnoses. The history of the North Atlantic Nursing Diagnosis Alliance (NANDA) can be traced back to the middle 1970s as a common language for nursing was sought to identify the uniqueness of the profession. In 1987, NANDA collaborated with the ANA to endorse the development of nursing diagnoses (NANDA-I, 2008b). Started by nursing leaders and theorists as an initiative in the United States and then Canada, NANDA-I (2008a) evolved over 35 years with its current stated purpose as “increasing the visibility of nursing’s contribution to patient care by continuing to develop, refine, and classify phenomena of concern to nurses” (p. 1). It is now an international initiative for a standardized nursing classification system that updates nursing diagnoses every 2 years based on evidence-based data. Nursing diagnoses are added or deleted based on data. As you will see in Chapter 8, you are to use the specific nursing diagnosis as the diagnostic label for the problem. Since these problems are evidence-based, you may not alter the wording for the problem but support the problem with client-specific etiology and, in the case of actual diagnoses as opposed to risk diagnoses, the specific signs and symptoms of the problem. The nursing diagnosis also leads to the specification of client outcomes that will be the basis of the planning phase. Notice the focus of the process has evolved from the 1960s focus on planning care for the client, now highlighting the client and measures to achieve positive outcomes with the client involved in the process. As will be discussed in subsequent chapters, another approach to the traditional nursing process format is concept mapping. Although Schuster (2008) describes the concept mapping approach with specific steps, the process involves critical analysis and is consistent with the nursing process: ■ ■ ■ ■ ■ ■ ■

Gathering client data Organizing data into a basic diagram Analyzing the data and developing categories Identifying nursing diagnoses and relationships Establishing priorities as goals, outcomes, and interventions Identifying information not fully understood Evaluating client outcomes and refining the plan

The ANA (2004) has defined the plan of care as a “comprehensive outline of care to be delivered to attain expected outcomes” (p. 115). The planning phase of the nursing process includes the identification of independent and dependent functions that are associated with client goals and care outcomes.


Now is the point of implementing the plan to achieve the desired outcomes. These outcomes should be measurable outcomes for the client. Recall that the client is the individual, the family, or the group. The ANA (2004) identifies implementation activities for the professional nurse as intervening, delegating, and coordinating (p. 115). As we will see in Chapter 9, an important component of the implementation phase is client teaching. Another important consideration for intervention activities is that they are evidence-based, as will be discussed in Chapter 11. As with nursing diagnoses and NANDA classification, there is the need for common and consistent terminology for both nursing interventions and outcomes. We need to be using consistent terms when describing nursing activities. Development of standardized and common terminology has been the goal of researchers from the University of Iowa who developed the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC) systems (Appendix C). The focus is on use of consistent language to address the domain of nursing. As illustrated in Appendix C, the NIC taxonomy or terminology identifies domains of nursing interventions in the following domains of care: ■ ■ ■ ■ ■ ■ ■

Basic physiological Complex physiological Behavioral Safety Family Health system Community

Classes of care are then organized under these domains to address client needs followed by the identification of more than 500 specific nursing interventions that are applicable across all areas of nursing practice. For example, interventions include the administration of analgesics for pain management, cardiac rehabilitation and precautions, electrolyte management, fall prevention, intrapartal care, teaching, and seizure precautions to name a few. Notice that these are nursing interventions and not medical orders, across a wide range of practice areas. As noted by Johnson, et al. (2006), the focus of the NIC system is on nursing behaviors to assist the client to a specific outcome compared with the NOC system that assists in the evaluation of the client outcomes (pp. 4–5). NOC is a taxonomy that is research-based with more than 300 client outcomes identified and defined to assist in the measurement of client outcomes, particularly the effectiveness of nursing interventions across all areas of nursing practice. Consider some of the NOC labels and notice the focus on the client, rather than the nurse: child development, coping, wound healing, and bowel elimination. These two additional classifications systems are also consistent with NANDA diagnoses and with ongoing research on the linkages among the systems. The focus is on safe, appropriate, and effective care for the client.


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The last phase of the nursing ANA http://www.nursingworld.org process is the evaluation phase in NANDA http://www.nanda.org which the implementation activities University of Iowa Center for Nursing are evaluated and the process revised, Classification and Clinical Effectiveness (NIC/NOC) as needed. A word of caution, this is http://www.nursing.uiowa.edu/excellence/nursing_know ledge/clinical_effectiveness/index.htm the client’s care of plan, not the nurse’s. It must be client-specific, culturally appropriate, and outcomesoriented. In addition, client safety in all settings, including the home after discharge is an ongoing consideration. Alfaro-LeFevre (2005) has described the movement in the use of the nursing process from one of diagnosis and treatment to the model of prediction, prevention, management, and promotion within the following responsibilities: ■ Recognizing the signs and symptoms of common health problems ■ Prediction problems for those at risk and acting to manage risks and prevent complications ■ Identifying responses, promoting optimum health and quality of life ■ Initiating actions and referrals in a timely manner for appropriate care (p. 93) In the next chapter, we will go beyond data collection to a complete nursing assessment. The data from the assessment phase of the nursing process is comprehensive and client-focused.

KEY POINTS • In the culture of blame someone is traditionally identified as the cause of an adverse event. Systemic issues are now questioned and targeted for improvement in the culture of safety in which the environment and the entire system is the focus to allow healthcare providers and consumers to address quality improvement. • The JCAHO (2007c) defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof . . . [and] signals the need for immediate investigation and response” (p. 1). • A root cause analysis is an intensive questioning into the cause of a problem with the goals of providing corrective action, eliminating the problem from recurrence, and instilling quality improvements. This type of intensive analysis considers what happened, why it happened, and the causative factors, including factors relating to human beings, equipment, and the environment. • Preventive activities and services address three areas of prevention. Primary prevention consists of healthy actions taken to avoid illness or disease. Secondary prevention involves screening for early detection and treatment of health problems. Tertiary prevention during the rehabilitative phase of an illness prevents complications and further disability.


• Nursing process is the systematic use of the skills of critical thinking in the professional nursing role using the steps of assessment, diagnosis, planning, implantation, and evaluation. • NANDA is an international initiative for a standardized nursing classification system that updates nursing diagnoses based on evidencebased data. • NIC is a research-based and comprehensive taxonomy or classification system of more than 500 nursing interventions applicable to all areas of nursing practice. • NOC is a taxonomy that is research-based with more than 300 client outcomes identified and defined to assist in the measurement of client outcomes, particularly the effectiveness of nursing interventions across all areas of nursing practice.


1. Interview a colleague at work and have him or her describe the focus on safety and the initiatives that have taken place in the healthcare setting since the 1998 IOM report was released. 2. Use the JCAHO “Do Not Use” List and visit various areas of a healthcare institution and describe adherence to these recommendations by different healthcare providers. 3. Describe your past experiences with the cultures of safety and blame. 4. Describe a root cause analysis in the case of an incorrect dosage to a geriatric client. 5. Select an individual in a community setting and identify current health promotion activities and classify them as primary, secondary, and tertiary. Go to the Intranet site and complete the interactive exercises provided for this chapter.

REFERENCES Alfaro-LeFevre, R. (2005). Applying nursing process: A tool for critical thinking (6th ed.). Philadelphia: Lippincott Williams & Wilkins. American Nurses Association. (2004). Nursing: Scope and standards of practice (Publication No. 03SSNP). Washington, DC: American Nurses Publishing. American Nurses Association. (2006). Assuring patient safety: The Employer’s role in promoting healthy nursing work hours for registered nurses in all roles and settings. Retrieved on December 27, 2007, from http://www.nursingworld.org/ MainMenuCategories/HealthcareandPolicyIssues/ANAPositionStatements/ workplac/EmployersRole.aspx American Nurses Association. (2007). The Nursing Process: A common thread amongst all nurses. Retrieved December 27, 2007, from http://www.nursingworld.org/EspeciallForYou/StudentNurses/thenutrsingprocess.aspx American Nurses Association. (2008). National center for nursing quality. Retrieved January 27, 2008, from http://www.nursingworld.org/MainMenuCategories/ ThePracticeofProfessionalNursing/PatientSafetyQuality/NDNQI.aspx Aspden, P., Wolcott, J., Bootman, L., & Cronenwett, L. R. (Eds.). (2006). Preventing medication errors. Washington, DC: National Academies Press.


Greiner, A. C., & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: Institute of Medicine. Institute for Healthcare Improvement. (IHI). (2007). Accelerating improvement worldwide: A history of IHI 1986-2007. Retrieved January 27, 2008, from http://www.ihi.org/NR/rdonlyres/4F8E7E0B-E241-4903-9DE1592CEB83BA8D/0/IHI_Timeline_2007_SingleSheets.pdf Institute for Healthcare Improvement. (IHI). (2008). Protecting 5 million lives from harm. Retrieved January 27, 2008, from http://www.ihi.org/IHI/Programs/ Campaign Institute of Medicine (IOM). (2006). Crossing the quality chasm: The IOM Health Care Quality Initiative. Retrieved June 11, 2008, from http://www.iom.edu/ focuson.asp?id=8089 Johnson, M., Bulechek, G., Butcher, H., Dochterman, J. M., Maas, M., Moorhead, S., & Swanson, E. (Eds.). (2006). NANDA, NOC, and NIC linkages: Nursing diagnosis, outcomes and interventions. St. Louis: Mosby Elsevier. Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). (2007a). About us: Facts about the Joint Commission. Retrieved January 1, 2008, from http://www.jointcommission.org/AboutUs/joint_commission_facts.htm Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). (2007b). The official “Do Not Use” List. Retrieved January 1, 2008, from http://www.jointcommission.org/PatientSafety/DoNotUseList/ Joint Commission on the Accreditation of Healthcare Organizations. (JCAHO). (2007c). Root causes of sentinel events: 2006. Retrieved January 14, 2008, from http://www.jointcommission.org/NR/rdonlyres/FA465646-5F5F-4543-AC8FE8AF6571E372/0/root_cause_se.jpg Joint Commission on the Accreditation of Healthcare Organizations. (JCAHO). (2008). National patient safety goals: 2008 national patient safety goals, hospital program. Retrieved January 27, 2008, from http://www.jointcommission.org/ PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm Joseph, A. (2006). The role of the physical and social environment in promoting health, safety, and effectiveness in the healthcare workplace. Retrieved October 14, 2007, from http://www.healthdesign.org/research/reports/index/subject/ documents/CHD_Issue_Paper3.pdf Kohn, L. T., Corrigan, M. S., & Donaldson, M. S. (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press. Leapfrog Group. (2008). Fact sheet. Retrieved January 27, 2008, from http://www.leapfroggroup.org/media/file/leapfrog_factsheet.pdf National Quality Forum. (2006). About us. Retrieved January 27, 2008, from http://www.qualityforum.org/about/ North American Nursing Diagnosis Association International. (NANDA-I). (2008a). About NANDA International. Retrieved February 1, 2008, from http://www.nanda.org/html/about.html North American Nursing Diagnosis Association International. (NANDA-I). (2008b). History & historical highlights 1973 through 1998. Retrieved February 1, 2008, from http://www.nanda.org/html/history1.html and http://www.nanda.org/html/ history2.html Page, A. (Ed.). (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press. Schuster, P. H. (2008). Concept mapping: A critical thinking approach to care planning (2nd ed.). Philadelphia: F.A. Davis. Yura, H., & Walsh, M. B. (1967). The nursing process: Assessing, planning, implementing, evaluating. The Proceeding of the Continuing Education Series Conducted at the Catholic University of America, March 2 through April 27, 1967. Washington, DC: The Catholic University of America Press.


Yura, H., & Walsh, M.B. (1978). The nursing process: Assessing, planning, implementing, evaluating (3rd ed.). New York: Appleton-Century-Crofts.

BIBLIOGRAPHY Agency for Healthcare Research and Quality (AHRQ). (2008). Health care efficiency measures: Identification, categorization, and evaluation (AHRQ Publication No. 08-0030). Rockville, MD: Author. Retrieved June 11, 2008, from http://www.ahrq.gov/qual/efficiency/efficiency.pdf Agency for Healthcare Research and Quality (AHRQ). (2008). Patient safety and quality: An evidence-based handbook for nurses (AHRQ Publication No. 08-0043). Rockville, MD: Author. Retrieved June 11, 2008, from http://www.ahrq.gov/qual/nurseshdbk/ American Nurses Association. (2003). Nursing’s social policy statement (2nd ed.) (Publication No. 03NSPS 15M 09/03). Washington, DC: American Nurses Publishing. Barringer, P., & Dauer, E. (2007). End the blame and shame game. Modern Health Care, 37(21), 36. Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (Eds.). (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis: Mosby Elsevier. Corrigan, M. S., Donaldson, M. S., Kohn, L. T., Maguire, S. K., & Pike, K. C. (2001). Crossing the quality chasm: A new health system for the 21st Century. Washington, DC: National Academy Press. Joint Commission on the Accreditation of Healthcare Organizations. (JCAHO). (2007). Sentinel event statistics as of September 30, 2007. Retrieved January 14, 2008, from http://www.jointcommission.org/NR/rdonlyres/D7836542-A3724F93-8BD7-DDD11D43E484/0/SE_Stats_9_2007.pdf Mantone, J. (2006). A dose of collaboration: New JCAHO safety goal has hospitals scrambling. Modern Healthcare, 36(45). Retrieved November 16, 2007, from CINHL Plus with full text database. McCarthy, D., & Blumenthal, D. (2006). Committed to safety: Ten case studies on reducing harm to patients. Retrieved October 14, 2007, from http://www.cmf.org Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis: Mosby Elsevier. Morse, K. J., Warshawsky, D., Moore, J. M., & Pecora, D. C. (May 2007 Supplement). Rapid response teams: Reducers of death. Nursing, 37, 2–8. Retrieved November 7, 2007, from CINHL Plus with full text database. North American Nursing Diagnosis Association International. (NANDA-I). (2007). Nursing diagnoses: Definitions and classification, 2007–2008. Philadelphia: Author. Pronovost, P. J., Berenholtz, S. M., & Needham, D. M. (2007). A framework for health care organizations to develop and evaluate a safety scorecard. JAMA, 298, 2063–2065. Shojania K. G., Duncan, B. W., McDonald, K. M., et al. (Eds.). Making health care safer: A critical analysis of patient safety practices. Evidence report/technology assessment no. 43 (Prepared by the University of California at San Francisco– Stanford Evidence-based Practice Center under Contract No. 290-97-0013), AHRQ Publication No. 01-E058, Rockville, MD: Agency for Healthcare Research and Quality. July 2001. Available at: http://www.ahrq.gov/downloads/pub/ evidence/pdf/qualgap3/qualgap3.pdf


ONLINE RESOURCES Agency for Healthcare Research and Quality (AHRQ): http://www.ahrq.gov/qual/ American Nurses Association (ANA): http://www.nursingworld.org Institute for Healthcare Improvement (IHI): http://www.ihi.org/ihi Joint Commission on the Accreditation of Healthcare Organizations (JCAHO): http://www.jointcommission.org/PatientSafety/ The Leapfrog Group: http://www.leapfroggroup.org National Patient Safety Foundation: http://www.npsf.org National Quality Forum: http://www.qualityforum.org North American Nursing Diagnosis Association (NANDA): http://www.nanda.org University of Iowa Center for Nursing Classification and Clinical Effectiveness (NIC/NOC): http://www.nursing.uiowa.edu/excellence/nursing_knowledge/ clinical_effectiveness/index.htm


CHAPTER 7

Assessment CHAPTER OBJECTIVES

Key Terms Data collection Assessment Comprehensive assessment Focused assessment Subjective data Objective data Health history Physical assessment Inspection Palpation Auscultation Percussion Functional health patterns

After completing this chapter, you will be able to: 1. Differentiate between data collection and assessment in nursing practice. 2. Describe the different techniques used in a comprehensive nursing assessment. 3. Differentiate situations in which a focused assessment is appropriate. 4. Review expected findings in a complete health assessment. 5. Discuss the use of critical thinking in the assessment phase of the nursing process.

Data Collection as One Part of the Assessment Process There is much discussion about the difference between assessment and data collection. As a LPN or a paramedic, you have been active in the data collection component of the assessment process. You have heard numerous times that assessment is the role of the registered nurse (RN). It is probably also included in your State Nurse Practice Act that assessment is in the scope of practice of the RN. Recall that the LPN contributes in the data collection process but is under the supervision of another assigned licensed practitioner. So it is with data collection, it contributes to the assessment process but assessment goes further. Assessment requires a complete picture of the individual’s health status with critical analysis and clinical judgment based on the data collected and evaluation of the situation. Dillon (2007) considers assessment as the most important step in the nursing process and includes the collection, validation, and clustering of data (p. 4). A couple of factors need to be considered when we talk about the assessment process. First, the nursing health assessment is different for physicians and nurses. Although they use similar tools and techniques, nursing’s focus is different. Physicians look to the identification of pathophysiology, disease processes, and determining a medical diagnosis and treatment plan. The nursing health assessment focuses on client responses to their unique situation and individual factors, their health status and their environment, the responses to the treatment plan, and development, implementation, and evaluation of nursing diagnoses within the nursing process.


A second consideration is the difference between a complete assessment (or health appraisal) and a focused assessment. There are different situations when each is appropriate. A comprehensive assessment is the collection and critical appraisal of the information based on a total picture of the client’s status including obtaining both subjective and objective data from a complete health history and health assessment. A comprehensive physical assessment is one component of the data provided in the process. Sufficient information, time, tools, and skills must be available for the comprehensive health assessment. A focused assessment is a component of the comprehensive assessment but may be restricted to a particular system or set of signs and symptoms. It also may be more appropriate in certain client situations, as with an emergency or when the client is in pain. Similar assessment skills may be used but the scope of the assessment is more narrow or focused. Now, consider the different types and sources of data.

SOURCES OF INFORMATION The assessment incorporates both subjective and objective data from multiple sources. Subjective data is provided by clients, family members, and others providing their stated interpretations of the situation. Subjective data also may be obtained from previous hospital records and consultations. These stated observations should then be correlated with objective, observable, or verifiable data. Objective data is observable by some verifiable measure, like oxygen saturation and blood pressure. Diagnostic studies with specified ranges are another type of objective data. Relevant literature for evidence-based practice may be used as either subjective or objective data based on a personal report or a metaanalysis of multiple research studies related to a specific client situation, as we will discuss further in Chapter 11. THE HEALTH HISTORY The health history is the background information provided on the client and contributes to the picture of the current situation and provides data for analysis for the development of Chapter 7 l Assessment 95

BOX 7–1

Information Obtained in the Health History

a complete assessment. The health history is subjective data contributing to the assessment picture and is provided by the client and his or her significant others. Consider the different parts of the health history listed in Box 7–1. Demographic information includes general information like age or date of birth, gender, ethnicity, and marital status. The chief complaint is the reason why the client is present at this point in time and is usually quoted in the client’s own words. The present problem is a description of recent events, signs and symptoms reported that contributed to the current client problem. Past history includes past conditions, illnesses, and healthcare and includes important items such as immunizations. Family history should be reported for immediate family members alive and deceased, such as parents, siblings, and grandparents. The family history may be more comprehensive, especially with genetic or familial conditions and may include a genogram that resembles a family tree illustrating family patterns and illness by relationship and generation. Lifestyle habits include occupation, activity, and daily habits including alcohol, tobacco, and substance use. Social/experiential and psychosocial history include particular psychosocial influences that may affect the health status or can be assets in health teaching or health promotion activities. Finally, the review of systems is presented in a head-to-toe listing of client-identified signs and symptoms. This review may also be categorized as a functional health pattern as you will see later in this chapter. Refer to Table 7–1 for an example of a health history using the review of systems on a client with chronic obstructive pulmonary disease (COPD).

✻ Demographic information ✻ Chief complaint ✻ Present problem ✻ Past history ✻ Family history ✻ Lifestyle habits ✻ Social/experiential or psychosocial history ✻ Review of systems or functional health patterns

✳

Check out the immunizations recommended by the Centers for Disease Control at http://www.cdc.gov/vaccines

■ ■ ■ ■

THE PHYSICAL ASSESSMENT The next step is the physical assessment or a head-to-toe health appraisal. Four techniques are used in the physical assessment process:

Inspection Palpation Auscultation Percussion

Each of these health assessment techniques requires careful use of your senses— vision, hearing, smell, and touch. Inspection is the use of your eyes and visual assessment skills to differentiate normal from an abnormal finding. Palpation uses your sense of touch to detect normal and abnormal findings as with temperature differences or skin lesions, edema, or masses. Auscultation involves your sense of hearing, both with and without a stethoscope in the detection of heart, breath, vascular, and abdominal sounds. Percussion is also used to detect differences in sounds using a drum-like tactile technique (with your middle finger of one hand stationary and the index finger of the other hand performing a striking motion on the stationary finger) to listen for the differences in sounds (see Box 7–2).


TABLE 7–1

Case Study: Mr. J’s Health History–Review of Systems

Demographic information Chief complaint Present problem Past history

Family history Lifestyle habits

Social/experiential or Psychosocial history Review of systems General Skin HEENT

Musculoskeletal Cardiovascular Respiratory GI system

GU system Neurological

77-year-old white male; married with wife present. “I have no energy and have problems catching my breath.” Has been having increasing difficulty with breathing and walking more than six steps without resting. Chronic COPD diagnosed 9 years ago with periodic episodes of asthma and bronchitis. Hypertension and rheumatoid arthritis under treatment since 1985 and prostate hyperplasia under medication since 1997. Last hospitalization in March 2007 and keeps routine MD appointment scheduled every 3 months. Has been on O2 via nasal cannula at 2.5 liters at night and as needed during the day since 2001. Uses oxygen concentrator and periodically takes own O2 sats. Nebulizer treatments with Ipratropium bromide and albuterol sulfate ordered QID but client reports twice daily treatments done after breakfast and at bedtime. Current meds include Advair 500/50 twice daily and Combivent Inhaler twice daily and PRN Arthrotec 75 mg twice daily Hyzaar 100 mg daily Foltx 25 mg daily Lasix 20 mg every other day Avodart 0.5 mg daily Singulair 10 mg at bedtime Effexor XR 150 mg at bedtime Protonix 40 mg at bedtime Flomax 0.4 mg and Detrol LA 4 mg at bedtime OTC Med & Vitamins include: multivitamin and “ginseng” cap daily, “Lung Support” twice daily, and “baby” ASA and Colace at bedtime. Immunizations up-to-date. Had flu and pneumonia vaccines in November and tetanus in 2004. Mother died of septicemia at age 24 when client was 2 years. Unknown history of father or grandparents. No siblings. Still smokes approximately one pack cigarettes daily and describes two “cocktails” each evening. Retired in 1989. Sedentary lifestyle following tear of rotator cuff in 2003 and inability to continue in noncompetitive golf. Likes to read. Former college professor and business person. Lives in gated community with spouse. Likes to entertain and travels periodically. No current change in weight and usually feels fair but has had increasing problems with endurance. Fragile skin with frequent bruising on extremities. Eyes: wears glasses for reading and distance/sunlight; cataracts removed bilaterally with implants in 2002. Ears: Report no hearing left ear—unknown cause. Nose: No problems except occasional clear drainage. Mouth and Throat: Experiences episodes of hoarseness. Denies dysphagia. Frequent productive cough with thick yellow mucus. Neck: No symptoms. Complaints of stiffness and limited ability to bend. Hypertension controlled with Hyzaar. Last year taken off two other BP meds after “fainting” in evening. Denies pain, palpitations, or syncope except dyspnea on exertion. Edema in ankles reported occasionally when not on Lasix. Reports eating three meals daily. Appetite is fair and wife cooks “too much.” Denies food intolerance, emesis, and jaundice. Complains of frequent “gas.” Takes Colace daily and expects “good” bowel movement each morning or feels “constipated.” No report of melena. Frequency on “Lasix Days” and slow stream most times reported. Has history of depression and is “tired” of these limitations. Has had three sets of “epidurals” for back pain—last series in 2001. Numbness in extremities noted occasionally and frequent lack of sensation in lower limbs.

Chapter 7 l Assessment 97

BOX 7–2

Percussion of Different Sounds

Flatness—heard over a major muscle Dullness—heard over a bone or a dense organ like the liver Resonance—indicating air, heard over the normal lung Hyperresonance—may indicate trapped air, as with the client with COPD Tympany—an echoing sound heard over the stomach

Now, consider the various body systems in a head-to-toe physical assessment using the order identified in Box 7–3. Start with the general appearance and state your assessment of the general health status of the client, including vital signs and other relevant observations. In the case of Mr. J, you would probably state that Mr. J is a 77-year-old white male with a pale complexion and a history of COPD who appears frail and presents with noisy respirations. Next, start at the head and consider the client’s face, head and scalp, neck and throat. This appraisal includes: ■ Facial expressions, including muscle contractions or tics ■ Shape and condition of the head, skin, and scalp ■ Appearance, placement, and condition of eyes and ears and use of any assistive devices or aids ■ Check visual fields and assess for extraocular movements (EOM) along with pupillary reaction (Are the pupils equal and reactive to light accommodation? [PERLA]) ■ Alignment and patency of nares (nostrils) ■ Gross assessment of the senses of sight, smell, and hearing ■ Condition of mouth, lips, tongue, gums, and mucous membranes ■ Throat and neck musculature, pulses, and lymph nodes

Eye contact is also a consideration in most North American cultures but can be culturally determined, as in the case of some cultures such as Asian and Native Americans in which eye contact is considered disrespectful or makes one fear a sense of invasion into their soul. A careful appraisal of cultural factors will assist greatly in the process of obtaining valid information and also placing the client at ease and as the central focus of the process. Remember, the use of good communication skills throughout the process will assist both you and the client and allow for good assessment information. Next, move to the extremities and continue the examination in the following areas: ■ Check the character and quality of the peripheral pulses: brachial, radial, popliteal, and pedal ■ Examine bilateral skin temperature, texture, turgor, integrity, and lesions BOX 7–3 Order of Systems in the Physical ■ Examine the hands including strength Assessment and equality of hand grasp and capillary refill of the nail beds General appearance ■ Check range of motion bilaterally Head, eyes, ears, neck & throat (HEENT) for both upper and lower extremities Upper and lower extremities ■ Note gait and stance Torso and chest including heart and lung sounds ■ Check for edema and circulatory Abdomen status of the lower extremities includGenitourinary ing strength, sensation, and function Neurological 98 Section 2 l Clinical Judgment and the Nursing Process

You may examine the client’s back including spinal column at this point or later in the examination. The decision for the appropriate placement of this area will depend on your preferences as well as the client’s condition. Now, move to an examination of the client’s torso in the following areas using skills in inspection, palpation, auscultation, and percussion. ■ Examine for normal structure and function ■ Skin integrity, temperature, texture ■ Palpate for the point of maximum impulse (PMI) and note the location; normally at the apex at the 5th intercostal space (ICS) at the midclavicular line (MCL) ■ Heart sounds: normal cardiac heart sounds should be assessed as illustrated in Figure 7–1 • S1 as the beginning of systole with mitral and tricuspid Aortic valve valve closure sounds at the 5th ICS or apex Pulmonic valve • S2 at the end of systole with closure of the aortic and pul1 monic valves at the 2nd ICS, Mitral valve 2 midline 3 To find these landmarks for ap- Tricuspid valve 4 Left propriate auscultation of heart sounds lateral 5 will require palpation of the ribs and sternal border percussion of the intercostal spaces. 6 Recall that Mr. J has an irregular pulse. Listen very carefully for the rhythm and intensity of his apical pulse and heart sounds. All techniques of inspection, pal- Figure 7–1 Location of Areas to Auscultate Heart Sounds. pation, auscultation, and percussion (From Dillon, P. M. (2007). Nursing health assessment a critical thinking case studies approach (2nd ed.). Philadelphia: F.A. Davis, with permission.)


will be required for a good assessment of a client’s pulmonary status. Inspect for normal configuration and structures. As part of the assessment of the extremities, you should have already noted any pallor, coolness, or clubbing indicating poor circulatory or pulmonary function. Palpate for tenderness or masses. Percussion is another technique to be used, and as in the case of a client with COPD, you should hear hyperresonance over lung tissue as extra air is trapped in these areas. Breath sounds should be auscultated over both the anterior and posterior chest surfaces in a systematic manner. Recall that there are three lobes on the right side and two lobes on the left side. Normal breath sounds are gentle and regular. Normal breath sounds include vesicular (over normal lungs), bronchovesicular (listen over the upper lobes near the midline), and bronchial (listen to the raspy sounds over the normal trachea). Abnormal or adventitious breath sounds include: ■ Crackles (rales) heard mainly on inspiration and characterized as fine, medium, or coarse or wet or dry as heard in many clients with pneumonia ■ Rhonchi and wheezes heard primarily on expiration as in the individual with asthma ■ Pleural friction rubs sound like leather-against-leather heard during inspiration and expiration in clients who have fluid in the pleural cavity as with a medical diagnosis of pleurisy Recall that Mr. J has COPD and you will probably not be hearing normal breath sounds. In this situation, you should be hearing the adventitious sounds of crackles and wheezes. We will practice normal and adventitious sounds in one of the interactive exercises for this chapter. Now, move lower to the abdominal area and again use your skills of inspection, palpation, auscultation, and percussion, but in a different order, to assess the four quadrants illustrated in Figure 7–2. First, inspect the skin appearance, texture, temperature, and symmetry. Next, use auscultation skills to listen for bowel sounds in all four quadrants. Using palpation before auscultation may falsely initiate hyperactive bowel sounds. Then, use palpation to check for tenderness and masses next followed by percussion. Remember, tympany is normally percussed over the stomach as an area normally conRUQ LUQ taining air. Also palpate and observe for abnormal findings, such as rigidity, abdominal pain, enlarged organs, or rebound tenderness. RLQ LLQ This then leads to the genitourinary system when individual and cultural sensitivity must be present. Inspection for normal structure and function should provide the initial assessment skills. Depending on your skill and the client’s condition, palpation techniques may or may not be warranted. A good history is critical to assist the nurse and ensure that the client receives an appropriate assessment and care. Recall that Mr. J has prostate hyperplasia Figure 7–2 Four Quadrants of the and additional questioning on urinary retention and flow Abdomen. may be needed. (From Dillon, P. M. (2007). Nursing health assessment a The last major area to be assessed may be the neurocritical thinking case studies approach (2nd ed.). logical system. You may prefer to do this neurological Philadelphia: F.A. Davis, with permission.) 100 Section 2 l Clinical Judgment and the Nursing Process

assessment when you assess the head, eyes, ears, nose, and throat. This includes the cranial nerves that may have been assessed as part of the HEENT section of the health appraisal. Remember to include speech, orientation, and ability to follow directions, sensation, and reflexes. In infants and children, documentation of the primitive reflexes is vital. In the adult, these reflexes should not be present unless there is some pathology, as in the case of the return of a positive Babinski reflex following a cerebral vascular event. The use of a percussion hammer may be used to assess deep reflexes like the normal patellar or knee-jerk reflex. Laboratory findings as additional objective data may be included at this point. In addition, interviews and data from significant others may be provided as additional subjective data, as in the case when the significant other is the primary care provider and when the client may be providing limited information. Now, review the information provided on Mr. J in Box 7–4.

BOX 7–4

Case Study: Physical Assessment of Mr. J

Physical Examination 77-year-old, white man with a grayish complexion who appears chronically ill. Coughing intermittently (productive with thick yellow mucus) and appears anxious. Weight is 172 pounds; height is 5’ 11’’; temperature is 98.8°F (oral), pulse is 72 irregular with occasional dropped beat. Respirations 20 and labored; blood pressure 160/90. O2 via nasal cannula at 2.5 liters with O2 Sat 90. Pain ⫽ 3 with complaints of shortness of breath (scale 1–10). Skin: Thin and fragile with bruising on forearms and lower extremities. Head: Normocephalic. Eyes: PERLA. Vision corrected with glasses. Extraocular movements full; no nystagmus is noted. Visual fields are intact as tested. Conjunctivae are slightly injected. Sclerae clear. Lenses are implants bilaterally following prior cataract surgery. Funduscopic examination reveals the discs normally cupped, and no vascular changes bilaterally. Ears: External ears symmetrical, without lesions. Otic canals are clear. Tympanic membranes pearly gray bilaterally. Hearing is within normal limits per watch tick at 6 in. on right side; no response on left side. Mouth and Throat: Lips, tongue, and buccal mucosa are pink and moist. Teeth are white with crowns apparent. Gingivae are atrophic. No inflammation of posterior nasopharynx. Nose: Nasal septum in the midline. Nares are patent bilaterally. Sinuses not tender. Neck: Full mobility and no significant lymphadenopathy. Thyroid not enlarged and without nodules. Chest: Bony thorax seems to have increased AP diameter consistent with COPD. Respiratory movements are labored and shallow with mouth breathing apparent. Lungs with crackles on auscultation. Cardiovascular: The PMI is in the fifth intercostal space of the LMCL. Asymmetrical rhythm without murmurs but occasional PVC. Abdomen: Abdomen is soft and flat. Bowel sounds are heard in four quadrants. Liver is descended 2 cm below the costal margin. No splenomegaly, tenderness, or mass. Surgical scar present in right lower quadrant. Genitourinary: Normal male genitalia. Umbilical hernia apparent with cough and upon palpitation. No inguinal hernias palpated. Continued


BOX 7–4

Case Study: Physical Assessment of Mr. J—Cont’d

Rectal: Internal and external hemorrhoids noted at 5 o’clock. Normal sphincter tone. Anal canal free of tenderness. Prostate is in the midline, firm without nodules but moderately enlarged. Extremities and Back: Muscular development symmetrical. Nodular area at T4 consistent with prior fracture reported during examination. Remaining structure normal in appearance, color, and temperature. Peripheral pulses palpable and symmetrical but diminished in lower extremities. Extremities cool to touch. No diaphoresis. Free of varicosities. No pitting edema. Neurological: Speech and sensorium clear; oriented X3. Cranial nerves II through XII are intact as tested per gross screen. Moderately tremulous. Biceps, triceps, brachioradialis, patella, and Achilles reflexes are symmetrical and WNL. Babinski absent bilaterally. Significant Laboratory Findings Stool guaiac: negative; EKG: irregular rhythm; occasional PVC; chest x-ray: persistent COPD with some recent inflammation apparent without consolidation; Hgb 14.0 g/dL, HCT 42% (WNL), CL 92 mEq/L (L); and urine: bacteria 21, WBC 8–12. Interview with Significant Other According to significant other, Mr. J sits reading the newspaper for long periods each day and rarely goes out except with great encouragement or if he needs cigarettes and there are none in the house or in his car. Reports he no longer attends church and is “afraid” of large gatherings where people may be coughing and he may “catch pneumonia.” This is the third marriage for Mr. J with his prior two wives dying of natural causes several years following divorce.

CLUSTERING DATA IN FUNCTIONAL HEALTH PATTERNS Gordon (2006) identified 11 functional health patterns for inclusion in the nursing assessment and diagnosis process. These patterns can be used as an organizing framework for assessment data (see Box 7–5). Unlike the use of body systems, these patterns focus on normal functional health and can be used to develop nursing diagnoses in the planning phase of the nursing process as we will see in Chapter 8. Recall how we used body systems for the review of systems earlier with Mr. J in developing his health history in the initial assessment. Consider how functional health patterns can be used in this process as illustrated in Table 7–2. BOX 7–5

Gordon’s 11 Functional Health Patterns

✻ Health perception and health management ✻ Nutrition and metabolic ✻ Elimination ✻ Activity and exercise ✻ Sleep and rest ✻ Cognitive and perceptual ✻ Self-perception and self-concept ✻ Role and relationship ✻ Sexuality and reproductive ✻ Coping and stress tolerance ✻ Values and beliefs Source: From Gordon, M. (2006). Nursing diagnosis: Process and application (11th ed.). St. Louis: Elsevier Science.

Assessment Findings Up to this point we have been collecting data. Granted, some of the assessment skills have been complex. However, we still need to make sense of the subjective and objective data collected in the assessment process. This is where careful critical analysis and clinical judgment is required. We are considering both subjective and objective data. Subjective data should be supported with verfiable or measurable data. The client’s impression of their current perception of pain on a 10-point scale should be asked again


TABLE 7–2

Case Study: Mr. J’s Health History—Functional Health Patterns

Demographic information Chief complaint Present problem Past history

Family history Lifestyle habits

Social/experiential or Psychosocial history Functional health patterns Health perception/health management Nutritional-metabolic

Elimination Activity/exercise Cognitive-perceptual

Sleep/rest

77-year-old white male; pale with O2 via nasal cannula. “I have no energy and have problems catching my breath.” Has been having increasing difficulty with breathing and walking more than six steps without resting. Chronic COPD diagnosed 9 years ago with periodic episodes of asthma and bronchitis. Hypertension and rheumatoid arthritis under treatment since 1985 and prostate hyperplasia treated with medication since 1997. Last hospitalization in March 2007 and keeps routine MD appointment scheduled every 3 months. Has been on O2 via nasal cannula at 2.5 liters at night and as needed during the day since 2001. Uses oxygen concentrator and periodically takes own O2 sats. Nebulizer treatments with Ipratropium bromide and albuterol sulfate ordered QID but client reports twice daily treatments done after breakfast and at bedtime. Current meds include Advair 500/50 twice daily and Combivent Inhaler twice daily and PRN Arthrotec 75 mg twice daily Effexor XR 150 mg at bedtime Hyzaar 100 mg daily Protonix 40 mg at bedtime Foltx 25 mg daily Flomax 0.4 mg and Detrol LA 4 mg at bedtime Lasix 20 mg every other day Avodart 0.5 mg daily Singular 10 mg at bedtime OTC Med & Vitamins include: multivitamin and “ginseng” cap daily, “Lung Support” twice daily, and “baby” ASA and Colace at bedtime. Immunizations up-to-date. Had flu and pneumonia vaccines in November and tetanus in 2004. Mother died of septicemia at age 24 when client was 2 years. Unknown history of father or grandparents. No siblings. Still smokes approximately one pack cigarettes daily and describes two “cocktails” each evening. Retired in 1989. Sedentary lifestyle following tear of rotator cuff in 2003 and inability to continue in noncompetitive golf. Likes to read. Former college professor and business person. Lives in gated community with spouse. Likes to entertain and travels periodically. Usually feels “fair” but has had increasing problem with endurance. Takes ginseng to “increase energy” but is not sure whether it really helps. Experiences episodes of hoarseness. Frequent productive cough with thick yellow mucus. No current change in weight. Reports eating three meals daily. Appetite is fair and wife cooks “too much.” Denies food intolerance, emesis, and jaundice but has been prescribed Protonix 40 mg at bedtime for acid reflux. Complains of frequent “gas.” Fragile skin with frequent bruising of extremities. Edema in ankles reported occasionally when not on Lasix. Hypertension controlled with Hyzaar. Last year taken off two other BP meds after “fainting” in evening. Urinary frequency on “Lasix Days” and slow stream most times. Takes Colace at bedtime and expects “good” bowel movement each morning or feels “constipated.” No report of melena. Sedentary lifestyle. Retired. Reads newspapers daily and watches CNN at night. No interest in e-mail or Internet access. Complaints of stiffness and limited ability to bend. Complaints of stiffness with numbness in extremities noted occasionally and frequent lack of sensation in lower limbs. Has had three sets of “epidurals” for back pain related to compressed vertebra L5–last series in 2001. Wears glasses for reading and distance/sunlight; cataracts removed bilaterally with implants in 2002. Reports no hearing left ear—unknown cause. No olfactory problems. Experiences episodes of hoarseness. Denies dysphagia. Occasional clear nasal drainage. Sleep approximately 10–12 hours daily and naps or rests for 40–45 minutes in the afternoon and on O2 at 2.5 liters via nasal cannula.

Continued


TABLE 7–2

Case Study: Mr. J’s Health History—Functional Health Patterns—Cont’d

Self-perception/ self-concept Role/relationship Sexuality/reproductive Coping/stress tolerance Value/belief

Has history of depression and is “tired” of these limitations. Takes Effexor XR 150 mg at bedtime. Married; no children or extended family. History of “enlarged prostate” without CA. Takes Flomax 0.4 mg and Detrol LA 4 mg at bedtime. Denies pain, palpitations, or syncope except dyspnea on exertion. Describes himself as a “nonbeliever.” Formerly active in the Baptist Church but has not practiced since the death of his teenage daughter in a motor vehicle accident more than 30 years ago. Uses five different physicians/specialists for his routine care and adheres to annual physicals and follow-ups as recommended. Describes himself as “a tired worn out old man.”

to ensure that the same scale is in the client’s reference. Other personal observations should be verified or double checked. Objective data is also subject to verification. We should always ensure that equipment is working properly as with equipment for checking blood pressure or oxygen satuation. We may also need to verify observations with other members of the healthcare team. Remember, our observations are also subjective data and should be subject to verification. As in the case of measuring a head circumference of an infant, it is often best to measure twice and record once as a verification of the finding. In addition, if something seems really “off the scale,” it is best to remeasure or recheck the measurements. This is the point the registered nurse identifies the appropriate patterns from the subjective and objective data. The impressions or findings are presented. Next, the diagnosis, planning, and implemental phase of the nursing process takes place. We will cover these steps in more detail in subsequent chapters. Remember, this is an individual or client-centered activity, whether the client is the individual, family, or a group. It is unique to the client system and cultural influences are a consideration.

Cultural Influences As mentioned earlier regarding eye contact, certain cultural groups may have individual characteristics that should be thoughtfully considered in any interview or health assessment. It is important to consider the characteristics of both the client and the health professional. Different views show us how individuals differ in their beliefs— beliefs in the supernatural, the scientific community, or the holistic mind-body-spirit interrelationship. Recall that the traditional healthcare system operates from the scientific view that is different from that of many cultures and their subgroups. Some cultures honor beliefs of health and healing with supernatural influences. These beliefs can include ancient rites and rituals, reliance on prayer and the will of a supreme being, pilgrimages, spiritual healing, and the like. This is unlike our prevailing healthcare system, which is based on a dominant scientific model with reliance on medicine and biomedical treatments for illness and disease.


The Giger and Davidhizar (2006) Transcultural Assessment Model focuses on the importance of culture and care in the assessment process. Giger and Davidhizar have identified a variety of cultural behavior patterns relevant to health assessment that have an influence on the delivery of care. They define culture as “a patterned behavioral response that develops over time as a result of imprinting the mind through social and religious structures and intellectual and artistic manifestations” (Giger & Davidhizar, 2006, p. 3). Their assessment model has been used in a variety of practice settings and includes the concepts listed in Box 7–6. Cultures of origin, subcultures, and acculturalization are important considerations in this assessment model. Notice that in this assessment model, the focus is on the culturally unique individual. The initial area for assessment is on individual characteristics, including the individual’s definition of culture. The next assessment areas include specifics on communication patterns and use of space, in which we see cultural differences but which also have a profound influence on interactions and acceptability of information sharing. Social organization is designed to obtain information on current health status as well as family, work, social, political and religious affiliations, practices, and preferences. Assessment of time consideration also looks at cultural patterns, practices, and preferences. Environmental control focuses on the individual’s perception of control (internal versus external control as with a deeply religious paradigm), values and supernatural influences, and their description of their environment and their concept of health. The area of biological variations includes a complete physical examination with particular attention to cultural variations, including physical, metabolic, genetic, and sociocultural variations. The final area of this assessment model focuses on clinical judgment of the individual and the assessment data for incorporation into the plan of care. In the assessment process we seek to actively understand the uniqueness of human beings in their context, such as cultural competence. In doing this, care for individuals, families, and groups will result in more positive outcomes because we know that individuals within a selected culture are very different. As we seek to understand different cultures and heritages, we must still focus on human beings. Again, consider the following variables for culturally competent care: ■ Time with clients to become accepted and gain an understanding of their belief system ■ Differences in belief systems among generations and geographic origins ■ Past experiences and current situation ■ Religious influences ■ Familial influences ■ Understanding of advance directives ■ Acceptance of the healthcare services, systems, and practitioners ■ Linguistic issues

BOX 7–6

Patterns for Assessment in the Giger and Davidhizar Transcultural Assessment Model

✻ Culturally unique individual factors ✻ Communication ✻ Space ✻ Social organization ✻ Time ✻ Environmental control ✻ Biological variations ✻ Nursing assessment From Giger, J. N., & Davidhizar, R. E. (2006). Transcultural nursing: Assessment and intervention (4th ed.). St. Louis: Mosby.


Other individual values may not be initially apparent or may grow more dominant. Complementary and alternative medicine (CAM) and healthcare practices, such as acupuncture, imagery, and herbal medicines, are being tried as people become dissatisfied with the biomedical view and move to holistic care. These practices may differ from a client’s inherited cultural background but may be adopted or become more dominant. In addition, they may be used along with (complementary) or instead of (alternative) conventional medicine, and their use may or may not be reported by the client to the healthcare provider. Spector (2000) reports the rapidly growing use of homeopathic healthcare choices as alternative or complementary (e.g., aromatherapy, biofeedback, hypnotherapy, massage) and ethnocultural or traditional (e.g., herbals and holistic healing practices and rituals). The research and body of knowledge on many of these practices is growing. This increase in use and acceptance of CAM also points to the need for a comprehensive cultural assessment with the client and may require great openness, sensitivity, and time on the part of the clinician. This is just one additional challenge in the assessment by the registered nurse.

KEY POINTS • Data collection contributes to the assessment process. • Assessment requires a complete picture of the individual’s health

✳

status with critical analysis and clinical judgment based on the data collected and evaluation of the situation. • A comprehensive assessment is the collection and critical appraisal of the information based on a total picture of the client’s status including obtaining both subjective and objective data from a complete health history and health assessment. • A focused assessment is a component of the comprehensive assessment but may be restricted to a particular system or set of signs and symptoms. It also may be more appropriate in certain client situations, such as with an emergency or when the client is in pain. The Center for Cross-Cultural Health at • Subjective data is provided www.crosshealth.com by clients, family memInitiative to Eliminate Racial & Ethnic Disparities bers, and others providing in Health at their stated interpretations http://www.cdc.gov/omh/AboutUs/disparities.htm of the situation and also Office of Minority Health at http://www.omhrc.gov/ may be obtained from preNational Center for CAM at vious hospital records and http://nccam.nih.gov consultations. Transcultural C.A.R.E. Associates at http://www.transculturalcare.net


• Objective data is observable by some verifiable measure, such as •

•

•

•

•

oxygen saturation and blood pressure. The health history is the background information and subjective data provided on the client and contributes to the picture of the current situation and provides data for analysis for the development of a complete assessment. The different parts of the health history include demographic information, the chief complaint, the present problem, past history, family history, lifestyle habits, social/experiential or psychosocial history, and review of systems or functional health patterns. The physical assessment is the head-to-toe health appraisal. Four techniques are used in the physical assessment process. ➡ Inspection is the use of one’s eyes and visual assessment skills to differentiate normal from an abnormal finding. ➡ Palpation uses the sense of touch to detect normal and abnormal findings as with temperature differences or skin lesions, edema, or masses. ➡ Auscultation uses the sense of hearing, both with and without a stethoscope in the detection of heart, breath, vascular, and abdominal sounds. ➡ Percussion is used to detect differences in sounds using a drum-like tactile technique to listen for the differences in air trapped in selected body cavities. Percussion is also used to assess reflexes, as with the use of a percussion hammer. Gordon’s (2006) 11 functional health patterns can be used as a valuable tool in the nursing assessment and diagnosis process and in the application of models to address health and illness focused on human potential or a sense of coherence. Culture involves a combination of social, familial, religious, national, and professional characteristics that affect the way we think, act, and interact with others. Differences among groups and subgroups produce diversity that can lead from uniculturalism to appreciation of a multicultural environment and healthcare behaviors. The Giger and Davidhizar (2006) Transcultural Assessment Model, directed at the importance of culture and care focuses on the assessment process and patterns of culturally unique individual factors, communication, space, social orientation, time, environmental control, biological variations, and nursing assessment.



each completed your interview. 1. Moving from data collection in Address the following cultural the LPN role to the RN skills considerations in your assessneeded for a comprehensive ment: health assessment, describe • Time for acceptance and to what new assessment skills and gain an understanding of their techniques you must develop for belief system the RN scope of practice. • Differences in belief systems 2. You are the triage nurse in the among generations and Emergency Department when a geographic origins 48-year-old female arrives with • Past experiences and current chest tightness. Describe the assituation sessment process in this case. • Religious influences 3. Select the use of a review of • Familial influences systems framework or the use of • Understanding of advance functional health patterns in the directives assessment process. • Acceptance of the healthcare 4. Complete a health history with a services, systems, and cultural assessment on a peer practitioners and compare findings for valida• Linguistic issues tion of the data when you have Go to the Intranet site and complete the interactive exercises provided for this chapter.

REFERENCES Dillon, P. M. (2007). Nursing health assessment: A critical thinking, case studies approach (2nd ed.). Philadelphia: F.A. Davis. Giger, J. N., & Davidhizar, R. E. (2006). Transcultural nursing: Assessment and intervention (4th ed.). St. Louis: Mosby. Gordon, M. (2006). Nursing diagnosis: Process and application (11th ed.). St. Louis: Elsevier Science. Spector, R. E. (2000). Cultural diversity in health & illness (5th ed.). Upper Saddle River, NJ: Prentice Hall Health.

BIBLIOGRAPHY Andrews, M. M. (2003). Theoretical foundations of transcultural nursing. In M. M. Andrews, & J. S. Boyle, Transcultural Concepts in Nursing Care (4th ed.). Philadelphia: Lippincott Williams & Wilkins.

ONLINE RESOURCES Auscultation Assistant : http://www.med.ucla.edu/wilkes/inex.htm Cardiac Sounds: http://www.med.ucla.edu/wilkes/intro.html Lung Sounds: http://www.med.ucla.edu/wilkes/lungintro.htm Center for Disease Control: http://www.cdc.gov/vaccines/default.htm The Center for Cross-Cultural Health: www.crosshealth.com Initiative to Eliminate Racial & Ethnic Disparities in Health: http://www.cdc.gov/omh/AboutUs/disparities.htm Office of Minority Health: http://www.omhrc.gov National Center for CAM: http://nccam.nih.gov Transcultural C.A.R.E. Associates: http://www.transculturalcare.net


CHAPTER 8

Diagnosis and Planning Teresa S. Burckhalter, MSN, RN, BC

CHAPTER OBJECTIVES After completing this chapter, you will be able to: 1. Name the major types of nursing diagnoses. 2. Formulate actual and risk nursing diagnoses. 3. Determine goals and outcomes that give direction to nursing care activities. 4. Describe the difference between goals and outcomes.

Introduction Some thoughts on planning (Box 8–1) offer some perspectives about the topics of this chapter. When you begin a journey, you should have a destination in mind. If you don’t, the journey has no direction and no end. You will not know when you have arrived. A successful journey involves planning. When you plan, you decide what you need in order to embark on the journey and get to where you are going. While a formal plan does not always help you know what to do when a situation changes, the process of planning helps you recognize what obstacles you may encounter along the way. As you can see, these ideas are very applicable to caring for clients. You should have a goal or an end in mind. You base this goal on where you begin. What did the assessment show? You must decide what the major problems are and how to solve them. What is needed to solve the problems? How will you know the problems are solved? What should you do if care does not proceed as planned? These questions continue to take you through the nursing process. As you have examined the nursing process so far in this book, it may seem similar to the manner in which you have used it as a practical nurse. As a registered nurse, you will expand the process. What are the RN’s responsibilities?

Key Terms Planning Analysis Outcome identification Holistic Nursing diagnosis Taxonomy NANDA Functional health patterns Analogy Etiology Actual nursing diagnoses Risk nursing diagnoses Outcome Identification Concept map

■ Recognize actual and potential health problems ■ Anticipate complications ■ Identify actions to ensure appropriate, effective, and timely care Chapter 8 l Diagnosis and Planning 109

BOX 8–1

Thoughts on Planning

“If you don’t know where you are going, you will wind up somewhere else.”—Yogi Berra

“In preparing for battle I have always found that plans are useless, but planning is indispensable.” —Dwight D. Eisenhower (1890–1969) U.S. president and World War II leader

BOX 8–2

Definitions of Nursing Diagnoses

Nursing diagnosis is a clinical judgment about an individual, family, or community that is derived through a deliberate, systematic process of data collection and analysis. (Shoemaker, 1984) “A clinical judgment about an individual, family, or community response to actual or potential health problems and life processes.” (North American Nursing Diagnosis Association, 1999) “Diagnosis is a reasoning process that nurses use to interpret client data.” (Wilkinson, 2007, p. 152)

These responsibilities are fulfilled in the next two steps of the process: nursing diagnosis and planning. The assessment showed you your starting point; nursing diagnosis and planning help you determine the path you will take for a client’s care. Nursing diagnosis is defined in a variety of ways by various experts and organizations (Box 8–2). Some groups use the term “analysis” to refer to diagnosis. Nursing diagnosis is the step of the nursing process where a client’s individual problems are identified, which will form the basis for the plan of care. Planning care involves creating a map of destinations, routes, and supplies. Planning is defined by various experts and organizations in Box 8–3. Planning has three major aspects: deciding on the goals of care, outcome identification, and determining the resources needed to reach the goals and outcomes.

Analysis and Outcomes Identification Analysis is a component of nursing diagnosis that is used by the registered nurse but not the practical nurse; so, this part is new to you. Or is it? Consider this clinical situation. A client has a fractured tibia that was surgically repaired by ORIF (open reduction, internal fixation). You observe the client with a facial grimace and state, “Rate your pain on a scale of 1 to 10.” The client responds, “10.” What do you do? You give the client an analgesic. Why? Because you recognized that the client was in pain. When you recognized the pain, you were analyzing and diagnosing the situation. The clinical information indicated there was a problem: pain. Pain, which in this case was acute, is a nursing diagnosis. You wanted to do something about the pain, so you planned ways to help the client feel more comfortable. Comfort was the goal you were seeking to achieve. This goal of comfort is multifaceted. What does comfort mean? We know that it has different meanings for different people. Comfort is a physical and a psychological state, but it is not measurable. People define comfort differently. 110 Section 2 l Clinical Judgment and the Nursing Process

BOX 8–3

Definitions of Planning

“The nurse, with client and family input, derives Outcome identification is part of desired outcomes from the diagnostic statements and the planning phase and involves specifyidentifies nursing interventions to achieve those ing what will be achieved by this client goals.” (Wilkinson, 2007, p. 260) and when it will happen. How will you Predicting outcomes and deciding on nursing know the client is physically comfortinterventions. (Gordon, 2006) able? How will you know the client is “Planning involves three subsets: setting priorities, psychologically comfortable? Outcomes writing expected outcomes, and establishing target are measurable milestones that move dates. . . . Planning further assists in the final phase you, step by step, toward the goal. of evaluation by defining the standard against which So, these components are not we will measure progress.” (Newfield, Hinz, Tilley, really new to you, but as a registered Sridaromont, & Maramba, 2007, p. 8) nurse you will use them differently. You will use these parts in a more formal way, creating the foundation to direct, or manage, the plan of care. In addition, you will address the client’s situation in a more holistic way using your critical thinking skills. In our clinical example earlier, you addressed the here and now situation of pain. When analyzing, you would certainly include the issues of pain, but what other issues may face this client? ■ The client’s mobility is impaired by the fracture. What happens to a person who spends long periods in bed? ■ The client may not be able to work because of the injury. Will the client be able to pay the rent or mortgage? ■ If the client is a parent, will he/she be able to take care of children? ■ If the client’s car has a standard transmission (straight drive), will the client be able to depress the clutch and change gears with pins in place? No? Will that mean the client has no transportation to get to and from doctor and physical therapy appointments? ■ Has the pain or analgesic medication caused nausea and vomiting? If so, maybe the client does not want to eat and drink. How would nausea and vomiting affect nutrition? ■ If the client frequently takes narcotic analgesics, what will happen to bowel elimination? ■ This client faces a long rehabilitation. How is the client handling that prospect from an emotional standpoint? ■ The list goes on and on. Consider all the what-ifs; then, decide which what-ifs are most important. Which what-ifs must be addressed now and which ones can wait? These are the holistic (or more comprehensive) issues you must consider, in addition to the pain, when analyzing a client’s problems and needs. These issues serve as the basis for diagnosing the situation, then creating and managing a plan of care that takes the client to the intended goal or destination.

Nursing Diagnosis After completing the assessment, you will analyze the information and formulate nursing diagnoses. This analysis further serves as the basis for Chapter 8 l Diagnosis and Planning 111

planning and then selecting nursing interventions to achieve the desired outcomes. You are accountable, or answerable, for making sure the plan of care is individualized, orderly, correctly prioritized, and communicated to other team members and the client. These diagnoses are nursing diagnoses, not medical diagnoses. The medical diagnosis sets the stage for treatment. It focuses on treating a problem, symptom, or disease process. In other words, a problem already exists. That’s the medical model. It focuses on finding a cure, but is weak on prevention and health promotion. You may use an understanding of the medical diagnosis to help give direction to selecting the nursing diagnoses, but nursing and medicine are different disciplines. Each has its own focus in caring for clients. The registered nurse (RN) predicts, prevents, and manages. ■ The RN’s focus is on early intervention. Why is it important to provide nutritional counseling early in pregnancy? Why is it important to recognize and provide care for a Stage 1 pressure ulcer? ■ The RN uses research findings to provide the best care. Research helps you use the best care for each client situation. You will use evidence-based practice, as will be discussed in further detail in Chapter 11. ■ The RN predicts and anticipates problems. You want to avoid complications for your clients. Why do you encourage postoperative clients to cough and deep breathe? Why do you listen for bowel sounds after a person has abdominal surgery? You can predict common postoperative complications; so you use these interventions to make sure they do not happen. ■ The RN looks for risk factors that may lead to additional problems. This action takes you back to holism. If we consider only the risks for atelectasis or paralytic ileus for a postoperative client who does not have a safe and clean place to recover after discharge, what have you missed? What additional problems are likely to develop for this client? Prevention is also part of your focus. Recall the three levels of prevention discussed in Chapter 6, and include your understanding of these levels when formulating nursing diagnoses. ■ Primary prevention: Protection from a disease while still in a healthy state ■ Secondary prevention: Early detection and treatment of disease ■ Tertiary prevention: Preventing complications as well as maintaining health after a disease process has occurred If the nursing assessment was omitted, incomplete, or flawed, the analysis also will be flawed because you have made decisions based on inadequate or inaccurate information. The nursing diagnoses will not be correct or individualized. The steps of nursing process must follow in order. Fortunately, you have diagnoses that have been named and supported by nursing research. The most popular taxonomy (standardized classification of terms) of diagnoses is issued by the North American Nursing Diagnosis Association, or NANDA (NANDA International, 2007). These diagnoses have been organized by two major approaches: functional health patterns (see Appendix B) and human response patterns. Every nursing diagnosis must be individualized for each client and clinical situation. Each diagnosis is individualized using a client’s specific assessment findings. 112 Section 2 l Clinical Judgment and the Nursing Process

THINKING TOOL (ANALOGY) To formulate individualized nursing diagnoses, goals, and outcomes, you must use critical thinking and reasoning. Analogies are one tool for critical thinking. They show relationships in a comparative way. Here’s an example of an analogy. French fries : Hamburgers :: Dressing : Turkey “:” means “is to” or “are to” and “::” means “as”. Read this analogy aloud: French fries are to hamburgers as dressing is to turkey. See the comparative relationship? Each side of the analogy shows a similar relationship between two things. French fries and hamburgers go together; dressing and turkey also go together. Of course, you do not usually think of having turkey with French fries or hamburgers with dressing! Now that you understand what an analogy is, let’s try an analogy that relates to healthcare. Gastrointestinal bleeding : alcoholism :: Pneumocystic pneumonia : AIDS So, we would read this analogy aloud: gastrointestinal bleeding is to alcoholism as pneumocystic pneumonia is to AIDS. Think about the relationships. Gastrointestinal bleeding is a complication of alcoholism, and pneumocystic pneumonia is a complication of AIDS. Both sides of the analogy identified a complication associated with a particular health problem. The analogy helps you compare the relationships. These are simple analogies using words. Analogies can also be demonstrated using pictures, stories, or other methods. APPLICATION—YOU CAN DO IT Let’s use an analogy to learn how to formulate nursing diagnoses and determine goals and outcomes. Read and think about the following situation; then, we will use the understanding you gain from it to formulate nursing diagnoses, goals, and outcomes. First, forget about nursing process and that this is a nursing textbook! Let’s think outside the box. Let’s say you’re driving along and you see a fluffy little bunny beside the road. Chapter 8 l Diagnosis and Planning 113

■ “Fluffy little bunny beside the road” is your finding, right? Fluffy little bunny beside the road is what you found or assessed. Assessment findings come from what you see, hear, smell, or touch. How did this happen? ■ Because the door on the bunny’s cage was left open. The open cage door was a contributing factor to the bunny’s situation. Actually, it was the cause. Another word for cause is etiology. The etiology describes what may be causing or contributing to the assessment findings. Assessment Findings 1st Step Fluffy little bunny beside the road

What does this situation produce? ■ An escaped bunny. That’s the label we would put on the bunny. Now, put it all together in one statement. The statement is our diagnosis and it reflects our analysis of the situation. An escaped bunny (the diagnosis or label) related to the cage door being left open (the etiology, or cause of the finding) as evidenced by fluffy little bunny beside the road (what you saw; your assessment findings).

Etiology 2nd Step The bunny’s cage was left open

Assessment Findings Fluffy little bunny beside the road

Diagnosis 3rd Step

Etiology

An escaped bunny

The bunny’s cage was left open

Diagnosis 3rd Step An escaped bunny

Etiology 2nd Step The bunny’s cage was left open

Test your diagnosis. Do the findings (fluffy little bunny beside the road) validate, or prove, the label (an escaped bunny)? Yes! Was the open cage door the reason this situation occurred? Yes! Notice that we began with the assessment findings, determined what caused the assessment findings, and then chose a label. AfterAssessment Findings ward, we reversed the order, citing the Fluffy little bunny beside label first, inserted the term related to the road followed by the cause, inserted the term as evidenced by, and lastly listed our assessment findings. Assessment Now, suppose you wanted to make Findings 1st Step some improvements in this situation. Fluffy little bunny beside the road You would make a plan. Where would you put your efforts? You would work


on what caused this situation. You would work on ways to make sure the cage door stayed closed so nothing would happen to the other bunnies in the cage. Think about the learning you have gained from the analogy. Let’s return to learning about nursing diagnoses, planning, and outcome identification, but we will come back to this situation later in the chapter. TYPES OF DIAGNOSES There are six major types of nursing diagnoses: actual, risk, possible, wellness, syndrome, and collaborative (Carpenito-Moyet, 2006). Their names help us understand the circumstances under which they are used. Each type of nursing diagnosis has a specific way it is formatted (Table 8–1). This chapter focuses on actual and risk diagnoses. TABLE 8–1

Types of Nursing Diagnoses

Diagnosis Type Actual

Risk

Wellness

Possible

Syndrome

Collaborative

Features A clinical judgment that a problem exists and is demonstrating by particular defining characteristics (Carpenito-Moyet, 2006). Three parts: diagnostic label, etiology, and assessment findings. A clinical judgment that a person or group has a higher vulnerability to a problem than other because of the presence of risk factors (Carpenito-Moyet, 2006). Two-part diagnoses: (risk for) diagnostic label and etiology. No evidence. A clinical judgment regarding the movement of a client or group to a higher level of wellness (Carpenito-Moyet, 2006). One-part diagnostic statement, preceded by readiness for enhanced. (Wilkinson, 2007). Potential problems the nurse suspects may develop but for which there is no evidence. Risk factors may be suspected but not confirmed. Two-part diagnoses: (possible) diagnostic label and etiology. A cluster of actual and/or risk diagnoses that are evident or predicted (Carpenito-Moyet, 2006). Two-part diagnoses: syndrome diagnostic label and defining characteristics. Physiological problems based on the medical diagnosis. The nurse monitors for onset, changes, and complications (Carpenito-Moyet, 2004). Two-part statements: Potential complication followed by the medical problem.

Example Decreased cardiac output related to reduced pumping power of the heart as evident by shortness of breath after ambulating 15 ft. Risk for falls related to side effects of medication, especially orthostatic hypotension.

Readiness for enhanced spiritual well-being (NANDA International, 2005, 2007).

Possible anxiety related to making decisions about where to live in the future.

Self care deficit syndrome as evidenced by inability to perform activities of daily living (ADLs) unassisted.

Potential complication: heart failure.

Chapter 8 l Diagnosis and Planning 115

ACTUAL NURSING DIAGNOSES Actual nursing diagnoses define existing health problems the nurse will independently and collaboratively manage. Use the understanding you gained from the escaped bunny scenario as an analogy to developing a nursing diagnosis for a client situation. Consider this clinical scenario.

Diagnosis 3rd Step

■ You see your client wringing her hands. You hear her crying and saying “Oh dear. What’s going to happen to me?” ■ Those are assessment findings. They’re the signs and symptoms Etiology Assessment that serve as evidence of a problem, 2nd Step Findings 1st Step or diagnosis. Client wringing her hands; crying and saying “Oh dear. What’s going to happen to me?”

Diagnosis 3rd Step

Etiology 2nd Step Annual Pap smear showed precancerous cells

Assessment Findings 1st Step Client wringing her hands; crying and saying “Oh dear. What’s going to happen to me?”`

What’s producing this situation? ■ Let’s say she just learned that her annual Pap smear showed precancerous cells. That’s the etiology; the “related to” part of the diagnosis. She’s crying and wringing her hands because of her Pap smear report.

Now, put a label on it.

Diagnosis 3rd Step Fear

■ Consider which functional health patterns apply most to the situation. In this situation, the client’s self-perceptiosn is threatened. Self-perception is a functional health pattern. Consider the diagnoses under this pattern and decide which one(s) may apply. Use the definitions of the diagnoses to make sure your selections fit. Definitions of nursing diagnoses are found in nursing diagnosis reference books, such as those listed at the end of this chapter. Select the diagnosis that fits best. ■ The label is the nursing diagnosis from the North American Nursing Diagnosis Association (NANDA) list. We may not change NANDA terminology. The diagnoses were developed by nursing researchers. The NANDA conference must approve new diagnoses. This list of diagnoses is a taxonomy, our standardized classification of terms for naming. ■ In the situation we’re applying, choose Fear as the diagnosis. That’s a NANDA term under the Functional Health Pattern Self-perception. Fear is defined as “The state in which an individual or group experience a feeling of physiologic or emotional disruption related to an identifiable course that is perceived as dangerous” (Carpenito-Moyet, 2006, p. 161). Does that definition apply to our clinical situation? ■ Yes. We can imagine what this client is fearful about. She’s thinkEtiology Assessment ing the worst! 2nd Step Annual Pap smear showed precancerous cells

Findings 1st Step Client wringing her hands; crying and saying “Oh dear. What’s going to happen to me?”


Put it all together, with the connecting terms, for your actual diagnosis. ■ Fear related to results of recent Pap smear showing precancerous cells as evident by crying, wringing hands, and saying, “What’s going to happen to me?” ■ Ask yourself: does the evidence prove the diagnosis? Yes, it does. That’s a good diagnosis! Diagnosis Fear

Etiology Annual Pap smear showed precancerous cells

Assessment Findings Client wringing her hands; crying and saying “Oh dear. What’s going to happen to me?”

That was an actual nursing diagnosis. It has three parts: diagnosis, etiology, and assessment findings. This way of building nursing diagnoses was originally called the PES (Carnevali, 1983; Carnevali & Thomas, 1993; Gordon, 1976, 1994). ■ Problem, stated using a nursing diagnosis from NANDA ■ Etiology, formulated by determining why the assessment findings have occurred ■ Symptoms, the assessment findings or defining characteristics We built our diagnosis backward. Building a diagnosis backward helps to ensure that it is individualized to the client’s specific assessment findings. We started with the evidence (assessment findings), decided what was causing the findings (etiology), and then selected a NANDA diagnosis that fit. Use a nursing diagnosis reference book to decide which diagnosis fits best. This resource provides a definition of each diagnosis and defining characteristics that must be present in order to use the diagnosis. Defining characteristics is another term for the assessment findings or the signs and symptoms. Defining characteristics are the evidence of the diagnosis. Do not use a medical diagnosis as the etiology, or related to part, of your nursing diagnosis. Use your understanding of the physical and social sciences as well as your Chapter 8 l Diagnosis and Planning 117

knowledge of pathophysiology, medicine, and nursing. Sometimes the medical diagnosis is important to the etiology. When that situation occurs, write the etiology followed by the term secondary to and the medical diagnosis. Here’s an example. Reflex incontinence related to neurogenic bladder secondary to multiple sclerosis as evidenced by frequent urinary dribbling and residual volume less than 50 mL. See Table 8–2 for tips on formulating diagnoses. RISK NURSING DIAGNOSES A registered nurse thinks holistically about client care. We must consider not only the actual problems a clinical situation presents, but also what risks are or may be present. We use risk nursing diagnoses in the plan of care as an

TABLE 8–2 Tip Use sound documentation principles. Be objective.

Teach others and show the nurse’s independent role through the nursing diagnosis. Individualize problems.

Each diagnosis should stand alone. Multiple assessment findings or etiologies may support each diagnosis. Cluster the data together.

Tips for Formulating Nursing Diagnoses Correct Diagnosis Example Ineffective role performance related to unsteady work and income as evident by late payment of household bills. Powerlessness related to adjusting to role of being a single parent as evident by spanking children. Imbalanced nutrition, less than body requirements, related to excessive exercise, binging, and severely limiting oral intake secondary to anorexia nervosa as evidenced by body weight less than 50% IBW. Activity intolerance related to decreased cardiac contractility as evident by shortness of breath after ambulating 20 ft. Disturbed self-esteem related to loss of independent living skills as evident by stating “I’m no good to anybody like I am.” Decreased cardiac output related to loss of cardiac elasticity & pumping power 2° to heart failure as evidenced by 2⫹ ankle edema, shortness of breath on mild exertion, and intermittent brief periods of confusion.

Don’ts Don’t write a legally incriminating statement.

Incorrect Diagnosis Example Ineffective role performance related to buying and selling illicit drugs in the community.

Don’t write nursing diagnoses based on value judgments.

Impaired parenting related to misuse of disciplinary techniques as evident by spanking children. Imbalanced nutrition, less than body requirements, related to anorexia nervosa as evidenced by body weight 50% less than IBW.

Don’t use or rename the medical diagnosis as the basis of the nursing diagnosis.

Don’t state two problems at the same time.

Don’t relate one nursing diagnosis to another.

Don’t designate a separate nursing diagnosis for each assessment finding.


Fatigue and activity intolerance related to decreased cardiac contractility as evident by shortness of breath after ambulating 20 ft. Disturbed self-esteem related to disturbed body image as evident by stating, “I’m no good to anybody like I am.” Decreased cardiac output related to loss of cardiac elasticity & pumping power 2° to heart failure as evidenced by 2⫹ ankle edema. Acute confusion related to reduced cardiac pumping power as evidenced by intermittent brief periods of confusion. Activity intolerance related to loss of cardiac pumping power secondary to heart failure as evidenced by shortness of breath on mild exertion.

additional focus of nursing activities that have a risk, or likelihood, to occur. Because it is a risk and not a reality, there is no evidence, yet. So, a risk diagnosis has Diagnosis Etiology Assessment only a diagnostic label and an etiology. 3rd Step 2nd Step Findings 1st Step There are no specific assessment findNot present with a risk diagnosis ings or defining characteristics. Here is an example. Let’s go back to our bunnies. ■ Let’s say you just bought six bunnies and put them all in a cage together ■ How many bunnies do you have? Six right now, but given your knowledge of bunnies, what is the risk in this situation? ■ The risk is that you’re going to have more bunnies, right? Maybe more bunnies than can safely live in the cage or more bunnies than you can afford to feed?

Which functional health pattern applies to this situation? ■ Role-relationship If they are your bunnies, you have a responsibility to take care of them. As the owner, bunny care is your role. Considering the Role-Relationship functional health pattern, which diagnoses apply most to the situation? Use the NANDA approved definitions of nursing diagnoses to make sure your selections fit. Then, select the diagnosis that is most applicable. Consider the following risk diagnosis. Risk for caregiver role strain related to bunny overpopulation. There’s no evidence, but we certainly should be concerned about the risks. Remember, a risk diagnosis has only two parts: nursing diagnosis and etiology. Chapter 8 l Diagnosis and Planning 119

Caregiver role strain is defined as “The state in which an individual is at high risk to experience physical, emotional, social, and/or financial burden(s) in the process of giving care to another” (Carpenito-Moyet, 2006, p. 48). Does that definition fit our bunny overpopulation scenario? HOW MANY NURSING DIAGNOSES SHOULD BE IDENTIFIED? There are potentially thousands of actual and risk, or what-if, nursing diagnoses for a clinical situation. If you formulate too many diagnoses, risk or actual, your care loses focus. Decide which problems and issues are most important now. Once those issues have been addressed and resolved, you can add or move on to more nursing diagnoses later. PRIORITIZING How do you decide which nursing diagnoses and how many to include in the plan of care? Consider which problems are most likely to occur or cause serious problems for your client. Formulate the actual and risk diagnoses based on these issues. In other words, what are the priorities? It’s helpful to think holistically when deciding what the priorities are. You should consider: ■ ■ ■ ■ ■ ■

Maslow’s pyramid (see Fig. 3-1 in Chapter 3) (Maslow, 1970) A-B-C-D: airway, breathing, circulation, disability Developmental issues Spirituality Culture Emotional issues

Prioritization is also part of the next step of nursing process: planning.

Planning With the nursing diagnoses formulated, the next step is planning. Planning simply means deciding on a destination for a client’s care. This step includes determining goals and outcomes as well as what resources are needed to achieve them. Consider: ■ ■ ■ ■

Where do you want the client’s care to go? What is important to the client? How will you know we have achieved our mission? What resources (equipment, financial support, transportation, etc.) are needed to achieve the mission?

Planning serves as the foundation for the remaining steps of the nursing process. Without it, you have reached a dead end in client care. Let’s go back to our clinical scenario of a client fearful about her abnormal Pap smear. What are the priorities? We must decide where the nurse’s efforts should be directed first. While there are certainly some physiological concerns associated with the abnormal Pap smear, addressing these physiological concerns is predominantly the physician’s responsibility. From a nursing perspective, the threat to the client’s sense of safety and security is more pressing. So, this issue is a high priority for the nurse’s plan of care. If we think holistically about the situation, we also may gain these perspectives. ■ Developmental. Does the client fear she may never be able to have children? Will she begin to question her sexuality? If so, will her intimate relationships be affected? 120 Section 2 l Clinical Judgment and the Nursing Process

■ Spiritual. Might the client be worried that the Pap smear results occurred because she has not kept her faith? Does she see the test results as a divine punishment for prior sins? Has it caused her to question her place in the universe and lose hope for the future? ■ Culture. What are the traditional beliefs this client brings to our clinical situation? What did her parents teach her about health, sexuality, and reproduction? Does she make her own decisions about how to deal with this situation or is there a family member or significant other who will make the decisions for her? ■ Emotional. Might the client become depressed over the test results? If she’s tearful and preoccupied with her health, she may lose her ability to concentrate or experience anxiety. GOALS What’s the goal in this situation? What do you want to achieve with this client? Knowledge is therapeutic and will help alleviate her fears. You want her to understand her diagnosis and condition. That’s a goal; it’s general. You could phrase your goal: Client will be knowledgeable about her diagnosis and condition. That goal is not measurable as stated; so you need to identify outcomes that will lead us to the goal. OUTCOME IDENTIFICATION Outcome identification means deciding where the client will be or what the client will achieve by a designated time. What are the results the client can expect? These results must be stated in measurable terms (Table 8–3). Measurable means we will be able say: yes, it happened; no, it didn’t happen; or part of it happened when we get to the evaluation step of nursing process. What outcomes do you want to see? There may be one outcome or more than one, but the outcome(s) should lead step-by-step to the achievement of the goal. Consider this outcome for the client with the abnormal Pap smear. ■ Client will identify feelings of hopefulness as she discusses her diagnosis by July 15. Is that outcome measurable? Yes. Either it happens by July 15th or it doesn’t. The client can either identify her feelings or she cannot. Does that outcome lead to the goal? Yes. Psychosocial issues are very much a part of learning. Consider these examples of other outcomes that may apply to this situation. ■ The client will be able to accurately describe follow-up activities related to her abnormal Pap smear report by July 20th. ■ The client will state an accurate understanding of the importance of follow-up Pap smear testing by July 18th. The goal and outcomes indicate what is to be achieved for a client. You will work in partnership with clients. The client should have input into the goals and outcomes. What’s important to the client? What would she like to accomplish? If clients do not help determine the goals and outcomes, they will not value them. You want the client to work with you, but that will not happen if the client does not think the goals and outcomes are important. Where would the nurse direct care activities? ■ On the etiology, or cause. Chapter 8 l Diagnosis and Planning 121

TABLE 8–3

Tips for Identifying Measurable Outcomes

Tip Complete the assessment and analysis first. Designate the goal(s) before the outcomes.

Rationale

Build the outcome(s) using the specific assessment findings.

The specific assessment findings were the evidence of the diagnosis. An outcome will show that those findings are no longer present. For example: Breath sounds will be clear to auscultation bilaterally by (date).

Specify a target date for achievement of the outcome.

Nurses can accurately anticipate how long it will take for an outcome to occur. Consider this example. Client will demonstrate correct technique for applying eye drops by (date).

Regarding client education, state what the client will be able to do by when.

In the evaluation step of nursing process, we will need specific evidence to conclude whether an outcome was achieved. Consider these examples of outcomes. Client will use mirror to check own skin for breakdown by (date). Client will accurately use Glucometer 6 times to measure blood glucose by (date). The nurse wants to demonstrate progress, not stagnation. Clients should expect to be safe, comfortable, and make progress toward health. Here are examples of positively stated outcomes. Client will ambulate 20 ft with a steady gait & without c/o shortness of breath by 5/13/12—. Client will consistently rate pain as 2 or less by (date).

State the outcomes in positive terms.

The steps of nursing process must proceed in order. A goal is the destination for care, but is not measurable as stated. The outcomes will be based on the goal.

Common Errors We cannot designate goals and outcomes if we have not first defined the problems. Nurses sometimes designate numerous outcomes, but they are not connected to the goal for a client’s care. Nurses sometimes use the terms increase or decrease, which usually makes an outcome not measurable. Incorrect example: The client’s weight will increase. Correct example: The client’s weight will be 140 lb. by 6/15/12—. Do not use the term by discharge for the target date. Discharge is determined by the physician. The outcomes may or may not be achieved by the time a client is discharged. Unachieved outcomes become part of the nurse’s referral to the next caregiver. Nurses sometimes designate outcomes that state, “Client will know . .” but how would we determine that a client knows something?

Consider these poorly written outcomes. Client will be free of injury by discharge. Client will be free of pain.

INTERVENTIONS We are back to planning. You will prescribe interventions that will promote achievement of the outcomes and ultimately the goal. In our clinical example of a woman with an abnormal Pap smear, you should choose interventions to: ■ Help her learn more about what these findings mean and that it is not a death sentence 122 Section 2 l Clinical Judgment and the Nursing Process

■ Help her grieve what she believes is really bad news ■ Encourage and support her; let her know she is not alone ■ Educate her about the reliability of Pap smears and the importance follow-up testing You will prescribe interventions to help or cause the outcomes to happen. These prescriptions are identified in the planning step of the nursing process, but are carried out in the implementation step. As with other prescriptions, there should be an action and a frequency. For example: ■ ■ ■ ■

Direct the client to three reliable Internet sites to read about Pap smear testing x 1 In three one-on-one discussions, help the client to define her fears Educate the client about the stages of grieving x 1 Assist the client to make a follow-up appointment x 1

Refer to Chapter 9 for more information on the implementation step of the nursing process.

Additional Tools to Support Excellence in Nursing Diagnosis and Planning NURSING DIAGNOSIS REFERENCE BOOKS As mentioned earlier, there are numerous nursing diagnosis reference books available (see the listing at the end of this chapter). These resources assist the nurse in determining which diagnoses are best suited for various clinical problems. Features common to these references include: ■ Definitions of each nursing diagnosis, sanctioned by NANDA. ■ Defining characteristics, also known as evidence. These characteristics are the assessment findings present if the diagnosis applies. Defining characteristics are further subdivided into major characteristics, at least one of which must be present in order to use the diagnosis, and minor characteristics, which may or may not be present. ■ Suggested etiological factors for each diagnosis. The etiological factors are the related to part of the nursing diagnosis. If you are having difficulty stating an etiology, these resources can help refine this part of your nursing diagnosis. ■ Suggested goals, outcomes, and interventions. These suggestions are general, so the nurse must individualize them for each client. Some nursing diagnosis reference books also offer common diagnoses associated with various medical problems. For example, consider the care of a client with meningitis. When you designate the nursing diagnoses, you would immediately consider pain and the risks for infection transmission, respiratory problems, and injury. When using this section of a nursing diagnosis reference book, you would also be prompted to consider activity intolerance and anxiety, along with risks for impaired skin integrity and oral mucous membranes, imbalanced nutrition, interrupted family processes, and ineffective management of the therapeutic regimen. You would also find a list of common collaborative problems, or Chapter 8 l Diagnosis and Planning 123

medical complications, for which you should monitor (Carpenito-Moyet, 2006). These considerations assist you to prepare a holistic plan of care. CONCEPT MAPS Concept maps are another popular tool for analysis and planning. Concepts maps are diagrams you may use to help visualize the assessment findings, decide how they are or might be connected, determine the nursing diagnoses, prioritize, as well as develop goals, outcomes, and interventions. These diagrams are often depicted using circles or squares containing the assessment findings, which are then connected by solid or dotted lines to show relationships between problems. See Figure 8–1 for an example of a concept map (Schuster, 2008).

#6

#1

Key Problem Impaired Urinary Elimination

I don’t know how this fits with the problems. Acetaminophen? Widower?

Intake = 2200 Output = 1800 Polyuria 3+sugar

Key Problem Acute Anxiety

Key Problem Imbalanced Nutrition: Less than Body Requirements Polydipsia Intake = 2200 Output = 1800 Weakness 174# Humulin N Glucose (450)120 Glyco Hgb = 12% Cholesterol 240 Glucometer 1800 ADA no sugar added

#2 Reason For Needing Health Care: Medical Diagnosis/Surgical Procedure: Newly Diagnosed Diabetes

Expresses concern over injections and diet New Diagnosis

Key Problem Ineffective Tissue Perfusion (Peripheral)

Key Assessments: Signs and symptoms of hypoglycemia & hyperglycemia, monitor blood glucose, food intake & VS

#4

138.92 Valsartan (Diovan) VS qid 98.4-77-18 Potential Skin Breakdown

Key Problem Deficient Knowledge

#3

Diagnosis Medications Diet Skin Care Foot Care Exercise

Key Problem Impaired Physical Mobility Risk for Falls-4 OOB/chair Weakness

Figure 8–1 Example of a Concept Map. (From Schuster, P. [2008]. Concept mapping: A critical thinking approach to care planning [2nd ed.]. Philadelphia: F.A. Davis, with permission.)


#5

KEY POINTS • Nursing process proceeds in an orderly, step-by-step fashion. • The registered nurse’s scope of practice adds two steps to this process

• • •

• • • •

•

• •

that are not part of the LPN’s scope of practice: analysis and outcome identification. After first gathering and clustering the assessment findings, the registered nurse formulates individualized nursing diagnoses. Nursing diagnoses serve as the basis for the plan of care. The RN is accountable, or answerable, for making sure the plan of care is individualized, orderly, correctly prioritized, and communicated to other team members and the client. Nursing diagnoses, provided by the North American Nursing Diagnosis Association, specify and individualize the client’s problems. There are six major types of nursing diagnoses: actual, risk, possible, wellness, syndrome, and collaborative (Carpenito-Moyet, 2006). One way to organize nursing diagnoses is by functional health patterns. The nurse individualizes diagnoses by stating the etiology, or cause, and the evidence of the problem drawn from the nurse’s assessment findings. Planning involves prioritizing the nursing diagnoses, determining the goals and outcomes of care, deciding what resources are needed to achieve the goals and outcomes, and prescribing interventions. Goals are global directions for client care. Outcomes are specific and measurable and lead to attainment of the goal.


4. Criticize this comment from an 1 Should analysis and outcome experienced nurse to a nursing identification be responsibilities student, “Nursing care plans are for LPNs? Why or why not? just something you do while 2. Some facilities use standardized you’re in school. After you gradunursing diagnoses and plans of ate, you don’t have to do them care. Why are individualized diaganymore.” noses and plans of care better? 3. Why is it important for clients to have input into their plans of care? Go to the Intranet site and complete the interactive exercises provided for this chapter.

REFERENCES Carnevali, D. (1983). Nursing care planning: Diagnosis and management (3rd ed.). Philadelphia: Lippincott. Carnevali, D., & Thomas, M. D. (1993). Diagnostic reasoning and treatment decision making in nursing. Philadelphia: Lippincott. Carpenito-Moyet, L. J. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia: Lippincott Williams & Wilkins.

Chapter 8 l Diagnosis and Planning 125

Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Gordon, M. (1976). Nursing diagnosis and the diagnostic process. American Journal of Nursing, 76 (8), p. 1276–1300. Gordon, M. (1994). Nursing diagnoses: Process and application (3rd ed.). St. Louis: Mosby-Year Book. Gordon, M. (2002). Manual of nursing diagnosis (10th ed.). St. Louis: Mosby-Year Book. Gordon, M. (2006). Manual of nursing diagnosis (11th ed.). Sudbury, MA: Jones and Bartlett. Maslow, A. H. (1970). Motivation and personality (2nd ed.). New York: Harper & Brothers. NANDA International. (2005). Nursing diagnoses: Definitions and classifications, 2005–2006. Philadelphia: NANDA International. NANDA International. (2007). Nursing diagnoses: Definitions and classifications, 2007–2008 (7th ed.). Philadelphia: NANDA International. Newfield, S. A., Hinz, M. D., Tilley, D. S., Sridaromont, K. L., & Maramba, P. J. (2007). Cox’s clinical applications of nursing diagnosis: Adult, child, women’s, mental health, gerontic, and home health considerations (5th ed). Philadelphia: F.A. Davis. North American Nursing Diagnosis Association. (1999). Nursing diagnoses: Definitions and classifications, 1999–2000. Philadelphia: NANDA. Schuster, P. M. (2008). Concept mapping: A critical-thinking approach to care planning (2nd ed.). Philadelphia: F.A. Davis. Shoemaker, J. (1984). Essential features of a nursing diagnosis. In M. J. Kim, G. K. McFarland, and A. M. McLane (Eds.), Classification of nursing diagnoses: Proceedings of the fifth national conference. St. Louis: Mosby. Wilkinson, J. M. (2007). Nursing process and critical thinking (4th ed). Upper Saddle River, NJ: Pearson Education.

ONLINE RESOURCES NANDA International: www.nanda.org Office of the Professions, New York State Education Department. Practice Alerts & Guidelines - The Differentiated Scope of Practice of Licensed Practical Nurses (LPNs) and Registered Professional Nurses (RNs): http://www.op.nysed.gov/ nurse-scope-lpn-rn.htm Texas Collaborative for Teaching Excellence. (See the example of another concept map at this site.): http://cord.org/txcollabnursing/onsite_conceptmap.htm

POPULAR NURSING DIAGNOSIS REFERENCE BOOKS Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Doenges, M. E., & Moorhous, M. F. (2008). Nursing diagnosis manual (2nd ed.). Philadelphia: F.A. Davis. Gordon, M. (2006). Manual of nursing diagnosis (11th ed.). Sudbury, MA: Jones and Bartlett. Wilkinson, J. M. (2005). Prentice Hall nursing diagnosis handbook with NIC interventions and NOC outcomes (8th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.


CHAPTER 9

Implementation CHAPTER OBJECTIVES After completing this chapter, you will be able to: 1. Discuss the implementation phase of the nursing process. 2. Examine concept mapping for application of the nursing process. 3. Describe techniques to assess learning readiness and motivation. 4. Use assessment findings to determine preferences in clients with a learning need. 5. Develop an implementation plan for a client with a knowledge deficit.

Implementation You now have your assessment, analysis and nursing diagnoses, and mutually agreed upon plan with the client on their care including outcome statements. You are at the point of activating the plan. Recall, the American Nurses Association (ANA, 2004) in the Scope and Standards of Nursing Practice defines implementation activities as intervening, delegating, and coordinating but also points out that “the client, significant others, or health care professionals may be designated to implement interventions within the plan of care” (p. 115). You may be providing the intervention, such as a dressing change, while teaching the client the procedure to perform following discharge. On the other hand, you may be delegating the dressing change to the practical nurse while determining home resources and the availability of family members to assist with care following discharge and the home resources that will be needed. Or, you may even be consulting with the insurance provider on the supplies needed, home health services required, and out-patient therapies required when discharged. You are not isolated in this process. The client, whether individual, family, or group, has also participated in the development of the plan and they have mutually agreed upon the plan of action and the proposed outcomes. It is an active, participatory, and coordinated effort to promote the client’s health. Other resources and healthcare professionals may be needed to fully implement the plan. Intervening includes actions of following the agreed-upon plan. As observed by Doenges, Moorhouse, and Murr (2006), you must ensure that the interventions are:

Key Terms Intervening Assignment Delegation Responsibility and accountability Coordinating Concept mapping Dependent nursing actions Independent nursing actions Teaching Learning Affective domain Cognitive domain Psychomotor domain Readiness Motivation Change

Chapter 9 l Implementation 127

■ ■ ■ ■

Consistent with the plan of care Implemented safely and appropriately Evaluated for effectiveness Documented in a timely manner (p. 4)

Ongoing critical thinking, interpersonal, and technical skills are required. Adaptations and changes to interventions will be required as we strive for client-centered and individualized care. Keen interpersonal skills are essential for client acceptance and participation in the process as well as to collaborate with other healthcare professionals on the care team. You may be the one leading the team in the coordination of care while in an acute care setting. You’ll also be responsible for collaborating on efficacy, documentation of outcomes, changes needed, and mobilizing additional resources or providers. Delegating is not a simple activity. In 2006, the ANA and the National Council of State Boards of Nursing (NCSBN) announced a joint statement on delegation. Delegation requires an awareness of the differences between assignment, delegation, responsibility, and accountability. Assignment is the distribution of work that each staff member is responsible for during a given work period (ANA, 2005, p. 4). An example is the distribution of tasks at the start of a shift. Delegation “is the transferring to a competent individual the authority to perform a selected nursing task in a selected situation; the nurse retains accountability for the delegation” (NCSBN, 2005, p. 193). The responsibility for completion of the task has been delegated, but not the accountability for ensuring that the task has been completed correctly by the right person who has been supervised appropriately. The nurse maintains both the responsibility and the accountability for the delegated action. Responsibility and accountability are clearly stated in fourth provision of the ANA (2001) Code of Ethics for Nurses as: The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care. (p. 16) The NCSBN (2005, 2006) envisions delegation as a four-step process: (1) assessment and planning; (2) communication; (3) surveillance and supervision; and (4) evaluation and feedback. The importance of delegation as a process is based on good assessment of the client, the environment, and providers who are capable and able to be delegated to provide appropriate care for the client. The process does not stop with the delegation. The delegation of a responsibility must be based on this assessment and must be made to the correct person, with monitoring by the registered nurse, who maintains the accountability for the function. The registered nurse assesses the client, the delegatee, the setting, and the task, but the nurse retains the accountability for the delegation and the client outcomes. Nursing judgment plays a role in the entire process through the evaluation phase. It is vital to remember that nursing judgment cannot be delegated. In their classic work on delegation, the NCSBN identified five “rights” of delegation (Box 9–1). These five 128 Section 2 l Clinical Judgment and the Nursing Process

BOX 9–1

The Five Rights of Delegation

rights have been further endorsed in the 2006 ANA/ The RIGHTS NCSBN Joint Statement. First, the task must be the right ✻ Task one for the client. The nurse must use clinical judgment, ✻ Circumstances not merely assign a CNA a group of rooms for taking ✻ Person vital signs. The circumstances must be right for the partic✻ Direction/communication ular client and his or her care needs—again a nursing ✻ Supervision/evaluation judgment. The right person means the right person for the care activity, nurse, technician, or assistive personnel. This person who will be delegated the care of the client must Source: From National Council of State Boards of Nursing. (1998). The five rights of delegation. Chicago: Author. clearly understand what is involved with the care to be given (direction). Two-way communication skills are critical. The fifth right is the provision of the correct supervision and evaluation of the care and the person who was delegated to provide the care. Once again, supervision and evaluation require the use of nursing judgment. Coordinating care in the implementation phase also requires critical thinking, interpersonal, and technical skills. Working with the client, you must ensure that all care is provided effectively, communicated, and documented appropriately by all healthcare providers. All caregivers need complete information so that revisions to the plan are timely and appropriate. Caregivers must collaborate and interact appropriately with the client as the first consideration at all times. U-turns are not allowed on highways and, in the healthcare arena, may jeopardize safety. As we will cover in Chapter 11, evidence-based care is essential. Constant vigilance to the client with necessary revisions to the plan is a given. In addition, the importance of the documentation cannot be overemphasized, especially on healthcare reimbursement issues for both the client and the healthcare agency. The nursing process provides the framework for an effective care process with the client as the focus. CONCEPT MAPPING As described in the previous chapter, concept mapping is another way of looking at the nursing process. This method focuses on your critical thinking skills to understand the interrelationship of client problems and the nursing diagnoses and needed interventions. Concept mapping has been used in the behavioral sciences, especially in the care of clients with dementia. Concept mapping still uses the steps of the nursing process but looks at relationships that are not apparent in the traditional five-column nursing process format. This different way of looking at care planning also has been referred to as “mind mapping.” Consider the similarities with concept mapping and use of the traditional nursing process in Box 9–2. The difference is that traditional care plans are a linear document with

BOX 9–2

Nursing Process and the Use of Concept Mapping

Nursing Process ✻ Assessment ✻ Diagnosis ✻ Planning ✻ Intervention ✻ Evaluation

Concept Mapping ✻ Diagramming, based on assessment data ✻ Analysis of data ✻ Analysis of relationships among nursing diagnoses ✻ Identification of goals, outcomes, and interventions ✻ Evaluation


five columns whereas concept care mapping is a diagram that you design to look at the client and his or her care needs. Schuster (2008) describes the concept mapping approach (Fig. 9–1). In the earlier steps of the nursing process, this approach involves obtaining assessment data and organizing it into a basic skeleton diagram. The next steps were a careful analysis and placement of the data into categories, identifying nursing diagnoses and relationships and establishing priorities as goals, outcomes, and interventions along with identifying any information not fully understood. This was your point of implementation of the plan and, ultimately, leading to evaluation of the effectiveness of client outcomes with the opportunity for refinement of the plan. The concept care map is a diagram that allows you to illustrate a relationship among client needs and relevant care needs. Concept care maps may be used in some agencies unlike the traditional care plans. These concept maps allow you to use skills of critical thinking and analysis to define relationships among the client’s needs and deliver individualized

Key Problem #

Key Problem #

Key Problem #

Pain

Impaired Skin Integrity

Elimination

Key Problem # Decreased Cardiac Output

I don’t know how this fits with the problems.

Key Problem # Reason For Needing Health Care: Medical Diagnosis/Surgical Procedure: Abdominal Abscess/Bowel Obstruction/Post-op Key Assessments:

Immobility

Key Problem #

Key Problem #

Key Problem #

Nutrition/Fluid and Electrolyte Imbalances

Impaired Gas Exchange/ Oxygenation

Anxiety

Figure 9–1 Reason Patient is Admitted and Key Ideas Based on Assessment or However You Want to Describe. (From Schuster, P. [2008]. Concept mapping: A critical thinking approach to care planning [2nd ed.]. Philadelphia: F.A. Davis, with permission.)


care. Let’s try one. First, in the center of a piece of blank paper, draw a box. In the box, write the client’s medical diagnosis or reason for seeking care. List the medical diagnoses including admitting medical diagnoses to allow you to plan your client-focused care. The nursing diagnoses will flow from the client’s central problem(s). Now, consider Gordon’s (2006) 11 functional health patterns (FHP): ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Health Perception/Health Management Nutrition-Metabolic Elimination Activity-Exercise Sleep-Rest Cognitive-Perceptual Self-Perception/Self-Concept Role-Relationship Sexuality-Reproductive Coping/Stress Tolerance Value-Belief

Analyze how these patterns are affected by the client’s condition. The FHP can then lead to the nursing diagnosis. For example, for the client with chronic obstructive lung disease (COPD), consider the following: Activity-Exercise with Activity intolerance Impaired gas exchange Or Self-perception/Self-concept Anxiety Fear These patterns will lead the NANDA nursing diagnoses and become the boxes around the central box, as spokes from a wheel (Fig. 9–2). You will then identify goals, outcomes, and interventions in the planning phase. The original concept map leads FHP to the planning phase on a separate piece of paper, using your concept “map” as the guide. First, goals and outcomes FHP FHP for each of the nursing diagnoses are identified followed by specification of nursing interventions, both independent and dependent nursing actions. What is the difference between independent and FHP FHP Dx: dependent nursing interventions? In your role as an LPN/ COPD LVN, you are under the direction of another licensed healthcare professional. Therefore, in this practical nursing role, FHP FHP you do not have independent nursing actions. All nursing actions are dependent being medical or nursing orders or a care assignment. This is not to say you are not using judgment in the care setting, for example allowing a client to rest for 10 minutes after administering a pain medication when Figure 9–2 Search for patterns. Chapter 9 l Implementation 131

he rated his pain (the “fifth” vital sign) at 9 on a scale of 10. That was a personal judgment and a good one but you had dependent orders to administer the pain medication and to take the vital signs. Notice that someone else ordered the activity; therefore, it is a dependent nursing action. Independent nursing actions fall within the domain of the professional registered nurse and are in the domain of nursing. As with the client in pain, this would include alternative comfort measures, perhaps guided imagery, positioning, vital signs comparison measures, instructing/incorporating significant others in nonpharmacological pain management techniques, or recommending reduction in caffeine intake.

Let’s return to the client with COPD. Consider the goal of maintenance of oxygenation with the outcomes of completing nebulizer treatments as scheduled with improved breath sounds (diminished wheezes bilaterally) within 48 hours. Then, list the nursing interventions. For example, maintain O2 and monitor vital signs, lung sounds, and pulse oximetry measurements every 4 hours and with additional activity noted and documented. Interventions should be specified in the plan for each nursing diagnosis. As we will cover further in the next chapter on evaluation, it is essential to evaluate the client’s response for each of the FHPs and nursing diagnoses. Although you are evaluating the client’s response during the implementation phase, more intense evaluation will occur later in the evaluation phase unless alternate interventions are needed immediately. For each of the nursing actions, patient responses should be evaluated and documented. In addition, the documentation is critical to view progress. So, concept mapping is just another way of approaching the nursing process. Implementation of interventions, delegation, and coordination are similar and lead to the evaluation of the process.

Intervening in the Case of a Knowledge Deficit With the diagnosis of knowledge deficit, the nurse has identified a learning need. However, as we discussed in Chapter 1, teaching and learning are multifaceted. This complexity is especially true in a client situation compared with a person who voluntarily registers for a 132 Section 2 l Clinical Judgment and the Nursing Process

course. Client teaching is much more than transmitting information in either verbal or written format. CLIENT TEACHING AND THE NURSING PROCESS Let’s return to the steps in the nursing process: ■ ■ ■ ■ ■

Assessment Diagnosis Outcome identification and planning Implementation Evaluation

These same steps are applicable to the client teaching process. Once you have identified knowledge deficit as a diagnosis and identified the etiology and contributing factors, you may need to return to earlier assessment data or even the assessment process to effectively address this nursing diagnosis. ASSESSMENT Consider your client as a learner but more than merely a receiver of information. Communication—verbal, nonverbal, and written—is a vital component in the client teaching process. Client teaching is a mutual process in which both the nurse and client obtain information, use reasoning skills, make analyses based on the data, and then move to decision making or problem-solving on the learning need. Ideally, the client learns from the nurse. But the nurse also gains awareness and skill from each interaction with clients. In the assessment stage, there is essential information we need to know for effective client learning and resolution of the knowledge deficit diagnosis. Consider some of the questions in Box 9–3. Notice that the assessment focuses on the learning process, not on the content to be included in a presentation of information. Determining content is a task later in the planning process, on the basis of specific attributes and needs of the client and the environment.

BOX 9–3

Assessment Considerations in the Case of a Knowledge Deficit

✻ What are the attributes of client, including family members and significant others? ✻ Are there literacy, bilingual, or information processing issues (like pain) to be addressed? ✻ What are the learning needs of the client? ✻ How has he or she learned best in the past? ✻ Has the client accepted the identification of a learning need? ✻ What is the readiness for and motivation to learn and address the knowledge deficit? ✻ What changes in behavior or attitude are perceived as needed by both the client and the nurse? ✻ What individual characteristics will enhance or inhibit learning? ✻ What is the nurse's teaching style, including preferred resources? ✻ What is the developmental level of the client? ✻ What is the client's cognitive style? ✻ What environmental factors will enhance or inhibit learning? ✻ What environmental factors at home may limit the incorporation of new information? ✻ What activities and resources will enhance learning? ✻ How can both the nurse and the client evaluate the effectiveness of the learning process?


OUTCOME IDENTIFICATION, PLANNING, AND IMPLEMENTATION Next, you will develop outcome objectives to give you direction for a teaching plan and evaluation of the learning. In the implementation phase, you will use teaching strategies, methods, and resources with specific content to meet the diagnosed learning need. EVALUATION The outcome of the teaching-learning process is evaluated by both you and the client. The evaluation component focuses on how the client met the outcome objectives and whether the knowledge deficit was resolved. The evaluation also should include sharing perspectives of the experience by both the client and you for future improvements or identification of additional needs. Although the nursing process provides a frame of reference for client teaching, learning and developmental theories also provide direction in the process. Even though many clients will be adults, individual differences of family members and significant others must be considered. ADULT LEARNING THEORIES Malcolm S. Knowles was a major educational theorist who focused on the adult learner. The term andragogical model was borrowed from European education (Knowles, 1980, 1990; Knowles et al., 1985). Expanding the traditional childhood learning models to incorporate learning characteristics and needs of adults, this developmental model proposes that the accumulated life experiences of adults give them different teaching and learning needs than those for younger learners. Children as learners are generally more passive, have few prior experiences to build on, and have pressures from parents, teachers, peers, and nurses to learn, or not. Adult learners are self-directing, have experiences that have shaped their identity, have experienced life events or a learning need that triggers their readiness to learn, have internal motivators, and demand an available, knowledgeable resource to assist them with practical problems and identified needs (Knowles et al., 1985). As Knowles and associates (1985) have pointed out, adult learners often initially assume the comforting and passive roles of child learners, but then an inner conflict develops with their self-directing nature. The adult’s ego system is based on his selfconcept and accumulated knowledge and experiences, whereas a child is gratified by impressing a parent, teacher, or peer. Knowles’ developmental focus is demonstrated further with his identification of life problems by age group in early, middle, and later adult life groups. He specified life problems in the areas of vocation and career, home and family life, personal development, enjoyment of leisure, health, and community living (Knowles, 1990). Adult learning also depends on both physical and psychological climates. Physical climate relates to the environment. The setup of the room should promote comfort for the client to focus on acquisition, acceptance, and incorporation of new information. The psychological climate must promote respect and dignity for adults to feel at ease. Knowles identified seven characteristics of the psychological climate conducive to adult learning: mutual respect, collaborativeness, mutual trust, supportiveness, openness and authenticity, 134 Section 2 l Clinical Judgment and the Nursing Process

pleasure, and humanness (Knowles et al., 1985, pp. 15–17). These characteristics should be considered in every client teaching situation. A key to successful learning in adults is their active involvement throughout the process. It is vital to promote the client’s empowerment to address their unique learning need. Recall from Chapter 1 that the basis for transformative learning is meaningfulness of experiences, especially for adults who have accumulated knowledge, cultural and environmental patterns, and experiences. Think about you and your desire to learn new information. Transformative learning involves three stages: ■ Critical reflection of the situation ■ Changing and integrating the new perspective and understanding ■ Acting on that new understanding These three states require more than one client encounter to provide information to address the knowledge deficit. Mezirow (2000) describes this process as reflective discourse: that specialized use of dialogue devoted to searching for a common understanding and assessment of the justification of an interpretation or belief (pp. 10–11). This use of dialogue with the client can be used effectively with adults who are actively challenged to find meaningfulness of the information. However, critical reflection involves challenging one’s assumptions and beliefs. This challenge may be difficult for the client who is in an altered state of health and required to accept limitations from past activities. The nurse is challenged with assisting the client to consider whether assumptions and beliefs still hold true, or perhaps there is an acceptable way to make changes. This active and thoughtful process is personally determined. But notice, the learner is the active one in the process. They are assisted with the information for critical reflection, but they must challenge their “habits of mind” and “resulting points of view” that Mezirow (2000) refers to as the two components of one’s “frame of reference” (p. 17). Then the person must decide whether to take action on the revised perspective as the transformation. As a result of the prior experiences of the adult, environmental influences, including persons, events, and tangible surroundings, must be taken into account with any learning need. CLIENT-TEACHING In a client-teaching situation, the goal is to address the knowledge deficit to promote or maintain the highest level of health attainable. The client’s definitions of health and wellness influence his or her physical, psychological, emotional, and spiritual health as personal determinants of behavior. These personal determinants are considerations in each client teaching encounter. Teaching is more than the transmission of information. The information must be received, understood, and evaluated by the learner. Teaching has been described as “an intentional and reasoned act” (Anderson et al., 2001). Benner (1984) has identified the teaching-coaching function of the expert nurse working with acutely ill patients: 1. Use timing to capture learning readiness and motivation 2. Assist with integration of learning into lifestyle 3. Demonstrate an understanding of client’s own interpretation of the situation 4. Provide interpretations of situations and rationales for new behaviors 5. Show, through example, coaching behaviors in culturally sensitive issues (Benner, 1984, pp. 77–94) Chapter 9 l Implementation 135

These characteristics demonstrate the active roles of both you and the client in the process. Readiness and motivation must be present for both of you during the process. You cannot be distracted with other obligations for client-centered learning to occur. The active role of the client in the process is vital, because passive learning rarely results in persistent change in attitudes or behaviors. Motivation is also important, as you demonstrate an understanding of the client’s unique characteristics and perspectives on the learning need and the client addresses a knowledge deficit. Coaching through example and with sensitivity is a component of effective client teaching. Remember, client teaching is an interactive process, not a one-directional transmission of information. Learning is the perception and assimilation of the information presented to us in a variety of ways and includes: ■ ■ ■ ■ ■ ■ ■ ■

Perception of new information Initial reaction to the information Ability to recall or repeat the information Rejection or acceptance of the information Application in a similar situation Critical analysis of the information Incorporation of the information as a new personal value Use of the information in various situations and combinations

For example, consider the learning process for a client who performs self-breast examination. She accepts information on the importance of self-awareness of breast familiarity; is able to correctly perform the self-examination; performs self-examinations on a regular basis in combination with screenings; teaches her daughter the process; and is now investigating regular screening for other forms of cancer. This client has moved from simple knowledge to incorporation of new values and behaviors of herself and other family members. Learning can be enhanced with specific strategies or approaches with clients, with particular consideration of the learning domains. A domain is merely a category. There are three domains of learning: affective, cognitive, and psychomotor (Table 9–1). TABLE 9–1

Learning Domains

Affective Domain Attitudes, feelings, and values.

Cognitive Domain

This could involve how a client feels about the importance of a needed change and will influence whether he will make the change. Cultural influences can affect whether the goal is achieved however.

This involves understanding the information received and the ability to understand types of actions that must be taken. This understanding is needed for application in an independent setting when the client performs the actual behaviors.

Knowledge and thought processes and the client’s intellectual ability.


Psychomotor Domain Processing and demonstration of behaviors; the information is understood and the client can demonstrate specific behaviors. Now skills are demonstrated by how the client has performed, as with a dressing change or administration of insulin as seen in return demonstrations, personal logs or diaries, and even laboratory reports with appropriate lab values.

It is important to consider these three domains in the client-teaching process. Outcome objectives, teaching content and methods, and evaluation of learning can be different for the three domains and should be distinct. All three domains of learning must be addressed for a lasting change in behavior and demonstrate resolution of the knowledge deficit. The actual learning environment for the client is important in any learning activity. Physical comfort as well as respect and acceptance of the learner are humanistic factors. The client may have physical, sensory, or psychological deficits that can interfere with comfort in the learning environment. Comfort measures should be validated with the client before and during the process. Physical comfort can include such things as the temperature of the room and the height or firmness of the chairs, in addition to specific effects of acute or chronic health problems. Sensory concerns include the extraneous sensory stimuli perceived in the environment, such as sounds, smells, and sights. In addition, the client may have sensory deficits (visual, hearing, or information processing problems) that may interfere with learning or may require more resources. Psychological deficits, including fear, problems with cognition, attention span, effects from medications, and worry, can be major inhibitors to learning. Consider the client with COPD who fears getting pneumonia again and is distracted by hearing someone in the hall sneezing or coughing. Receptivity of the learner to new and different ideas is vital. Creative measures by the nurse to provide for an environment conducive to learning are essential.

Readiness and Motivation Readiness is an important concept in learning, regardless of the learner’s chronologic age. Readiness relates to the developmental level and needs of individuals. Consider the developmental theorists described in Chapter 3. Erikson (1963) described readiness as critical periods. For learning to take place, the readiness of the learner must be a consideration. A good example is the issue of compliance and noncompliance. We talk about clients being noncompliant when they do not follow their discharge orders. The reasons for the behavior must be understood, not assumed. Compliance is yielding to the desire of others, possibly as a result of threats or force. But for a lasting change, threats and force do not encourage a permanent change in behavior. Human behavioral change is more effective when one is personally involved in the process. Specifically, how do learning and readiness apply to receiving and accepting information for a change in lifestyle? Consider the teenager undergoing dialysis. This adolescent may carefully monitor his sodium intake after dialysis but fills up on fast food the morning before the scheduled dialysis. Is this truly noncompliance or developmental maneuvering due to dietary restrictiveness? Now consider the adult cardiac client with a strict dietary sodium restriction. Is noncompliance by this individual due to adherence to food preferences, culture, or custom? Or, perhaps we failed in teaching for change or there was a failure to understand learning readiness? The client must be willing to change and accept the learning need. When this occurs, readiness for learning is apparent. Both you and the client must be focused on and sensitive to the same goal. Ultimately, the effectiveness of the teaching is evaluated on the basis of the learning that did or did not take place. Learning readiness involves human motivation, understanding or cognitive level, and applicability or acceptability. Learning readiness may also involve physiological ability, for example, consider the toddler who reaches a critical period for toilet training because of neuromuscular development, or the person in pain who is not distracted by other sensations. Chapter 9 l Implementation 137

Literacy and language issues are additional considerations in readiness. For the individual with a low literacy level, years of adaptive behavior may disguise the inability to read basic information. Likewise, an individual who speaks English as a second language may perceive information differently and perform several translation processes in an attempt to understand. In each situation, the individual may be unwilling to indicate to the nurse that he did not fully understand the information presented. The readiness to learn is inhibited by additional factors in these cases. Motivation in humans includes internal and external personal and environmental factors that cause people to respond to a situation in the way that they do. Motivation has been classically viewed as needs, drives, and impulses that cause behavior. But motivation is as complex as the person. The concept of motivation encompasses the person’s interpretations of the situation and his or her ability and willingness. Readiness, therefore, involves motivation and understanding. Understanding is the cognitive ability to perceive and intellectualize the content and consequences of information. The way the person views future consequences of the behavior may become the motivation to act in the present. Motivation is important to client teaching, in that the client can be motivated to learn with a realistic anticipation of the situation as well as the consequences of action or inaction. During the assessment process, motivation can be assessed and stimulated. A person’s cognitive level is a component of understanding; the content provided must be at the person’s level of understanding. Piaget’s theory of cognitive development describes the differences in learning levels between the sensorimotor infant developing object permanence and the older child who is able to learn abstract mathematical skills through formal operations. Information must be available to the person at his cognitive level for processing and development of knowledge. The person may require concrete examples to envision future consequences or may be able to handle more abstract examples. Again, an important consideration is the client’s state of health. Current physiological or psychological functioning and medications may interfere with reasoning and understanding as well as the attention span. Readiness for health teaching in this instance may be at different levels, depending on physical and emotional functioning. Another component of readiness for learning is applicability and acceptability of the information. The client must perceive that the information is applicable to him, as an individual, a member of the family, or a member of a group. If the client denies that a health problem exists, he will not be ready for health teaching in that area. The information is not perceived as personally applicable. Acceptability means that the information must be within the person’s worldview. Cultural influences are important, because values and belief systems influence understanding and acceptability of information. The health problem and readiness must be seen in the context of the individual’s belief system. Cultural assessment data provide important information on the client’s belief system that should be incorporated into the client-teaching process. THE CHANGE PROCESS You are actually promoting change in the client-teaching process. Change can be defined as a process that results in altered behavior of individuals or groups. Still, making change is not an easy process. In professional practice, you need to focus on the process of planned change. Planned change for individuals or groups in the environment requires structural shifts or altered behaviors for improved functioning. Improved functioning involves new (changed) behaviors, attitudes, and relationships. As a professional nurse, you are a change


agent for people and health. Their role is to move for needed, planned change for individuals, families, and groups. The classic change theorist was Kurt Lewin with model based on human motivation and group norms. Lewin (1951) proposed that the status quo, or a state of equilibrium, is maintained when restraining forces and driving forces balance each other. To achieve change, the restraining forces must be weakened and the driving forces strengthened. Consider the illustration of change in Figure 9–3.

Figure 9–3 Restraining and Driving Forces in the Change Process or Your Description. (From Kearney-Nunnery, R. (2008). Advancing your professions: Concepts of professional nursing [3rd ed.]. Philadelphia: F.A. Davis, with permission.)


Restraining forces in society resist change; they include norms, values, relationships among people, morals, fears, perceived threats, and regulations. In essence, these restraining forces are the “old guard” that maintains the status quo. Driving forces, on the other hand, support change and include the desire to please or the desire for more novel, effective, efficient, or merely different activities. System imbalance becomes the impetus for change. The process involves weakening the restraining forces and strengthening the driving forces. To do this, Lewin proposes three methods: unfreezing, moving, and refreezing of group standards. Unfreezing involves disequilibrium, discontent, and uneasiness. The restraining and driving forces are identified, and comparisons are drawn between the ideal and the actual situation. To bring about change, participants are prepared for change (unfreezing), so the need for change is apparent and accepted. In many situations, making individuals uneasy and discontented with the environmental system is the initial step in the process. Malcontents want change, whereas individuals who are satisfied and comfortable with the current state of affairs resist changes that will create unequilibrium. Activities are centered on unfreezing the existing equilibrium. Moving occurs when the previous structure is rearranged and realistic goals are set. The system is moved to a new level of equilibrium. Choices must be made about accepting the change agent and the roles of the group members in the change process. At this stage, group decisions are preferable for moving toward permanent change. This represents the distribution of power among the group members to make them driving forces engaged in the process. The individual involved in the change process acts as a member of a group in which new social values and norms are being established. A new status quo is established with refreezing. Refreezing describes the new level of equilibrium and reinforcement needed for the new patterns of behavior. The focus is on maintaining the goal achieved and highlighting the present benefits over past practices. Consider Lewin’s model for a client with an identified knowledge deficit. The client with heart disease who is started on a low-salt, low-fat diet has a learning need to bring permanent change to his diet. You discover through interviews with the client and family members that the diet at home is highly seasoned and high in animal protein and fats. Restraining forces in this situation are cultural values, family traditions, family preferences in food selection and preparation, attitudes toward diet, fear of further illness with changes in diet, and attitudes toward restrictions on personal lifestyle. Now consider each of these factors in relation to all members of the household and the client’s work, recreation, and social environments. Think about the driving forces: fear of further illness without the dietary changes, respect for advice given, support network, educational presentations, role models, and so forth. Unfreezing involves the identification of the restraining and driving forces, motivating the client toward change, and assessing learning readiness and motivation. Moving consists of supporting a positive attitude toward change and providing nutritional information, including food selection, preparation, and presentation options. Refreezing would occur with the client’s stabilization, evidenced through subjective reports (e.g., food diary), objective observations (e.g., health assessment), and laboratory findings in the rehabilitation phase. TECHNIQUES AND TOOLS FOR CLIENT TEACHING After you have mutually agreed upon outcome objectives to address the client’s learning need and have assessed his or her learning characteristics, you must plan for the specific 140 Section 2 l Clinical Judgment and the Nursing Process

content and how it will be transmitted to the client. The assessment data obtained earlier in this process have been used to define and describe the client, including characteristics, attributes, learning assets and deficits, readiness, and specific needs to be addressed. This procedure was conducted with the client as an individual, family, or group to diagnose the learning needs and prepare for continuation of the process. Next, outcome objectives and criteria were identified to guide the process and plan for the evaluation of outcomes. Now you must plan the content, teaching strategies and methods of delivery, learning resources, and specific evaluation procedures. The learning content is the specific content outline designed to meet the objectives. Teaching strategies relate to the objective and the specific content, including variations for the learning setting and clients. Suggested learning resources and materials, perhaps identifying the appropriate “tear-sheet” or learning module, are proposed to enhance the teaching strategy and meet the learner’s cognitive style, especially to meet the needs of individual learners. Evaluation methods along with a proposed time-frame for the process should be specified. Implementation of the teaching-learning process can then proceed using the strategies identified in the plan. Consider our example of the client with COPD who is being discharged to home in 2 days after a 5-day stay with bronchitis and emphysema. He has performed nebulizer treatments at home prior to hospitalization and has bedside and portable oxygen concentrators at home. However, he now has a new medication for his nebulizer that is in a multidose vial from which he must withdraw 1 mL for treatment twice daily. In the past, he has always used single-use ampules. Think about an instructional activity to address this learning need. The client has verbalized the need to measure his new medication but also admits that he usually only performs his nebulizer treatments twice daily rather than the prescribed four times because it is “tiresome.” He also volunteers much information about liking to read much of the day because he has limited physical stamina but that he is looking forward to a cruise with his wife in 2 months. The assessment data indicate a teaching deficit, learning readiness, and the motivation to adhere to a treatment plan within a confined time frame. You and the client determine that you will schedule six individualized teaching sessions for him with the respiratory therapist. Outcome criteria for this teaching-learning process might include the following: Within 24 hours, 1. Explains preparation and set-up of the nebulizer and the two different medications prescribed. 2. Explains home modifications that he plans to make in his bathroom to store and use the new nebulizer medications. 3. Demonstrates appropriate technique for filling nebulizer with the correct types and amounts of inhalation medications. 4. Performs nebulizer treatments a minimum of three times daily. 5. Verbalizes potential side effects, adverse effects, and toxicity requiring contact with his physician. 6. Presents values to the need to perform the treatments as prescribed. 7. Discusses future physical activities including maintenance of oxygenation and inhalation therapies. The objectives should be mutually acceptable to both you and the client. Also, can you identify which of these objectives meet the cognitive, affective, and psychomotor domains? Chapter 9 l Implementation 141

The learning content addresses the objectives by teaching medication preparation and performance of the prescribed therapies, monitoring for side effects and toxicity, and maintaining a healthy lifestyle with adequate oxygenation. Teaching strategies are then selected for the individualized cognitive style of the client, using resources such as videos and written information to take home. Evaluation methods are proposed to address each of the objectives the next 24 hours in collaboration with the respiratory therapist. TEACHING STRATEGIES AND METHODS Teaching strategies and methods are geared toward accomplishing the objectives with the individual client in mind. Selection is also based on how the content can best be delivered and addresses the affective, cognitive, and psychomotor domains of learning. Teaching methods generally are lectures, demonstrations, discussions, modeling, role-playing, individualized instruction, computer-assisted instruction (CAI), other simulations, and group activities. Selection of a teaching strategy and some combination of teaching methods depends on the client. For a client group of 24, a lecture format followed by breaking out into four small groups to apply the lecture content may be quite appropriate for presenting information on child development and wellness practices. For a group of three new mothers on the postpartum unit, a lecture would be impersonal and less effective than a small-group discussion on plans for returning home with their healthy neonates. In our example of the client with COPD, individualized teaching would be most effective, because he will be discharged in 2 days. However, recall that he likes to read and will do well with additional reading materials and handouts. The characteristics of the client and the intended outcomes, therefore, guide the selection of appropriate teaching methods. For further information on selected instructional methods, refer to Table 9–2.

TABLE 9–2

Sample Teaching Methods

Method Lecture

Group discussion

Computer-assisted instruction Simulated environment, games, activities, and role-playing

Strategies • To make more learner-centered, provide time for questions or small group sessions • Must address mixed audience of clients • Focus on important concepts and provide aids for application of the information presented • Requires good skills in group management by the nurse to keep on the topic and focus the learning • Allows opportunities for application of critical thinking skills, problem-solving, and group teamwork • May include demonstrations for active learning • Requires careful design to maintain interest • Requires motivation and persistence by learner • Design promotes individual learner feedback but isolated • Requires environmental staging and engaging activity • Role-play may be done with descriptive scripts or be more flexible • Requires development of trust, rapport, and group skills • Actively engages learners when presented in a nonpersonal manner and viewed as “what if...”


Enhancing the delivery of content and improving learning on the basis of the client’s learning style require careful selection of learning resources. Teaching aids are frequently used in client teaching situations to enhance the content and actively involve the client in the process. Using assessment data, consider how the client told you he best learned information in the past. When preparing for larger group presentations, consider how smaller group activities or assignments will address the needs of learners who do not do their best in the large group setting. Remember, adults learn best when actively involved in the process, both intellectually and physically. Think of ways to move the client from a passive to an active learning situation. Implementation activities of intervening, delegation, and coordinating in the nursing process require critical thinking, interpersonal, and technical skills. An important intervention with clients is teaching to address a knowledge deficit and promote a change. You must carefully address the client’s readiness and motivation to create a positive resolution to the learning need. In the next chapter, we will look further at evaluation of the results of the nursing process.

KEY POINTS • Intervening includes actions following the agreed-upon plan. • Delegation “is the transferring to a competent individual the authority to perform a selected nursing task in a selected situation; the nurse retains accountability for the delegation” (NCSBN, 2005, p. 193). The “five rights” of NCSBN’s (2006) delegation model include consideration of the right task, circumstances, person, direction or communication, and supervision or evaluation. • Responsibility and accountability are clearly stated in fourth provision of the ANA (2001) Code of Ethics for Nurses as an obligation for the provision of optimum care. • Coordinating care in the implementation phase also requires working with the client and all caregivers to ensure that all care is provided Chapter 9 l Implementation 143

•

• • • •

•

•

•

•

effectively and documented appropriately so that all caregivers have complete information and revisions to the plan are timely and appropriate. Concept care mapping is another way of using the nursing process by designing a diagram to analyze the client’s care needs and designing, implementing, and evaluating a plan of action. Dependent nursing actions are based on dependent orders to follow in a client’s plan of care. Independent nursing actions are within the domain of the professional registered nurse to address the client’s care needs. Teaching is more than transmitting information. The information must be received, understood, and evaluated. Learning is the perception and assimilation of the information presented to us in a variety of ways with the following characteristics: ➡ Perception of new information ➡ Initial reaction to the information ➡ Ability to recall or repeat the information ➡ Rejection or acceptance of the information ➡ Application in a similar situation ➡ Critical analysis of the information ➡ Incorporation of the information as a new personal value system ➡ Use of the information in various situations or combinations The three learning domains are: ➡ Affective: attitudes, feelings, and values ➡ Cognitive: knowledge and thought processes ➡ Psychomotor: demonstration of behaviors Readiness occurs when the learner is willing to change and view the learning need and includes human motivation, understanding, and applicability or acceptability. Motivation in humans is a manifestation of internal and external personal and environmental factors that cause people to respond to a situation the way they do. Change can be defined as a process that results in altered behavior of individuals or groups. for improved functioning with new behaviors, attitudes, and relationships.



1. Develop a concept map and plan of care for the client with COPD with the following assessment data. Medications: Admitting data: 76-year-old male, seen in the ER, has bilateral Oxygen at 3 LPM NC wheezes, confused responses Solu-Medrol IV 250 mg in 100 mL Diagnosis & VS: Pneumonia. Oxygen NS over 60 minutes q 6 hr sats 91%, T 101.6, P 110, R 28, B/P Levaquin 750 mg IV over 146/88, productive cough, 60 minutes daily weakness, pallor, poor skin turgor. Past medical history: COPD, Asthma, RT Albuterol q 4 hours Arthrotec 75 mg twice daily HTN, rheumatoid arthritis, vertebral fractures Hyzaar 100: 25 mg PO daily Lab data: Norvasc 5 mg PO daily WBC 12.5 (3–11) Singulair 10 mg PO at bedtime RBC, HCT WNL Tylenol 650 mg q 4–6 hours prn fever/pain HGB 10 (13–16) Percocet 2 tab q 6 hr PO PRN NA 131 (135–153) NS 1000 mL to infuse at 125 mL K 3.5, CL 98 (100–114) per hour PaO2 74 mm Hg (80–100) Ambien 5 mg PO at bedtime prn CA WNL Advair 500 inhaler q 12 hours Combivent B1, TID 2. Interview a client on how they prefer to learn new information and about new situations. Compare your findings with those of a classmate and compare your understanding of the clients’ motivation and readiness for learning. 3. Use the nursing process with a specific client situation and differentiate the implementation activities of intervening, delegating, and coordinating. 4. In the clinical setting, observe the change of shift process. Identify assignment and delegation activities. Be prepared to participate in class or online discussion on these activities. Go to the Intranet site and complete the interactive exercises provided for this chapter.

REFERENCES American Nurses Association. (2001). Code of ethics for nurses with interpretative statements (Publication No. CEN21 10M 08/01). Washington, DC: American Nurses Publishing. American Nurses Association. (2004). Nursing: Scope and standards of practice (Publication No. 03SSNP). Washington, DC: American Nurses Publishing. American Nurses Association (ANA). (2005). Principles for delegation. Retrieved February 3, 2008, from http://nursingworld.org/MainMenuCategories/ HealthcareandPolicyIssues/Reports/ANAPrinciples/PrinciplesofDelegation.aspx Anderson, L. W., Krathwohl, D. R., Airasian, P. W., Cruikshank, K. A., Mayer, R. E., Pintrich, P. R.,. Raths, R. E., & Wittrock, M .C. (Eds.). (2001). A taxonomy for learning, teaching, and assessing: A revision of Bloom’s educational objectives (abridged ed.). New York: Longman. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2006). Nurse’s pocket guide: Diagnosis, prioritized interventions, and rationales (10th ed.). Philadelphia: F.A. Davis.


Erikson, E. H. (1963). Childhood and society (2nd ed.). New York: Norton. Gordon, M. (2006). Manual of nursing diagnosis (11th ed.). Boston: Jones & Bartlett. Knowles, M. S. (1980). The modern practice of adult education: From pedagogy to andragogy (Rev. ed.). Chicago: Follett. Knowles, M. S., & associates (1985). Andragogy in action. San Francisco: Jossey-Bass. Lewin, K. (1951). Field theory in social science. New York: Harper & Row. Knowles, M. S. (1990). The adult learner: A neglected species (4th ed.). Houston: Gulf. Mezirow, J. (2000). Learning to think like an adult: Core concepts of transformation theory. In J. Mezirow and Associates, Learning as transformation: Critical perspectives on a theory in progress (pp. 3–33). San Francisco: Jossey-Bass. National Council of State Boards of Nursing. (1998). The five rights of delegation. Chicago: Author. National Council of State Boards of Nursing (NCSBN). (2005). Working with others: A position paper. 2005 Annual Meeting Business Book (pp. 160–195). Chicago, Author. National Council of State Board of Nursing (NCSBN). (2006). Joint statement on delegation. American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN). Retrieved February 3, 2008, from https:// www.ncsbn.org/Joint_statement.pdf Schuster, P. M. (2008). Concept mapping: A critical-thinking approach to care planning (2nd ed.). Philadelphia: F.A. Davis.

BIBLIOGRAPHY Bastable, S. B. (2003). Nurse as educator: Principles of teaching and learning for nursing practice. Boston: Jones and Bartlett. Bloom, B. S. (Ed.). (1956). Taxonomy of educational objectives. New York: Longman. Canobbio, M. M. (2006). Mosby’s handbook of patient education (3rd ed.). St. Louis: Mosby. Maslow, A. H. (1954). Motivation and personality. New York: Harper. Mezirow, J. (1991). Transformational dimensions of adult learning. San Francisco: Jossey-Bass. Rankin, S. H., Stallings, K. D., & London, F. (2005). Patient education in health and illness (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Redman, B. K. (2001). The practice of patient education (9th ed.). St. Louis: Mosby. Schloman, B. F. (2006). MedlinePlus®: Key resource for both health consumers and health professionals. Retrieved June 30, 2006 from http://www.nursingworld.org/ ojin/infocol/info_19.htm Stephenson, P. L. (2006). Before the teaching begins: Managing patient anxiety prior to providing education. Clinical Journal of Oncology Nursing, 10, 241–245.

ONLINE RESOURCES MedlinePlus: http://www.nlm.nih.gov/medlineplus/medlineplus.html


CHAPTER 10

Evaluation CHAPTER OBJECTIVES After completing this chapter, you will be able to: 1 Discuss the importance of the evaluation phase of the nursing process. 2. Describe the cyclical procedure of the nursing process to revise a client plan. 3. Review the Nursing Interventions Classifications (NIC) and the Nursing Outcomes Classification (NOC) systems and their use in the evaluation phase of the nursing process. 4. Evaluate client outcomes to determine the effectiveness of nursing care. 5. Identify documentation requirements in the evaluation phase of the nursing process.

valuation is a vital component of the nursing process and professional practice. The American Nurses Association (ANA, 2004) defines standards of nursing practice as “authoritative statements that describe a level of care or performance common to the profession of nursing by which the quality of nursing practice can be judged” (p. 116). In the ANA (2004) Scope and Standards of Nursing Practice, evaluation is both a standard of care for the registered nurse and a standard for professional performance. Evaluation is an examination of the value of a process. Evaluation includes a careful examination of subjective and objective client data in terms of their progress in meeting the agreed-upon goals and expected outcomes from the implementation of the nursing process. It may be ongoing and may lead to important information for revisions needed in the plan and interventions. Although evaluation strategies focus on both the client and the nursing actions as part of the plan of care, the primary focus is on the client. Is the client able to demonstrate the outcomes envisioned at the beginning of the process? As a part of the nursing process, the evaluation phase is used to assess the effectiveness of the process and whether the client has resolved the nursing diagnosis or health need identified in the planning and implementation phases. The evaluation phase of the nursing process has always been an important component. As noted more than 30 years ago by Yura and Walsh (1978), “evaluation is always considered in terms of how the client responded to the planned

E

Key Terms Standards of nursing practice Evaluation Standard of care Outcome criteria Standardized languages Documentation Standard of professional performance

Chapter 10 l Evaluation 147

action” (p. 140). These client responses may result in continuance, revision, or completion of the planned actions. However, notice that the focus is on clients and their response to the previously stated outcomes and goals in their care, not on the nursing actions. These nursing actions are considerations in any revisions to the plan, but the plan and the actions always relate back to clients and their intended outcomes as the central focus, whether individual, family, or group.

Evaluation of Client Outcomes As a standard of practice, evaluation includes measurement of the predicted outcomes along with documentation, sharing observations with the client and other healthcare providers as appropriate, and negotiating any revisions to the plan. The evaluation of outcomes is focused on the client and his or her behaviors (cognitive, affective, or psychomotor) to meet that objective. As a standard of care, the ANA (2005) describes the evaluation process as “systematic, on-going, and criterion-based” focused on the attainment of client outcomes (p. 106). As mentioned, measurement of client outcomes will lead to revisions, continuance, discontinuance, or completion of the implementation activities. The focus is on the client with his or her individual characteristics, significant others, and unique environment. Additional assessment data may be collected and analyzed. Nursing diagnoses may be revised, added, or resolved. Progress should be noted and shared with the client and others, as appropriate. Any changes to the implementation plan should be mutually negotiated and acceptable to the client. Outcome statements may need revision and implementation activities revised. Evaluation activities continue. Consider an example of evaluation of standards of practice in the case of a client with limited mobility progressing from a wheelchair to a walker. Our nursing diagnosis statement is impaired walking related to musculoskeletal impairment and inability to walk required distances as evidenced by reports of weakness and pain and three recent falls when getting out of bed. With the collaboration of the physical therapist, the outcome may be the ability to use the walker to ambulate with assistance 50 feet four times daily in 3 days. This statement is directly related to the client behavior, specifies a measurement (50 feet a minimum number of three times each day) and the time frame when the behavior was to be accomplished (in 3 days). Additional measurement tools may be used to evaluate client performance in this client activity, like the Self-efficacy for Functional Activities Scale (Resnick, 2003). Performance measures should be shared with the client along with encouragement as reinforcement and documented in the client record as an illustration of progress or for needed revisions to the plan. In this example, we return to the nursing diagnosis of impaired walking and focus evaluation activities and measures on specified outcome criteria and client performance. However, revisions to the plan may be needed, as with the timing of pain medication, activities of daily living, and rest. Remember, outcome criteria are defined as relevant, measurable, and expected client-focused behaviors (ANA, 2004).


The focus on the evaluation phase of the nursing process is on the skillful use of critical thinking and analysis skills. These nursing skills are directed at examining the efficacy of the implementation activities and the entire nursing process to revisit assessment findings, nursing diagnosis and expected outcomes, planning and implementation activities for a high level of quality of care for the client. When evaluating client outcomes as part of the nursing process, there are basic decisions that you will need to address. Consider some of these questions in Box 10–1. As you can see, we are at a stage of critical analysis of client’s plan of care and what interventions were implemented and what outcomes are apparent. This process may return you to the assessment, diagnosis and outcomes identification, planning, or implementation stages. You may need to revise the plan and the care to address effective client outcomes. An earlier nursing diagnosis may need to be discontinued as inappropriate based on the client’s current and anticipated progress.

BOX 10–1

Questions to Address in the Evaluation Phase of the Nursing Process

✻ Was the nursing diagnosis correct? ✻ Were the stated outcomes met? ✻ Was the nursing diagnosis resolved? ✻ Are additional nursing diagnoses needed based on the evaluation data? ✻ What revisions/refinements are needed to the stated outcomes? ✻ Is the problem resolved or does it need to be reframed? ✻ If the nursing diagnosis was correct but the stated outcome was partially

met, what further revision to the plan is needed? ✻ Have you addressed each nursing diagnosis? ✻ Have the client’s priorities changed? ✻ What new data is available on the problem? ✻ Does the nursing diagnosis need to be revised to a different NANDA

diagnosis? ✻ Are there new client problems that have occurred and the planning

revised to address new or potential problems? ✻ Which client goals or expected outcomes need to be revised to better

address the diagnosis, based on assessment data? ✻ What new nursing actions are needed? ✻ What other healthcare providers are needed to better implement the plan

of care? ✻ Have any knowledge deficits emerged? ✻ Will the problems reoccur in the home environment following discharge? ✻ Has the client been involved in the evaluation? ✻ What is the role of the significant others? ✻ Have cultural and client preferences been fully considered in the process? ✻ How could the process improve in the future?

In essence, what does the evaluation data reveal?


Recall our example of the client with chronic obstructive pulmonary disease (COPD) and the admitting data provided in Table 10–1. In Chapter 9, we identified the NANDA terminology that flowed from two identified functional health patterns. Consider the information provided in Table 10–2. These are a sample of the nursing diagnoses and treatment plan for the client. Consider the evaluation data. Determine whether the nursing diagnoses were: ■ ■ ■ ■ ■ ■

Met and can be discontinued. Met but continued with the current strategies. Partially met and need to be continued. Partially met and need further revisions. Unmet and need to be revised or discontinued. And, what other nursing diagnoses, goals, outcome criteria, and implementation plans should be added?

The information in Table 10–2 is provided as a small snapshot of the nursing process and evaluation of the client’s care. Consider additional nursing diagnoses and the full range of outcome criteria and interventions that would occur for a similar client before discharge from the acute care environment. Also, consider risk diagnoses. In the case of the client with COPD, several risk diagnoses could be included: ■ ■ ■ ■

Risk for Powerlessness related to chronic illness and dependency Risk for Loneliness related to social isolation Risk for Falls related to age and use of portable O2 assistive device Risk for Caregiver Role Strain related to Caregiver’s Competing Role Commitments

You also will need to include evaluation data with these to examine whether they are actual nursing diagnoses requiring revisions in the plan. In addition, planning for care in the home and reducing the chance of readmission from this episode is a prime concern for the registered nurse. This goal for the client’s return to their home environment requires TABLE 10–1

Case Study on the Client with COPD: Hospital Admission Data

Admitting data: 76-year-old male, seen in the ER, has bilateral wheezes, confused responses Admitting Diagnosis & VS: Pneumonia. Oxygen sats 91%, T 101.6, P 110, R 28, B/P 146/88, occasional productive cough with thick brown mucus, weakness, pallor, poor skin turgor. Past medical history: COPD, asthma, HTN, rheumatoid arthritis, vertebral fractures Lab data: WBC 12.5 (3–11) RBC, HCT, UA WNL HGB 10 (13–16) NA 131 (135–153) K 3.5, CL 98 (100–114) PaO2 74 mm Hg (80–100) CA WNL

Medications: Oxygen at 3 LPM NC Solu-Medrol IV 250 mg in 100 mL NS over 60 minutes q 6 h Levaquin 750 mg IV over 60 minutes daily RT Albuterol q 4 hours; Mucomyst q 4 h Arthrotec 75 mg twice daily Hyzaar 100—25 mg PO daily Norvasc 5 mg PO daily Singular 10 mg PO at bedtime Tylenol 650 mg q 4–6 hours prn fever/pain Percocet 2 tab q 6 hr PO PRN NS 1000 mL to infuse at 125 mL per hour Ambien 5 mg PO at bedtime prn Advair 500 inhaler q 12 hours Combivent B1, TID


TABLE 10–2

Case Study on the Client with COPD: Sample Evaluation of the Implementation Plan

Nursing Diagnosis FHP: ActivityExercise ND: Impaired gas exchange RT alveolar-capillary membrane changes AEB dyspnea, pallor, bilateral wheezes, confusion, and weakness FHP: ActivityExercise ND: Activity intolerance RT imbalance of oxygen supply/ demand AEB dyspnea and report of dizziness when ambulating to the bathroom, refusal to shave because it “takes too much effort, and “I am not going anywhere,” and SO reports he seldom dresses at home except in a robe. FHP: Selfperception/ Self-concept ND: Fear RT chronic illness AEB diaphoresis, elevated BP, and stating “it’s bad. I can’t get my breath and I hear someone coughing.”

Goals & Outcome Criteria Goal: Client will demonstrate improved ventilation and adequate oxygenation. OC: Absence of respiratory distress while on O2 within and ABGs WNL within 48 hours.

Goal: Client will perform ADLs safely at home. OC: Able to ambulate to the bathroom in 24 hours. OC: Oriented x 3 within 24 hours. OC: Ambulate 25 feet without distress in 48 hours. OC: Performs self-care hygiene activities while hospitalized with limited assistance. OC: Dresses in street clothes at least four days per week upon discharge.

Goal: Client will verbalize fears and methods to support breathing and reduce perceived fear of being around others. OC: Identify home resources needed to support adequate oxygenation and diminish fear during the day and at night within 48 hours.

Implementation Maintain O2 at 2.5 L/m via nasal cannula. Elevate head of bed. Monitor lung sounds and oxygenation status q 2 hrs. Monitor pulse oximetry q 2 hrs. and adjust flow rate if O2 saturation below 92 per order. Review lab data on ABGs daily. Maintain O2 at 2.5 L/m via nasal cannula. Elevate head of bed. Monitor lung sounds and O2 saturation q 2 hours and adjust flow rate if below 92 per order. Assess activity level and tolerance and LOC q 4 hr. Assist with ADLs and schedule rest periods until independent function. Assist in planning for increased activities in the environment, hospital, and home.

Evaluation O2 maintained at 2.5 L/m. Bilateral wheezes still apparent but diminished following Mucomyst treatments via resp. therapy. O2 sats. Remain 95–96 while at rest and with ambulation while on portable O2. ABGs WNL.

Promote verbalization of real and imagined fears related to adequate oxygenation. Arrange on-site support when SO is not present. Arrange Life Alert alarm system in home to call for assistance if needed.

Verbalizes fear of being around others with a “cold” because he will “catch it.” Has identified resources to stay at his home on the nights his SO is working. Reports sputum is “bad, bad” and things are “looking worse.”

O2 maintained at 2.5 L/m. Bilateral wheezes still apparent but diminished. O2 sats. Remain 95–96 while in bed and 93–94 with ambulation on portable O2. Is able to complete ADLs of toileting and bathing without assistance with O2. Oriented x 3 without confusion. Ambulated 10 feet and 15 feet without assistance while on portable O2. Needs encouragement for independent ambulation.

Key: FHP ⫽ functional health pattern; ND ⫽ nursing diagnosis; RT ⫽ related to; AEB ⫽ as evidenced by; OC ⫽ outcome criteria; ABGs ⫽ arterial blood gasses; WNL ⫽ within normal limits; SO ⫽ significant other

you to evaluate all nursing diagnoses and determine whether knowledge deficits exist while planning for discharge.

Evaluation of Client Education As we discussed in Chapter 9, client education to address a knowledge deficit is an important activity for the registered nurse. Evaluation of the learning outcomes and the learning process is a vital part of any teaching activity to address the nursing diagnosis of Chapter 10 l Evaluation 151

a knowledge deficit. Evaluating outcomes may be ongoing and may lead to important information for revisions needed in subsequent sessions. Was the client able to demonstrate the outcomes envisioned at the beginning of the process? Not just from your perspective, but also from the client and their perceived need and agreed-upon outcomes. Clients are more difficult to evaluate than traditional student learners. Cognitive domain learning outcomes of students are easily measured with tests. In the client teaching situation, such tests are rarely used except in research or large group situations. Client evaluation can be complex, with problems related to timing, access, continuity, measurement, and other factors. In addition, recall that clients should be involved in evaluating their own learning. Normally, client evaluation is done with methods such as return demonstrations, observation, diaries, rating scales, discussion, and electronic communication. However, you also need to address evaluation of the three different learning domains—affective, cognitive, and psychomotor. Recall that the affective domain consists of attitudes, feelings, and values. Evaluation data should show how the client progressed from receiving to internalizing the values mutually agreed on for the learning. In the case of the client with COPD who was learning about the new medication and the use of a syringe, both you and the client must be able to measure or see attitudinal or value changes through verbal and nonverbal behaviors. Recall that he sometimes did not complete all his nebulizer treatments as prescribed because they were “tiresome.” One of your outcome criteria was that he performed his nebulizer treatments a minimum of three times daily. An additional outcome measure to address the affective domain in this case would be valuing the need to perform a minimum of three times daily. This would be in your measurable outcome statements that you and the client would now evaluate. We need the client to communicate attitudes, feelings, and values in verbal and nonverbal behaviors. Methods of evaluation in this area include interviews, discussions, and observations that demonstrate certain beliefs and values. Another means of evaluating affective learning is a diary in which the client can record feelings, concerns, and problems that arise between teaching sessions. Analyzing the content of the diaries can provide useful information on the affective domain as well as knowledge gaps in cognitive processes. And with the availability of electronic communication, cognitive and affective domains can be evaluated via e-mail or electronic postings outside of the traditional hospital, clinic, or office setting. In the cognitive domain, knowledge builds from simple recall to understanding, application, analysis, evaluation, and synthesis or creation of information. Interviews and discussion with clients can be used to evaluate whether the client can repeat or recall the information. For understanding, the client describes, explains, and compares information during the interview. Application of the information can be evaluated as the client demonstrates and uses the information, providing specific examples of how this could be done at home following discharge. For example, identifying how the client will store and dispose of the syringes to measure his medication, especially because his grandson who is a toddler visits weekly. The most useful evaluation strategies to measure cognitive learning for you and the client in the clinical setting are discussion, questioning, and allowing for description, whether in person or by electronic means. Evaluating client outcomes in the psychomotor domain is easiest through direct observation of skill attainment. At the simplest level of psychomotor skill attainment is the client’s ability to imitate, as seen in a return demonstration. This allows one to assess understanding and the ability to perform a specific skill, such as drawing up the nebulizer medication in the


syringe and then placing it in the nebulizer for his treatment. But demonstration of a skill in a clinical setting can be artificial, because the client’s own environment often has additional factors not present in the healthcare agency, such as shared bathrooms or medication storage problems in a home with toddlers or in an independent or assisted living facility. Reminders such as flow charts, diaries, and check sheets are easy for clients to use in the home, and they can then be discussed at the next interview. The level of psychomotor skills can be assessed with a checklist or flow chart in terms of following instructions to proper scheduling, precision, and problem-solving in the procedure. You can encourage the client to keep notes on problems encountered and how they were handled, which demonstrates skills in both cognitive and psychomotor domains. In our example of the client with COPD, we implemented an individualized teaching strategy within a limited time frame to accomplish the outcome objectives aimed to the three domains. One method of evaluation would be for the client to maintain a diary, including nebulizer treatments and results of oxygen saturation and daily blood pressure measurements, medications taken, and effects on a check sheet. A personal diary could be a valuable strategy. This evaluation method provides visual data that address the initial outcome criteria agreed on by both the client and the nurse. At each client interview, you and the client will review and discuss the information in the diary. When both of you are satisfied that the outcome criteria have been met, the nursing diagnosis of the knowledge deficit should be resolved. At the final teaching session, you and the client will discuss the strategies and resources used during the process in order to evaluate the teaching that took place. Electronic communication provides an additional resource for follow-up and evaluation. Evaluation data can provide useful feedback that objectives have been met or that repetition, reinforcement, or revision is needed to address the knowledge deficit. Teaching strategies, such as methods and resources, should be evaluated by both you and the client. Discovering what worked and what may have worked better helps the client view the process and reinforce the learning while sharing with the nurse ways to improve and strategies for the future. Important factors here are encouragement and openness for honest and constructive evaluation data from both client and the nurse.


Nursing Classification Systems Recall that we are using standardized language or taxonomies to consistently address the uniqueness of the domain of nursing. NANDA (2009) provides the standardized language for the diagnostic statement with definitions, defining characteristics, and related factors. As with nursing diagnoses, we now have an evolving body of nursing knowledge that addresses the consistent terminology for both nursing interventions and outcomes. The Nursing Interventions Classification (NIC) (Appendix C) focuses on the nurse and the care activities to assist in documenting the impact of nursing care for clients both in terms of outcomes and cost (Bulechek, Butcher, & Dochterman, 2008). As we discussed briefly in Chapter 6, the NIC taxonomy identifies seven domains of nursing interventions with classes of care then ordered under these domains followed by the identification of more than 500 specific nursing interventions. This system assists the registered nurse to develop and evaluate the client’s implementation plan. For example, with our client with COPD, domain of nursing intervention for the nursing diagnosis of Ineffective Gas Exchange is classified as complex physiological care that supports homeostatic regulation with respiratory management as the classification of care for the client with COPD. Some of the major interventions in this care classification are applicable to this client: ■ Oxygen Therapy ■ Respiratory Monitoring Again, these are nursing interventions and not medical orders and are applicable across a wide range of practice areas. Additional interventions could include anxiety reduction, cough enhancement, chest physiotherapy, and energy management. Think for a minute about our aging client with COPD and then about the child with asthma or cystic fibrosis. As noted by Johnson, et al. (2006), the focus of the NIC system is on nursing behaviors to assist the client to a specific outcome (pp. 4–5). In this case, the outcome would be improved respiratory functioning. Implementation activities would be identified based on unique client needs as in the case of the client with COPD who feared being around others where he would be in danger of contracting pneumonia or with the child with asthma and his or her unique school and peer issues. The Nursing Outcomes Classification (NOC) is a taxonomy that is also researchbased with almost 400 client outcomes identified and defined to assist in the measurement of these client outcomes, particularly the effectiveness of nursing interventions across all areas of nursing practice. The NOC labels focus on 154 Section 2 l Clinical Judgment and the Nursing Process

the client and assist in the measurement of client outcomes. Specific client outcomes are further identified into specific client signs and symptoms as data elements and can be scored on a five-point Likert scale, as the client’s condition can range from extremely compromised to not compromised. This scale allows a quantifiable measure of the outcome based on actual client data. It allows for maintenance of the client outcome or an increase to a specific target. For example, with the client with COPD, the NOC scale for the outcome of respiratory status and gas exchange described in Table 10–3 ranges from severe deviation from the normal to no deviation from normal. The specific NOC indicators include the following: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

PaO2 PaCO2 Arterial pH O2 saturation End tidal CO2 Chest x-ray findings Ventilation perfusion balance Dyspnea at rest versus with mild exertion Restlessness Cyanosis Somnolence Impaired cognition (Moorhead, Johnson, Maas, & Swanson, 2008, p. 582)

So, on a five-point Likert scale, you will rate the client’s outcomes in each of these areas as they are applicable. Look at the range of data from objective laboratory data on arterial blood gases and x-ray findings to subjective data like cognition and the client’s level of consciousness to evaluate outcomes on gas exchange. Look back at the client with limited mobility progressing from a wheelchair to a walker. Our nursing diagnosis statement was impaired walking related to musculoskeletal impairment and inability to walk required distances as evidenced by reports of weakness and pain, and three recent falls when getting out of bed. The Likert rating scale for mobility ranges from severely compromised to not compromised with the following specific NOC indicators: ■ Balance ■ Coordination

TABLE 10–3

NANDA, NIC, and NOC Classification for the Client with COPD

NANDA Impaired gas exchange RT alveolar-capillary membrane changes AEB dyspnea, pallor and confusion Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane (NANDA-I, 2009, p. 112).

NIC Oxygen therapy (administering O2 and monitoring effectiveness) (CNCCE, 2008a, p. 12).

Respiratory monitoring (collecting and analyzing client data to ensure airway patency and adequate gas exchange) (CNCCE, 2008, p. 15).

NOC Respiratory Status: Gas Exchange (alveolar exchange of CO2 and O2 to maintain arterial blood gas concentrations) (Moorhead et al., 2008, p. 582).


■ ■ ■ ■ ■ ■ ■

✳

Gait Muscle movement Joint movement Body positioning performance Transfer performance Walking Moves with ease (Moorhead et al, 2008, p. 502)

In the case of this client, the indicators of running, jumping, and crawling would not be applicable. Notice how these outcomes could also be evaluated by the physical therapist when creating a plan of care. The NOC taxonomy provides a quantifiable evaluation of the client’s response to the care of plan. The client’s response to specified nursing interventions demonstrate the domain of and contribution of nursing in the client’s treatment plan. The taxonomy also provides a means of documentation with specificity and the ability for comparisons against some norm, in the case of the client with COPD, alveolar exchange of oxygen and carbon dioxide to provide physiological homeostasis and sufficient functioning, even in the case of a chronic illness. In the case of the client progressing from the wheelchair to the walker, the comparison with the norm would be independent and safe mobility with the use of the walker. Use of the standardized languages ANA require practice but provide a comhttp://www.nursingworld.org NANDA mon language and may be used to http://www.nanda.org various degrees in different agencies. University of Iowa Center for Nursing Classification However, documentation is critical to and Clinical Effectiveness (NIC/NOC) demonstrate the client’s course of http://www.nursing.uiowa.edu/excellence/nursing_know treatment and progress toward the ledge/clinical_effectiveness/index.htm intended outcomes.

Documentation An important component of the evaluation phase is effective documentation. In fact, before evaluation of the nursing process, unless effective documentation has been ongoing and provided, there is no evidence and valuable data is lost. Implementation activities are considered not done and nonreimbursable. Some form of documentation of the activities and the client’s status and progress to the goals and outcomes must be present. Documentation must address the outcome criteria specified and provide specific information. Slept well means little. Slept for 4 hours on O2 at 2.5 L/m via nasal cannula with pulse oximetry measures at 96 at 12:02 and 02:00 without labored breathing and no cyanosis or complaints provides more definitive information as a narrative entry. Notice that client assessment and outcome criteria as well as nursing interventions have been provided in the later statement. However, there are many forms and requirements for documentation depending on state and agency requirements. Documentation can take different forms, depending on institutional policy and reimbursement requirements. Specific standards are required for effectiveness. Documentation is a report of client-specific information focused on the plan of care and their responses at a point in time. As stated in the ANA Scope and Standards of Nursing Practice (2004), documentation is required in all six standards of practice while using the nursing


process: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. In their provision of specific Principles for Documentation, the ANA (2005) notes that documenting care is part of providing quality care with other considerations including effective communication, reimbursement, regulation, research, and legal issues (pp. 2–3). The type of documentation required may vary with different populations of clients, for example, pediatric intensive care versus a rehabilitation facility. The hospital may have the funding to implement an electronic health record with physician order entry that has been identified as a safety initiative. Or the agency may have required training sessions required for providers and students on their unique system and requirements. Good judgment is a requirement for all systems. When charting by exception (CBE) was implemented in some places more than 25 years ago, this actually required more judgment of what needed to be documented and if the associated forms captured sufficient information on the client. Focused documentation provided another system, directed at the nursing diagnostic focus to provide data, actions taken, and the client response. Whether CBE, using an integrated computer entry system, flow charts, focused charting, or narrative progress notes, certain basic expectations must be met. First, be aware of the institutional policy and procedure statements. These should be followed, as consistent with good practices. Institutional procedures do vary among institutions and within the agency, as with some specialty units. Legibility of records is a given. Another is the careful use of acceptable abbreviations. Recall in Chapter 6, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) published a “Do Not Use” list in 2004 as a safety initiative. Legible initials or signatures should be provided by the individual care provider and information not charted in advance (precharting) or on care provided by others. And time will always continue to be a factor when emergencies occur just when you had planned to document your care and the client’s responses. Know the agency policy on corrections and additional entries. Review some of the articles at the Nurses Service Organization (NSO) Web site. Some of their tips are good reminders, like making sure you “document often enough to tell the whole story” and not charting a Nurses Service Organization Documentation client’s symptom alone without includhttp://www.nso.com/nursing-resources/titlelinks.jsf ing the nursing action taken (NSO, 2008, p. 1).

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Evaluation of Professional Performance Recall that the ANA (2004) Scope and Standards of Nursing Practice has two sets of standards: (1) those for care directed at the client within the steps of the nursing process, and (2) standards of professional performance identified for the registered nurse and the advanced practice registered nurse. Evaluation, as a standard of professional performance, required the registered nurse to “systematically evaluate the quality and effectiveness of nursing practice” (ANA, 2004, p. 87). The focus here is on the nursing care provided and quality improvement of the nursing interventions to address the nursing diagnoses and the plan of care. Standards of professional performance for the registered nurse (ANA, 2004) specifically address the nursing role in quality improvement and in the skillful application of the nursing process. This area also includes the application of evidence-based practice that will


be discussed in detail in Chapter 11. Skillful self-appraisal and performance evaluation for continued quality improvement in the professional role are included in this professional expectation of the registered nurse. In the area of professional performance, quality initiatives including use of clinical guidelines, safety initiatives for client protection, effective communication, interpersonal and technical skills, and collaboration with the client and other healthcare providers are included. The concept of change is important here with the challenge for continued improvement in quality, both in practice and in the professional role. Evaluation, as a process, is not static or the last stage of the nursing process. It is an integral component of the nursing process that can lead to resolution, revision, or continuance. The entire focus is on efficacy of care for the client to meet the outcome criteria or make revisions for their health, safety, and welfare. As part of this process and through the results of evaluation of best practices, we move to the next chapter on the use of evidencebased practice.

KEY POINTS • The American Nurses Association (ANA, 2004) defines standards of nursing practice as “authoritative statements that describe a level of care or performance common to the profession of nursing by which the quality of nursing practice can be judged” (p. 116). • Evaluation is an examination of the value of a process. In the case of the nursing process, evaluation includes a careful examination of subjective and objective client data in terms of their progress in meeting the agreed-upon goals and expected outcomes from implementation. • Outcome criteria are relevant, measurable, and expected clientfocused behaviors (ANA, 2004). 158 Section 2 l Clinical Judgment and the Nursing Process

• Using standardized language or taxonomies allows us to consistently • •

• • •

address the uniqueness of the domain of nursing. NANDA (2009) provides the standardized language for the diagnostic statement with definitions, defining characteristics, and related factors. The NIC taxonomy focuses on the nurse and the care activities to assist in documenting the impact of nursing care for clients both in terms of outcomes and cost. (See Appendix C.) The NOC taxonomy contains almost 400 specific nursing outcomes that can be evaluated on a Likert scale. (See Appendix C.) Documentation is a report of client-specific information focused on the plan of care and their responses at a point in time. As a standard of professional performance, the registered nurse “systematically evaluates the quality and effectiveness of nursing practice” (ANA, 2004, p. 87). The focus here is on the nursing care provided and quality improvement.


1. Look again at the evaluation data for the diagnosis of activity intolerance on the client with COPD in Table 10–2. What further assessment data, goals and outcome criteria, revisions to the plan, and interventions would be helpful in planning for his safety upon discharge? Next, develop the plan for addressing the risk diagnosis of Risk for Falls related to age and use of portable O2 assistive device. 2. Consider the Nursing Diagnosis of Risk for Caregiver Role Strain.

Look back at the data and develop a plan to address this risk before discharge including outcome criteria for evaluation. Be prepared to participate in a class or online discussion on this risk diagnosis as scheduled by your instructor. 3. Identify a functional health pattern and select an applicable nursing diagnosis from Appendix B. Apply applicable NIC and NOC statements from Appendix C. Compare your finding with those of a classmate.

Go to the Intranet site and complete the interactive exercises provided for this chapter.

REFERENCES American Nurses Association. (2004). Nursing: Scope and standards of practice (Publication No. 03SSNP). Washington, DC: American Nurses Publishing. American Nurses Association. (2005). Principles for documentation (Publication No. PD1-05). Silver Springs, MD: Author. Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (Eds.). (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis: Mosby Elsevier. Johnson, M., Bulechek. G., Butcher, H., Dochterman, J. M., Maas, M., Moorhead, S., & Swanson, E. (Eds.). (2006). NANDA, NOC, and NIC linkages: Nursing diagnosis, outcomes and interventions. St. Louis: Mosby Elsevier. Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis: Mosby Elsevier.


North American Nursing Diagnosis Association International (NANDA-I). (2007). Nursing diagnoses: Definitions and classification, 2007-2008. Philadelphia: Author. Nurses Service Organization (NSO). (2008). Dos and don’ts of documentation. Retrieved February 23, 2008, from http://www.nso.com/nursing-resources/ article.jsf Resnick, B. (2003). Self-efficacy for functional activities scale. In O. L. Strickland & C. Dilorio (Eds.), Measurement of nursing outcomes. Volume 3: Self-care and coping (2nd ed., pp. 3–12). New York: Springer. University of Iowa College of Nursing Center for Nursing Classification and Clinical Effectiveness (CNCCE). (2008a). Nursing interventions classification (NIC). Retrieved February 20, 2008, from http://www.nursing.uiowa.edu/ excellence/nursing_knowledge/clinical_effectiveness/documents/ LabelDefinitionsNIC5.pdf University of Iowa College of Nursing Center for Nursing Classification and Clinical Effectiveness (CNCCE). (2008b). Nursing outcomes classification (NOC). Retrieved February 20, 2008, from http://www.nursing.uiowa.edu/ excellence/nursing_knowledge/clinical_effectiveness/documents/ LabelDefinitionsNOC3.pdf Yura, H., & Walsh, M. B. (1978). The nursing process: Assessing, planning, implementing, evaluating (3rd ed.). New York: Appleton-Century-Crofts.

BIBLIOGRAPHY Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2006). Nurse’s pocket guide: Diagnosis, prioritized interventions, and rationales (10th ed.). Philadelphia: F.A. Davis. Gordon, M. (2006). Manual of nursing diagnosis (11th ed.). Boston: Jones and Bartlett. Nurses Service Organization. (NSO). (2008). Eight common charting mistakes to avoid. Retrieved February 23, 2008, from http://www.nso.com/nursing-resources/ article.jsf Schuster, P. H. (2008). Concept mapping: A critical thinking approach to care planning (2nd ed.). Philadelphia: F.A. Davis. Sidani, S., & Braden, C. J. (1998). Evaluating nursing interventions: A theorydriven approach. Thousand Oaks, CA: Sage. Strickland, O. L., & Dilorio, C. (Eds.). (2003). Measurement of nursing outcomes. Volume 3: Self-care and coping (2nd ed.). New York: Springer.

ONLINE RESOURCES ANA: http://www.nursingworld.org NANDA: http://www.nanda.org University of Iowa Center for Nursing Classification and Clinical Effectiveness (NIC/NOC): http://www.nursing.uiowa.edu/excellence/nursing_knowledge/ clinical_effectiveness/index.htm


Section 3 Concepts for Your Continuing Journey

Knowledge is power itself. Francis Bacon, 1561–1626

T

his final section presents the concepts of basing your practice on evidence of efficacy and ongoing growth and planning for your future. Chapter 11 introduces you to the concept of n this initialpractice. section,The the evidence-based of professional coreconcepts competencies for all nursing practivce are introhealth professionals require duced, This is sultiple roles that practice is the based on curyou knowledge will be negotiating as and you rent that is safe pursue your degree.isReturning effective. Tradition no longer to school is not an easyRather, deciused to guide practice. sion, andmust strateiges foron success practice be based new in the daunting process of retunknowledge, critical reflection, viewed. Chapter evidence. 2 Focuses on and documented professional parameters You are atpractice a stage of transiand the characteristics profes tion in your career path.ofThis focus on the co transforming transition is one of many as you your for success in thejourney daunting chart your continuing in process of reteigescareer. for success your professional in the daunting. focus the Chapter 12 will A help youon plan co transforming your success for the future and forfor your in the daunting process ofand reteiges continued professional for success in the daunting. personal development.

I

161

CHAPTER 11

Evidence-Based Practice CHAPTER OBJECTIVES

Key Terms Evidence-based practice Research Basic human rights Quantitative (empirical) research Research process Qualitative research Knowledge transformation

After completing this chapter, you will be able to: 1. Explain the importance of evidence-based nursing practice. 2. Define basic terminology used in research for application of findings in practice. 3. Describe barriers to evidence-based practice. 4. Locate an example of an evidence-based practice in the literature or in a reputable online resource. 5. Plan for the inclusion of evidence-based care in your practice setting.

urrent knowledge and practice must be based on evidence of efficacy or effectiveness rather than intuition, tradition, or past practice. As we discussed in Chapter 6, the concern for safety in 1999 resulted in a national call for changes in the education and competencies of health professionals in all disciplines by 2003. The five core competencies for health professionals were identified. One of these competencies requires employing evidence-based practice (EBP). Sigma Theta Tau (2005), the International Honor Society of Nursing, defines the use of evidence-based practice as the “integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are selected” (p. 2). Further, Melnyk and Fineout-Overholt (2005) identify four components for evidence-based clinical decision making as:

C

■ ■ ■ ■

Evidence from research/evidence-based theories and expert panels Assessment findings and available healthcare resources Clinical expertise Client preferences and values (p. 7)

We must consistently use the best evidence available to guide care to clients. Having the best evidence is based on a body of research for the identification of this knowledge.

162 Section 3 l Concepts for Your Continuing Journey

Research supports our knowledge base and answers questions of clinical concern. It provides sound information on which to base practice, as the body of knowledge grows. This current, evolving body of knowledge is the basis for evidence-based nursing practice. Porter-O’Grady (2006) describes evidence-based practice as requiring “a degree of flexibility and fluidity based on firm scientific and clinical evidence validating appropriate and sustainable clinical practice” (p. 3). Evidence can come from a number of sources. However, we need to continue to expand and refine our knowledge base. Practicing healthcare professionals must identify the questions and determine where new information is needed. These healthcare providers should use the most current knowledge and applications based on evidence of efficacy for the client. These questions must be refined and studied so that nurse researchers can find solutions to healthcare practice problems. Researchers must provide sound answers to practice issues. We need further validation from the consumer as to the appropriateness of the intervention. This is truly evidence-based practice.

Nursing Research Research has been defined as a “systematic, controlled, empirical, amoral, public, and critical investigation of natural phenomena guided by theory and hypotheses about the presumed relations among such phenomena” (Kerlinger & Lee, 2000, p. 14). The purposes of research are to describe, explain, predict, and control phenomena, to provide information for future use in practice, and to increase our knowledge base. Nursing research began with Florence Nightingale and her identification of environmental influences on health and illness. In her classic Notes on Nursing: What It Is, and What It Is Not (1859), Nightingale identified factors that influence health and wellness, supporting them with observational accounts, statistics, and deductive reasoning. Support has grown for research as we see the needs to investigate the domain of nursing, test

Chapter 11 l Evidence-Based Practice 163

theories and interventions, and demonstrate efficacy and efficiency of nursing actions and outcomes for clients. A vital issue is the need for reliable and valid research on questions of clinical concern for evidence-based practice and change. In nursing, research must be directed at interventions over which nursing has control so that the knowledge developed can lead to needed change. An isolated research study does not constitute evidence-based practice. However, the accumulated knowledge from multiple research and analyses is the basis for evidencebased nursing practice. Nurses have a major responsibility to identify research problems, support ongoing research, and use applicable findings in practice. First, consider the process of research for the development of the accumulated knowledge, including ethical issues and the processes involved.

Ethical Considerations An essential responsibility in professional nursing practice is protecting the rights of research subjects. The rights of people in research have been of great concern to ethicists, legislators, and professionals, leading to ethical codes and guidelines for the protection of research subjects. History has provided much of the impetus for our professional codes and federal regulations. During World War II, experiments noted for the unethical treatment of subjects included the Nazi medical experiments and the Japanese concentration camp experiments on human subjects. As a result, international ethical codes evolved. In the United States, several notable research projects were further examples of unethical treatment of research subjects. In the quest for knowledge, researchers failed to consider the basic human rights of their subjects, especially the right of informed consent and considerations for vulnerable populations. Federal regulations evolved as laws now mandating protections for human subjects in research. All activities involving humans as subjects must provide for the safety, health, and welfare of every individual. Subjects do not abdicate rights with their participation in a research study. As we discussed in Chapter 4, basic human rights must be considered. These human rights must be ensured for research subjects. These principles speak to ethical considerations and human rights (Box 11–1). The “do no harm” concept includes careful consideration of the risk-benefit ratio with any research project. One must keep in mind that minimal risk requires that “the probability and magnitude of harm or discomfort anticipated in the research are not greater in and of themselves than those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests” (Protection of Human Subjects, 45 CFR 46, §42.102 [i], 2005). Justice and fidelity require that all subjects are treated equitably and fairly. Full BOX 11–1 Basic Human disclosure of truthful information and self-determination by Rights of Research potential subjects are necessary conditions for informed conSubjects sent. In addition, subjects’ rights to privacy and confidentiality must be ensured throughout the process. As protections for ✻ Beneficence or nonmaleficence these basic human rights, specific guidelines must be consid(do no harm) ered by researchers to ensure that risks are minimized and are ✻ Justice and fidelity reasonable in relation to anticipated benefits, safety to subjects ✻ Full disclosure and veracity is ensured, and additional protections are provided for special, ✻ Self-determination and vulnerable populations such as children, prisoners, pregnant informed consent women, mentally disabled persons, or economically or educa✻ Privacy and confidentiality tionally disadvantaged persons. 164 Section 3 l Concepts for Your Continuing Journey

The American Nurses Association (ANA) has also specified guidelines for research based on nine principles that address beneficence, full disclosure, self-determination, privacy and confidentiality, and the skills of the researcher. All of the principles require that professionals in a practice setting be aware of any ongoing research and its associated risks to both subjects and participants. Nurses have both the right and the responsibility to participate in research. Nurses can participate on committees, as members of research teams, and as principle investigators focusing on the domain of nursing. Nurses can also actively participate by giving support and assistance to others involved in research for the advancement of knowledge and enhancement of practice and positive outcomes for clients. The process of research with human subjects must be diligent and beneficial to subjects and participants through the quest for new knowledge.

Processes of Research The actual research process is generally thought of as the scientific method. This can be misleading, however, when one considers the different types of research. To understand the basics of nursing research, first think about the scientific method as a systematic process for answering a question or testing a hypothesis. QUANTITATIVE RESEARCH METHODS First, consider the steps of research. Quantitative or empirical research is based on the strict rules of the scientific method and the focus is on an observable, measurable, and predictable world. It is guided by a controlled set of steps that one goes through to observe something or test a hypothesis. It is a deductive and linear method following a sequence of steps (Box 11–2). The researcher will go through successive steps in a systematic and controlled manner to maintain the integrity of the process. Once the plans for the study are finalized, strict research protocols are adhered to with quantitative methods, to reduce threats to the validity of the study. The following is a review of the research process. In the initial step of problem identification, the researchers specify what they are interested in studying. This is the “what” that will be done as the study progresses. For example, a specific nursing intervention is compared with a traditional nursing intervention for a selected group of clients. Next, researchers specify the BOX 11–2 Steps of Empirical Research reason they are interested in this problem, or the purpose of the research. 1. Identification of the problem At this time, the significance of the 2. Statement of the purpose problem for the body of knowledge 3. Review of the literature and ethical issues associated with the 4. Description of theoretical framework proposed investigation are considera5. Definition of terms tions. This is “why” the researchers 6. Statement of hypothesis(es) want to investigate the new interven7. Selection of the research design, population, and tion, for example, to effectively imsample prove healthy behaviors of the client 8. IRB approval group. 9. Collection of data The researchers next search the 10. Analysis and interpretation of data literature to discover what is known 11. Presentation of findings and recommendations on the topics: the interventions, the Chapter 11 l Evidence-Based Practice 165

client group, cultural factors, useful practice theories, and what problems have been studied in the area. This time-intensive process requires understanding the current information known on the topic and planning for the project. Researchers perform literature searches, followed by careful analysis of the available information. Next, researchers specify the theoretical framework that will guide the research. For example, the study may be guided by one of the nursing theories discussed in Chapter 3. The defining terms and variables (concepts to be studied) specific to the study emerge from the theoretical framework, as do specific research questions that will be addressed or the hypotheses (predictions) the study will test. This process provides the basic idea for the investigation, but the researchers must select a design (or plan) for the study that is appropriate for the problem in light of the theoretical framework. Once the appropriate design has been selected, the researchers must define the population—those individuals or groups to whom the findings will be applicable, as with a specific client group. Researchers know that not all the people to whom the research applies can be studied, so they must study a select group of the population: the sample. The researchers’ decision about the type and the size of the sample is based on the research design, theoretical framework, research purpose, and research problem. It all relates back in a linear manner, but the goals in sampling are to limit bias and statistical error. The sample should be representative of the population. The researchers now have the basic plan for their investigation, but no one has been studied yet. The rights of human subjects must be considered and protected. At this point the researcher submits a proposal to an Institutional Review Board (IRB) for approval to proceed to the next step of data collection. The IRB is a specially designed committee that considers both the rights of subjects in the proposed study and the merit of the research. Once IRB approval has been secured, the researcher is ready to begin collecting data. Plans for data collection and analysis have already been made in the research proposal and are strictly followed. For example, researchers must follow the design they proposed and cannot decide to replace interviews that were planned with a self-report questionnaire. Data must be collected in an orderly and systematic manner. The data collected must be recorded before analysis and decision making begin. Research protocols are strictly followed with the identical process used with each research subject. Once all subjects have been investigated and all data collected, the researcher moves into the analysis stage. The analysis provides information to answer the research questions or support or disprove the hypotheses. Keep in mind that the research depends on a good analysis of the data so that reliable, valid information is made available on the topic. Reliable information means that the variables are measured in a consistent manner and validity ensures that the researchers are really measuring the variable to be studied and not something else. From the point of reporting the statistics, the researcher then interprets the meaning and implications relative to the stated research questions or hypotheses. The findings are reported objectively for each research question or hypothesis. Recommendations for use of the findings and further research are then presented in the research report. However, keep in mind, one research study does not constitute evidence-based practice. However, one study can provide support for the body of knowledge that is evidence-based practice.


QUALITATIVE RESEARCH The research process using qualitative research methods is somewhat different. Qualitative research is used to generate theory to explore, describe, and illuminate phenomena. The basis of qualitative research focuses on the meaning and interpretation of experiences to understand some phenomena. Major data collection methods are observation in the natural setting and on-site interviewing. Some researchers describe the data that emerge from this research as “rich” information, because the researcher begins a study with a need to understand from the perspective of people in the environment. The researcher is not limiting the data collection to a few variables. The researcher is trying to have the people in their environment describe their unique phenomena. Based on the information obtained, the researcher then classifies concepts, identifies themes, and generates theory. In qualitative research, the linear steps of the process are not the procedure. The researcher must still complete the initial process of developing the project, with identification of a “problem” of a little-understood area and the statement of purpose for “discovery” of the phenomena. The review of the literature looks at what is known, which is often tangential, because little may be known before the research “uncovers” the phenomena. The theory will evolve from this research, as are the terminology and future study hypotheses that use quantitative methods for testing the theory generated. The process of IRB approval is still required before data collection, for the protection of human subjects. Qualitative methods have different inquiry forms and processes. Data collection and analysis are driven by the particular qualitative method, as with ethnographic or grounded theory techniques to describe the phenomena from the perspective of the subjects. Reliability and validity issues may be addressed using triangulation of data with multiple data sources, complementary investigations, or theoretical perspectives to provide valid results. Whether quantitative or qualitative, what research methods are selected depends on the phenomena of interest and the purpose of the research. For example, the researcher


may use qualitative methods to investigate health practices of a particular cultural group, but would use quantitative methods to test a new intervention designed to enhance the functional independence of aging adults with mobility problems. Regardless of the methods selected to address the need for information on the problem, the research must respect the individual or group in the quest for knowledge. But remember, evidencebased practice is the use of clinical expertise and interventions that are based on evidence of efficacy for client outcomes and the preferences of the clients served. This evidence is for development of best practices and requires a body of knowledge and more than one research study.

Using Evidence-Based Practice We have a responsibility to base nursing practice on current knowledge. This responsibility highlights an accountability issue for the profession and focuses the direction of nursing research on issues for improved client outcomes and effective care in a time when resources are limited. We have progressed from isolated studies to the development of guidelines and specific protocols for evidence-based nursing interventions to help nurses base their practice with clients on evidence of efficacy. In 1997, the American Nurses Association (ANA) identified expectations for involvement of registered nurses in research, according to their level of educational preparation. In these guidelines, the graduate with doctoral or postdoctoral preparation is seen as providing leadership on investigations, applying theory, and developing methods to generate knowledge for the discipline. With an expertise in specialty practice, the master’s-prepared nurse is the facilitator for using research findings and conducting investigations. Associate degree and baccalaureate nursing graduates are research consumers and are responsible for identifying problems for further study and grounding their daily nursing practice on current information. Evidence-based practice is fundamental to contemporary nursing, providing a firm foundation for nursing interventions and quality improvement in healthcare. It has been identified as one of the core competencies for health professionals in all disciplines. To address this core competency, the Academic Center for Evidence-based Practice (ACE) led the way with a project to establish a national consensus on essential competences for EBP for use in education and practice (Stevens, 2005, p. 1). Competencies by educational level (undergraduate, master’s, and doctoral) have been identified based on their ACE Star Model of knowledge transformation with five stages (see Fig. 11–1). Knowledge transformation is defined as “the conversion of research findings from primary research results, through a series of stages and forms, to impact on health outcomes by way of [evidence-based] care” (Stevens, 2005, p. 25). New knowledge is transformed through the five stages: ■ Discovery ■ Evidence summary ■ Translation ■ Integration ■ Evaluation The intended outcome of this knowledge transformation is quality improvement of care (Stevens, 2005, pp 25–27). Discovery is primary research. The evidence summary is the available body of knowledge. Stevens (2005) describes the process with evidence summary as the synthesis of the primary research and the body of knowledge leading to 168 Section 3 l Concepts for Your Continuing Journey

ACE Star Model fo Knowledge Transformation 1

translation into practice guidelines Discovery and then integrated in practice and evaluation of outcomes (pp. 26–27). Notice how this is the building of curSummary Evaluation rent knowledge and best practices 5 known on the topic for effective client outcomes. When systematic reviews of research are available, more is known Translation Integration on the body of knowledge; the evi4 3 dence is stronger for clinical application, considering the unique needs Figure 11–1 Ace Model. of the client population. Proficiency (From Kearney-Nunnery, R: [2008]. Advancing your career: Concepts in professional nursing [4th ed.]. Philadelphia: F.A. Davis, with permission.) in critiquing or evaluating research or the evidence summaries is central to the ability to translate and integrate the evidence into professional practice. ACE: Learn about EBP

Reading the Literature

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2

http://www.acestar.uthscsa.edu/about.htm

Using evidence-based practice requires a careful and objective analysis of the body of knowledge. An objective analysis is required to have all the information as a basis for decision making for applicability to your practice setting. When reading a report on a research study, the reader must critically consider all components of the report—problem, purpose, supporting literature, theoretical framework, definitions, study questions or hypotheses, design, population and sample, data collection methods and procedures, analysis, and interpretation of findings. The ultimate goal is to evaluate applicability of appropriate scientific findings to the clients in your practice area in this stage of discovery with a primary research study. Thoughtful critique is based on critical thinking skills used to address the steps of the research process. When BOX 11–3 Sections of a publishing research reports, researchers must provide the Published Research essential information gained from the study. This sometimes Report limited information can create a challenge for the reader attempting to glean the vital information for applicability to ✻ Title and abstract practice. A published research report is frequently organized ✻ Introduction, problem, and into sections (Box 11–3). purpose The title must capture the reader’s interest; you ✻ Literature review the reader. Then, the abstract briefly reviews the problem, ✻ Theoretical framework purpose, methodology, findings, and conclusions, summa✻ Research questions or rizing the content to engage you to read further. Next, the hypotheses body of the article with an introduction to the research ✻ Methods: design, ethics, report is provided. The opening paragraphs outline the sam1pling, data collection background of the problem, including its purpose and sig✻ Results and analysis nificance to nursing and the care of clients. The research ✻ Discussion and problem is the central question that the research has been recommendations designed to answer, as the “what” was done in the study to Chapter 11 l Evidence-Based Practice 169

describe, explain, predict, or control some phenomenon of concern to nursing. The research problem contains the major variables and the population that the researcher has addressed. The specific research aims for the study may also be provided in this introductory section. Next, a review of literature pertinent to the research problem is a report and comparison of all prior investigations on the topic. This literature review concentrates on primary references or actual reports of prior investigations written by the researcher or theorist. Using the primary source eliminates the chance for error in interpretation that could occur through interpretation by others. The literature review should provide a synthesis of what is already known on the topic and support how the investigation proposes to contribute to the existing body of knowledge. Caution is recommended on the use of research reports found in chat rooms, on personal Web pages, or other sources that have not been subjected to a thoughtful peer review process before being accepted for publication. The theoretical framework may be described in a separate section or may be included with the literature review. As was discussed in Chapter 3, a theoretical framework or model is the way the researcher views the concepts and their interrelationships; it may be described in words or displayed as a figure. At this point, the researcher may present specific questions to address in the study or hypotheses to be tested. Specific research questions must flow from, and relate back to, the main research problem or purpose. Hypotheses are predictions about the variables that the investigation is testing with a subject group. Both research questions and hypotheses must be consistent with the framework that provides the theoretical guidance for the study. The variables to be investigated should be readily apparent in either the stated research questions or hypotheses. The next major section in a published report describes the research methods. This section contains information on the research design, subjects, and data collection and procedures used. The research design specifies the setting for the study, the subjects (sample), treatment or grouping methods, the data collection methods, and research procedures. The research design is selected to measure the variables to answer the research questions or test the hypotheses. You may refer to a nursing research text for more information on the various research designs. The researcher provides definitions for all major variables in the study. Operational definitions identify what the researchers are looking at and how they are measuring it. 170 Section 3 l Concepts for Your Continuing Journey

For example, consider a stethoscope and the difference with a bell-diaphragm combination, electronic, or pediatric stethoscope that must be specified in an operational definition. Variables are concepts defined and manipulated, controlled, or measured in a research study. Independent variables are variables manipulated by the researcher, such as the treatment or difference between the groups (for example, the type of dressing used). Dependent variables are the outcome variables that the researcher is measuring. The researcher wishes to see whether the change in the independent variable (type of dressing) caused a difference in the dependent variable (healing time). Uncontrolled or confounding variables (such as nutritional status or additional conditions such as diabetes) also must be considered because they can have unwanted effects on the dependent variable of healing time. The researcher often attempts to control the extraneous effects by selecting a population or study procedures that meet specific criteria, to reduce the chance of occurrence of these extraneous or unwanted influences, as with restricting the sample to clients with diabetes. This limitation will provide some control for extraneous variables, but also can limit generalizability of the results to other populations without further study. Pay particular attention in the methods section, where special attention is given to the descriptions of the subjects. Ultimately, this allows you to determine the applicability of results to your practice setting. Sampling is the use of a subset of the population as the group to study, ultimately generalizing the findings to the population. For example, not all diabetic clients in a wound care clinic program can be interviewed in person. Yet the researcher would like the study results to be applicable to all clients similar to the study subjects, so that the information will add to the body of nursing knowledge. Samples may be selected by statistical probability or nonprobability. Each type of sample has advantages and disadvantages. Specific research methods are described as data collection procedures. Data are the measures or responses obtained from the subjects in the study. Analyzed data become information. Instruments are the measurement tools for collecting data. They include paper-and-pencil instruments (such as questionnaires), biophysiological instruments (such as a stethoscope), interview guides, video/audio tapes, and others, depending on the specific investigation and variables. After the data collection methods have been described, the researcher describes methods used to analyze the data and reports the results in the findings or results section. Methods for analysis of the data are based on the specified research methods and the type of data involved. For numerical data, statistics are used in the analysis of quantitative research methods. Statistics are used to describe data, test hypotheses, and make predictions from the sample to the population. The results are reported for each research question or hypothesis in an objective manner. Finally, the researcher presents an interpretation of the results in a discussion section. Conclusions should be consistent with the theoretical framework used to guide the study. The discussion also includes the researcher’s identification of limitations and recommendations for using the findings in practice, teaching, administration, and further research. At this point, you must determine the applicability of the results to your individual practice area. Another consideration is whether the study added to and supported the current body of knowledge or whether it provided an isolated set of findings. However, you must decide whether the results are applicable in your practice area. If so, it is a professional responsibility to implement information found to be beneficial to clients, rather than to continue to practice on the basis of tradition. Reading research findings and evidentiary Chapter 11 l Evidence-Based Practice 171

summaries in professional journals and keeping abreast of current knowledge are essential in practice to provide client-centered and effective care.

Incorporating Evidence-Based Practice

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Remember, true evidence-based practice is more than one research study. For the implementation of evidence-based practice, alternative sources beyond traditional research articles are available such as systematic reviews, practice guidelines, and online reviews. As noted by Stevens (2005), systematic reviews have been greatly advanced and produce new knowledge. They combine findings from all studies, identify bias and limit chance effects, and increase reliability and replication of the results (p. 26). National clinical guidelines have been available since the 1990s but, unfortunately, are not consistently accessed or used. The National Guideline Clearinghouse provides archives of current practice guidelines that have been reviewed, revised, or deleted within the past 5 years, organized by health conditions and national organizations. The Cochrane Collaboration also provides international and interdisciplinary leading evidence-based practice information. The Agency for Healthcare Research Agency for Healthcare Research and Quality and Quality (AHRQ) also provides http://www.ahrq.gov Cochrane Collaboration useful information and quality meashttp://www.cochrane.org/ ures for application in evidence-based National Guidelines Clearinghouse practice. Check out the resources in http://www.guideline.gov the Online Consult for valuable EBP information. Look further at the process for evidence-based practice. Coopey, Nix, and Clancy (2006) from the Agency for Healthcare Research and Quality have described the process for translating research into EBP. They have identified the following five steps in a cyclic evidence process:


1. Body of individual evidence (multiple individual studies) 2. Systematic review to synthesize the body of evidence 3. Translating evidence into action and tools, i.e., guidelines 4. Implementation in practice 5. Evaluation of effectiveness for quality improvement (Coopey, Nix, & Clancy, 2006, p. 196) After you have obtained the information from the professional literature, the issue is implementation and sharing. This can be done informally among your colleagues or can be formally presented at a unit or agency conference. Investigate what is available in your environment. Obtaining new information is the intended aim of attending a clinical conference, whether or not you need continuing education units for licensure. Quality of programs and significance of the topics to your practice area must be considered for evidence-based practice. Attendance at grand rounds in an institution committed to research is also a valuable experience. Nurses can collaborate on different stages of the research process. In addition, the practice problems specific to your setting can emerge, be developed, and be investigated when professionals start the discussion and raise the issues. Use the case study provided in Box 11–4 to practice with recent evidence-based practice guidelines released by the National Institutes of Health for clients with asthma. Consider that you are working in a respiratory clinic with parents and children. Recall, asthma is a major cause of missed school days for children and associated missed work days for their parents or caregivers. This time factor requires both the best use of your time with these clients and the best information on efficacy of care. Long-term management is a vital consideration. We have located current national practice guidelines (USDHHS, NIH, NHLBI, 2007) that recommend four essential components to care management: ■ ■ ■ ■

Assessment and monitoring Client education Controlling factors contributing to severity Pharmacological treatment (p. ix)

The clinical guidelines indicate evidence of health disparities and higher rates of poorly controlled asthma and asthma deaths among blacks and Latinos compared to whites related to access to care, underutilization of long-term control medication, cultural beliefs and practices (USDHHS, NIH, NHLBI, 2007, p. 39). Knowing this, your assessment, interpersonal, and technical, and teaching skills are critical to assisting the client in their treatment plan. The RN’s responsibility extends well beyond initial assessment and includes ensuring that they have their prescriptions to be filled at the pharmacy along with instruction sheets. Consider all the aspects including an environmental assessment and multigenerational issues for client teaching of the child and the family in the case study provided in Box 11–4 and on the Intranet site. Asthma is one of the major health issues for children and adults. However, more evidence on this condition as well as other health problems is evolving on a daily basis in interdisciplinary healthcare practices. The challenge is keeping current on all the information available.

Eliminating Barriers Barriers to evidence-based nursing practice include real and perceived lack of educational preparation, administrative support, resources, and time. In this time of diminishing


BOX 11–4

Case Study on the Use of Evidence-Based Practice for the Client With Asthma

Background information: Jason is a 6-year-old, frail African American who was originally diagnosed with moderate asthma at age 4. He lives in a high-rise apartment with his mother and maternal grandmother. He was hospitalized 3 months ago with severe asthma and has been scheduled for follow-up clinic visits every 2 weeks during this time. He attends the local school and rides the bus each morning. His mother and grandmother have rotated his visits with their work schedules and have kept all visits but one during this time. Neither his mother or grandmother smoke; however, the neighbor who watches Jason after school does smoke approximately one pack of cigarettes daily and has a cat. Jason spends approximately 1 hour in her apartment on school days for a snack and watching cartoons. Vital signs: Temperature 99.8 (oral), BP 110/65, apical pulse 102, respirations 32 with bilateral wheezes. Reports some “chest tightness.” Height & Weight: 43 in., 39 lbs. Current medications: Low-dose inhaled corticosteroid (Fluticasone 44 mcg/puff) Metered-dose inhaler twice daily Methylprednisolone 4 mg daily Multivitamin

resources, the use of the most reliable and accurate information is crucial. Trial-and-error strategies as the basis for a client intervention waste valuable resources and are wrong if there is contrary evidence. We need an increasing sense of commitment to practice based on evidence of effective outcomes for clients. Clinicians have the frontline awareness of problem areas but must be assisted in accessing the current knowledge, looking at problems for improved client outcomes, and basing their nursing interventions on the current evidence of efficacy. The support and encouragement of supervisors are vital to ensure that the organizational climate, resources, and philosophy of practice are present in the practice setting. A dynamic person spearheading the process aids the implementation of evidence-based practice in the practice environment. Valuable informational resources may be in your employment setting. Keep an open mind and make the commitment to identify problems and search the current knowledge base for information for best practices and basing practice on evidence of efficacy. Constant updating and modification of any protocol is needed as more information becomes available. The critical thinking skills and learning the language of evidence-based practice are components of this process.

KEY POINTS • Evidence-based practice, a core competency for health professionals, is defined as the use of clinical expertise and interventions that are based on evidence of efficacy for client outcomes and the preferences of the clients served. • Research is a process for generating scientific knowledge and using the knowledge on which to base practice. Research evidence builds the body of knowledge for using evidence of efficacy in practice. 174 Section 3 l Concepts for Your Continuing Journey

• Ethical considerations in research must include basic human rights: ➡ Beneficence or nonmaleficence (do no harm) ➡ Justice and fidelity ➡ Full disclosure and veracity ➡ Self-determination and informed consent ➡ Privacy and confidentiality

• A professional nurse should be an active consumer of nursing

•

• •

•

research, promoting use of current and valid scientific knowledge, and identifying the questions to be addressed in further research. Professional accountability demands that one read the literature, attend educational sessions, use critical thinking skills, participate in investigations, and use evidence-based interventions. Quantitative or empirical research is based on the strict rules of the scientific method, with the specific and linear steps for the process. Qualitative research methods focus on information gathered from individuals and groups, often in their natural environment, to explore in depth their unique qualities and generate theory on a little-known topic. Knowledge transformation is defined as “the conversion of research findings from primary research results, through a series of stages and forms, to impact on health outcomes by way of EB care” (Stevens, 2005, p. 25).


need. Identify an area for incor1. Describe activities present in poration of evidence-based your practice setting that demonpractice and locate a research strate the use of evidence-based summary on the topic. practice. 2. Identify a practice issue that could 4. Locate a research article in a nursing journal that supports be developed into a nursing reevidence-based practice in an search problem for investigation. area applicable for your current 3. Review your intervention plan work with clients. and outcomes that you developed to address a client health Go to the Intranet site and complete the interactive exercises provided for this chapter.

REFERENCES American Nurses Association. (1997). Position statement: Education for participation in nursing research. Retrieved February 17, 2008, from http://nursingworld.org/ MainMenuCategories/HealthcareandPolicyIssues/ANAPositionStatements/ research.aspx Coopey, M., Nix, M., & Clancy, C. (2006). Translating research into evidence-based nursing practice and evaluating effectiveness. Journal of Nursing Care Quality, 21(3), 195–202. Kerlinger, F. N., & Lee, H. B. (2000). Foundations of behavioral research (4th ed.). Belmont, CA: Wadsworth Thompson Learning.


Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott Williams & Wilkins. Nightingale, F. (1859). Notes on nursing: What it is, and what it is not. London: Harrison and Sons. [Commemorative edition printed 1992, Philadelphia: J. B. Lippincott] Porter-O’Grady, T. (2006). A new age for practice: Creating the framework for evidence. In K. Mallock & T. Porter-O’Grady (Eds.), Introduction to evidencebased practice (pp. 1–29). Boston: Jones and Bartlett. Protection of Human Subjects, 45 CFR S 46 (2005). Title 45 Code of Federal Regulations Part 46 (45CFR 46), §46.101. Retrieved February 17, 2008, from http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.htm Sigma Theta Tau. (2005). Evidence-based nursing position statement. Retrieved from http://www.nursingsociety.org/aboutus/PositionPapers/Pages/ EBN_positionpaper.aspx Stevens, K. R. (2005). Essential competencies for evidence-based practice in nursing. San Antonio, TX: Academic Center for Evidence-Based Practice, UTHSCSA. U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. (USDHHS, NIH, NHLBI). (2007). Summary report 2007. National asthma education and prevention program expert panel report 3. Guidelines for the diagnosis and management of asthma. Retrieved February 18, 2008, from http://www.nhlbi.nih.gov/guidelines/asthma/ asthsumm.pdf

BIBLIOGRAPHY Academic Center for Evidence-Based Practice, UTHSCSA. Retrieved February 17, 2008, from http://www.acestar.uthscsa.edu/About.htm Asthma & Allergy Foundation of America. (2008). Asthma. Retrieved February 18, 2008, from http://aafa_as.healthology.com/asthma/focusarea.htm DiCenso, A., Guyatt, G., & Cilska, D. (2005). Evidence-based nursing: A guide to clinical practice. St. Louis: Mosby. Ellis, K. C. (2008). Keeping asthma at bay: The latest evidence-based guidelines highlight ways to help patients control the disorder. American Nurse Today, 3(2), 20–26. Greiner, A. C., & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: Institute of Medicine. Silva, M. (1995). Ethical guidelines in the conduct, dissemination, and implementation of nursing research. Washington, DC: American Nurses Association. Thompson, C., Cullum, N., McCaughan, D., Sheldon, T., & Raynor, P. (2004). Nurses, information use, and clinical decision making—the real world potential for evidence-based decisions in nursing. Evidence Based Nursing: EBN Online. Retrieved February 17, 2008, from http://ebn.bmjjournals.com/cgi/content/full/7/3/68 U.S. President’s Commission for the Study of Ethical Problems in Medicine and Behavioral Research. (1982). Compensating for research injuries: The ethical and legal implications of programs to redress injured subjects (Vol. I). Retrieved February 17, 2008, from http://www.gwu.edu/~nsarchiv/radiation/dir/mstreet/ commeet/meet16/brief16/tab_b/br16b1a.txt United States Department of Health and Human Services (USDHHS). (2004). Protecting personal health information in research: Understanding the HIPAA Privacy Rule (NIH Pub. No. 03–5388). Retrieved February 17, 2008, from http://privacyruleandresearch.nih.gov/pr_02.asp


ONLINE RESOURCES Academic Center for Evidence-Based Practice (ACE): http://www.acestar.uthscsa.edu Agency for Healthcare Research & Quality: http://www.ahrq.gov Cochrane Collaboration: http://www.cochrane.org/ National Institute of Nursing Research: http://ninr.nih.gov National Institutes of Health: http://www.nih.gov/ National League for Nursing: http://www.nln.org Office for Human Research Protections (OHRP): http://www.hhs.gov/ohrp/ Office of Civil Rights: http://www.hhs.gov/ocr/hipaa/ Sigma Theta Tau International: http://www.nursingsociety.org/research U.S. Department of Health & Human Services: http://www.hhs.gov


CHAPTER 12

Planning Your Future CHAPTER OBJECTIVES

Key Terms Quality Quality improvement Continuous quality improvement Leadership Management Collaboration Collegiality Provider of care Manager of care Client advocacy Member of the profession Standards of professional performance Challenges Ongoing learning

On completion of this chapter, the reader will be able to: 1. Examine options and future development in your nursing career. 2. Describe the leadership and management responsibilities of the registered nurse. 3. Reexamine your knowledge, skills and abilities, and resources to assist with your success. 4. Envision personal competencies in professional nursing practice. 5. Set realistic goals for your future as a professional nurse.

t is a time for discovery, reflection, and professional development. Now is an opportunity for looking at challenges ahead and growth in your scope of practice. Let’s consider the challenges in your future.

I

Professional Practice Recall from Chapter 2 that a profession is a unique career built upon a distinct knowledge base and guided by systematic theory with the authority to provide a distinct service in an ethical manner with prescribed standards of practice. Practice parameters define the scope of practice. The nursing license provides the privilege to practice within a certain scope with good judgment in accordance with established standards of practice and evidence of continued competence. We adhere to a higher standard of ethics than in daily life with the professional code of ethics and a focus on our metaparadigm concepts of human beings, health, the environment, and nursing. Our professional organizations promote currency and best practices with a focus on evidence-based practice and demonstration of our role in improved outcomes for the clients of nursing. We have a unique and shared body of knowledge that is growing rapidly. This future orientation focuses on quality and positive client outcomes. To assist in the provision of positive outcomes for clients, the core competencies for all health professionals were identified (Greiner & Knebel, 2003). Client-centered care is a natural focus for nurses, especially when we consider our metaparadigm concepts. However, working in interdisciplinary teams, using


evidence-based practice and informatics, and focusing on quality improvement are competencies that are evolving and need constant attention. Clients are often in a vulnerable health state when entering the healthcare system. Their experience as unique individuals with care particular to their needs may not be recognized initially, but will be reflected upon at some point. This human ability to experience personalized care with the healthcare team working together with the client on acceptable interventions to meet specific needs using the latest integrated technologies is an expectation in many healthcare environments. The client generally does not expect to see quality improvement. Quality is simply a characteristic but in the context of a profession or service, it adds value and is forward looking to provide a measure of excellence in a service or a product. Quality improvement is the goal of the professionals for making improvements in services or care based on efficacy and demonstrated client outcomes. The continuing quest for a safer environment for clients, both hospitalized and in the community, is an important part of this quality improvement directive. Continuous quality improvement is an active evaluation process for the system focused on making changes based on data of efficacy. Efficacy includes both best practices to meet measurable outcomes and the values for excellence by consumers and providers in the system. As noted by Dunefsky (2008), quality improvement is an ongoing process and “goes beyond meeting preestablished goals or catching up to the competition; rather, it involves exceeding expectations and creating new opportunities” (p. 323). Continuous quality improvement or CQI has been studied and promoted for years. Theorists such as Deming, Juran, and Baldridge have provided valuable insights and techniques for the process, whether used in business, industry, education, or healthcare. It moves beyond quality assurance and is proactive rather than reactive to ensure improvements in the future. The focus is change for the better. Some people also refer to this as total quality management or TQM. Quality improvement also has been highlighted with safety improvements and the correction of system problems that jeopardize clients. For the quality improvement process to occur, skilled leaders and managers in organizations must have the vision for improvements in the future and the skills to make it happen.

Chapter 12 l Planning Your Future 179

Leadership and Management The registered nurse must be an effective leader and manager in the current healthcare environment. However, leadership and management styles vary among individuals and in the different organizations. These styles may be directed from the topmost corporate offices downward in a bureaucratic organization or it may be more flexible and participatory in a decentralized agency. Regardless of the organizational structure, it is critical that environments have strong nursing leadership and effective nursing management. But first, consider the difference between leadership and management. A leader mobilizes individuals in groups to achieve great things. Leadership involves action, creativity, motivation, and visioning. It is viewing the possibilities and motivating others to make things happen. There are many theories of leadership, yet no consensus on how these talented individuals make things happen. Much also depends on the environment and the people in that environment. There are three basic leadership styles, bureaucratic, democratic, or laissez-faire. Leaders who are bureaucratic and authoritarian, generally issue directives and expect things to happen. The democratic leader involves others in the process, seeking group participation and consensus. The laissez-faire leader is more passive, expecting the group to progress toward goals with little active involvement. As you can imagine, the people in the environment can influence and are influenced by the leadership style. The ultimate measure of effective leadership is whether things are happening or changing to address the possibilities. Management should not be confused with leadership. Management involves the coordination of resources to achieve organizational outcomes and requires effective critical thinking, problem-solving, and decision making. A manager focuses on directing the group to meet the desired outcomes for the organization through thoughtful and careful planning, direction, monitoring, recognition, development, and representation. An effective manager focuses on goals, appropriate planning to address the goals, mobilizing the resources needed, taking action, and constantly evaluating the actions and whether the goals are being met so plans may be revised accordingly. The nurse working with the client in the context of the nursing process, must be a good manager, as a planner, coordinator, and problem-solver. Nursing management involves ensuring that the job is done through delegation and supervision, as in the provision of care to clients. Careful planning is critical and is communicating clear expectations and directions. It is picking the right people and capitalizing on their talents and requires knowledge of the care requirements, the clients, and environmental influences. It also involves recognition of individual talents and “a job well done.” The client needs this recognition of achievement and accomplishment as do other healthcare personnel. All levels of staffing are a vital consideration, including assistive personnel. Monitoring in management is more than a matter of periodically checking to see if a task is done. It requires ongoing assessment and evaluation of the situation. Buckingham (2005) identified four key skills of managers, as picking good people, setting clear expectations, praising excellence, and showing you care for your people—but above all, the manager must discover what is unique about each person and capitalize on it (pp. 81–83). This discovery process is a skill and ability for the registered nurse but requires a view of both clients, all care providers, and environmental resources. As discussed in Chapter 9, delegation is a skill that grows and evolves as the nurse manager develops from a novice to the expert. Planning and organizing are indeed talents of the nurse manager. This is an outcome of the steps of assessment and planning in the 180 Section 3 l Concepts for Your Continuing Journey

provision of nursing care. Coordination is another talent of the nurse manager, as skills in coordination of care have continued to be a component of the practice scope and setting. Recognition of individuals and the situations is ensuring that the care to clients has been provided effectively. However, recall that management is the coordination of resources to achieve organizational outcomes and involves critical thinking, problem-solving, communication, and decision-making skills. Now we are looking beyond individual clients and at the organizational culture and the goals of that organization. An effective manager must be a good leader, and the combination of effective leadership and management skills provides the registered nurse with the attributes to face the multitude of challenges in the current healthcare environment. Administrative positions have been expanded at all levels and nurses have major leadership and management roles in healthcare organizations. Nurse managers have knowledge of people and the environmental influences on healthcare needs, from individual clients, to staff, and other healthcare providers. Leadership in nursing occurs at all levels with the vision of making things better and bringing people along in the quest for improvement. Nurses as leaders and managers are critical to the effectiveness of the healthcare team. As noted in the IOM report, “teams tend to reduce the utilization of redundant or duplicate services, and they also tend to develop more creative solutions to complex problems because of their members’ diverse academic backgrounds and experience” (Greiner & Knebel, 2003, p. 54).

Collaboration and Collegiality Working in interdisciplinary teams requires collaboration and this can be a challenge among professionals, especially when scope of practice issues arise, time is limited, and workloads increase. Teamwork is essential to address multifaceted client needs. And registered nurses, with their broad view of the client’s health status and care needs, must continually refine their skills in collaboration with all levels of providers, from assistive personnel to specialty physicians. And the role of the advanced practice nurse (APRN) has evolved from a physician extender to a skilled practitioner grounded in the domain of nursing and performing advanced assessment and interventions based on additional education, and additional knowledge, skills, and abilities. We have applied the steps of the nursing process to address the range of client needs, from actual or risk nursing diagnosis to implementation and evaluation activities designed to address client outcomes through both independent and dependent nursing actions. Effective critical thinking, communication, and clinical judgment serve the nurse well as a leader and a manager in teamwork situations. Now, look back at the differences between collaboration and collegiality. Collaboration involves actively working together to meet some identified goal, such as the client’s treatment goals. Within the discipline, nurses from each area of nursing would contribute to that goal—the staff nurse, nurse manager, case manager, the APRN, and even the student in a clinical rotation—in providing care to raise the client’s level of well-being. In times of limited staffing and growing responsibilities, making the time for effective collaboration may be challenging but is necessary to ensure effective client outcomes. Collaboration is critical for the efficient use of scarce human and physical resources in a consumer environment focused on effectiveness of client outcomes and overall safety. A cooperative spirit with collaboration will bring more efficient achievement of goals and greater personal rewards for both colleagues and clients. Chapter 12 l Planning Your Future 181

Questions of authority and responsibility may arise, such as who is the leader of the team and who is responsible for ensuring quality client outcomes. Everyone is responsible for ensuing positive client outcomes in a collaborative environment. Effective communication and clinical skills, along with trust, leadership, and collegiality, are important attributes of healthcare professionals in a collaborative environment. Collegiality is sharing responsibility and authority to achieve a goal or prescribed outcome. The responsibility for client outcomes is invested in more than one person. Mutual respect and collaboration are important components of a collegial relationship. All colleagues contribute to the intended goals and are accountable for the outcomes. Both collaboration and collegiality are specified by the American Nurses Association as standards of professional performance in its document Nursing: Scope and Standards of Practice (ANA, 2004). As illustrated in the standards of performance, measures of collegiality include sharing knowledge and skills, providing constructive feedback, enhancement of practice, and creating and supporting a learning and work environment. Recall that the competencies identified for all healthcare professionals by the Institute of Medicine (IOM) address providing client centered care in interdisciplinary teams using evidence-based practice, quality improvement and informatics (Greiner & Knebel, 2003). In a subsequent report directed at nursing and the need for collaboration, the IOM further identified the need for individual clinical competence and mutual trust and respect with the following four characteristics of collaboration: ■ ■ ■ ■

Shared understanding of goals and roles Effective communication Shared decision making Conflict management (Page, 2004, pp. 212–213)

All of these are characteristics of registered nurses requiring ongoing development in the current healthcare environment.

The Changing Landscape in Healthcare The healthcare environment is constantly changing and affected by multiple influences. We have a growingly aging and diverse population. Longevity has increased and we have more individuals living in the community in their eighties, nineties, and beyond. Health insurance is available to some but there is not universal coverage in the United States. Cost is a major consideration to consumers, employers, providers, and third-party payers. Health disparities have been identified in select populations. And, available knowledge increases daily but is not consistently applied in practice. Resources are stretched and the demands continue and increase. We promote health but our emergency departments and community clinics are heavily utilized for chronic and acute care needs. And workforce issues are a consideration. Workforce issues include an aging and limited nursing workforce supplemented by increased assistive personnel. Client needs have become more complex as we address aging clients and those with chronic illnesses. Leadership and management skills are required on a daily basis to confront these issues. Nurses in our constantly changing environment are required to be knowledgeable, flexible, responsive, innovative, and above all, caring. Consider the implications of the following challenges in the healthcare workforce:


■ ■ ■ ■ ■ ■ ■ ■ ■ ■

A culture of safety and quality client outcomes Appropriate staffing patterns and skill mixes Appropriate delegation activities Training and supervision of assistive personnel Competencies of professionals Coordination of care, especially from acute care to the home and community Changes in populations and healthcare needs Cost containment along with client satisfaction Evidence-based interdisciplinary practice Using information technologies and continuous quality improvement

Are you up to the challenge? The current healthcare environment is undergoing rapid changes as we address the needs of clients. Effective working environments have been scrutinized by several national nursing organizations to provide leadership for positive changes. For example, the American Association of Critical Care Nurses (AACN, 2005) has identified the following standards for healthy work environments: ■ ■ ■ ■ ■ ■

Skilled communication True collaboration Effective decision making Appropriate staffing Meaningful recognition Authentic leadership

As you can see, these are the required skills of the registered nurse that we have been discussing. Another national initiative that has resulted in demonstrated improvements for both consumers and providers is the identification of magnet hospitals throughout the country. Recognition as a magnet hospital requires that the applicant hospital or healthcare organization meet specific eligibility criteria, including strong nursing leadership and


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demonstration of national standards of practice. The self-assessment requirement for the institution applying for magnet recognition is described as a “journey toward nursing excellence” and revealing and “creating opportunities for organizational advancement, team building, and enhancement of individuals’ professional self esteem” (American Nurses Credentialing Center [ANCC], 2008, p. 1). Retention and appropriate staffing of nurses are characteristics of magnet organizations. The development of this recognition program has grown and has resulted in demonstrated improvements for clients American Association of Critical Care Nurses and the profession. Check out their http://classic.aacn.org/aacn/pubpolcy.nsf/Files/ HWEStandards/$file/HWEStandards.pdf “forces of magnetism” focusing on the ANCC Magnet Recognition Program® role of professionalism in the environhttp://www.nursecredentialing.org/magnet/ ment using the online consult.

Member of the Profession We have primarily been looking at the roles of the registered nurse as a provider of care, manager of care, and client advocate. As a provider of care, the nurse actively implements the nursing process to address client needs. However, the focus is on outcomes, efficacy of care, and acceptability to the client. As a manager of care, the nurse coordinates resources and directs a specific group to meet the desired outcomes for the client and the organization through thoughtful and careful planning, direction, monitoring, recognition, development, and representation. Available resources are a constant consideration along with effective and efficient utilization of these resources in a time of increasing cost. Client advocacy focusing on the needs, safety, and best interests of the client or client group is pervasive in every nursing action. But increased safety has been identified as a major need for clients, both hospitalized and in the community. The registered nurse is involved in all these roles on a daily basis. However, the registered nurse also is a member of the profession and has expectations to address as identified in the the ANA (2004) Standards of Professional Performance. As we discussed in Chapter 10, the ANA (2004) Scope and Standards of Nursing Practice, specifies both standards BOX 12–1 ANA Standards of care and standards for professional performance of Professional for the registered nurse. The standards of professional Performance (p. 3) performance (Box 12–1) are an expectation and a professional responsibility. There are nine standards for the pro✻ Quality of practice fessional performance of a registered nurse. ✻ Education ✻ Professional practice evaluation ✻ Collegiality ✻ Collaboration ✻ Ethics ✻ Research ✻ Resource utilization ✻ Leadership

Source: From American Nurses Association. (2004). Nursing: Scope and standards of practice (Publication No. 03SSNP). Washington, DC: American Nurses Publishing, p. 3.

■ The quality of practice goes beyond the care provided to a client. It extends to taking an active leadership role in the promotion of quality improvement on the unit and throughout the practice setting. ■ You are a prime example of the performance criteria for education in seeking continued formal education. But this education is not restricted to the college setting and requires the maintenance of currency in the professional role, as in the selection of continuing education courses to match the practice role and clinical setting. ■ Professional practice evaluations are more than annual required performance appraisals. They extend to an


■ ■ ■ ■ ■ ■

evaluation of one’s own practice, the practice of others, and actively seeking peer evaluations in order to improve one’s practice and demonstrate the standards of professional performance. This peer review process is another form of quality improvement in the individual and also an opportunity to evaluate continued competency. We have discussed collegiality and the need to share information, promote development, and use effective communication with all colleagues, including unlicensed personnel. Collaboration includes working effectively with the client and others on the agreed-upon plan for care and working effectively toward that end. Ethics requires adherence to the professional ethical code described in Chapter 4. Research is the application of evidence-based practice discussed in Chapter 11 as well as the participation in research studies. Effective and efficient utilization of resources is an ongoing challenge to address daily as safe and appropriate practice. In addition, leadership is expected in both the practice setting and in the profession to envision the possibilities and motivate others to make things happen.

The ANA (2004) provides measurement criteria for each of these performance standards as well as additional criteria for advanced practice nurses and nurses with advanced education practicing in role specialties like education and administration. The focus is quality improvement and quality enhancement throughout your career and professional practice as a life long journey.

Options A challenge is an invitation, in this case, an invitation to envision your future and the options and opportunities ahead. You are no longer looking through the rear view mirror at the past, but driving ahead to the challenges that await you in your future career. Ongoing learning means critically analyzing and reflecting on a situation and applying the positive


aspect, based on the data, to a future situation. It is similar to Piaget’s theory of cognitive development in which assimilation is when the child learns new information but accommodation is the incorporation of the information and resulting change in cognitive and behavioral patterns. This change is the transformation of your frame of reference and changing habits of mind in Mezirow’s (2000) transformative learning theory we discussed in Chapter 1. It is more than lifelong learning. It involves taking command of your future and the challenges you are presented with in your quest for improving healthcare to clients of nursing. Building on your knowledge base and your personal perspectives on each situation, you are making decisions. As a registered nurse you will have many options for your career path. Working with clients in an acute care, long-term care, home care, or rehabilitation setting can be challenging and rewarding as the landscape of healthcare changes in the future. Telehealth is emerging as a major entity. You are at the brink of a wealth of opportunities with continuing your education. And this ongoing learning will not stop with the awarding of your initial degree. Think about the ongoing learning opportunities presented in the healthcare environment. You learn from clients, colleagues, and situations. You can take advantage of local inservice offerings and also interdisciplinary learning opportunities. Select noncredit continuing education offerings that you can apply to your unique situation and client base. Reach out to professional meetings and conferences where you can acquire further knowledge of current, evidence-based practice. And continue your formal education. These challenges are all part of the professional performance standards described. Growing, learning, and becoming that expert nurse. You may also wish to pursue education at the graduate level. Recall that the ANA (2004) standards had additional measurement criteria for APRNs and nurses in specialty practice roles. APRNs include nurse practitioners (NP), clinical nurse specialists (CNS), certified registered nurse anesthetists (CRNA), and certified nurse midwives (CNM), all prepared at the graduate level in nursing. Those nurses in role specialty practice have advanced preparation and skills in the process of ongoing learning and a focus on their client base. The ANA (2004) identifies areas of role specialty practice as administration, professional education of nurses, professional development, informatics, case management, research, quality initiatives, publishing, and law (p. 16). The opportunities and challenges are there for you to find your niche as a professional contribution to the quality of healthcare to clients. Keep refining your goals for your professional development and your plan to meet them. In his highly acclaimed lessons on personal change and identification of the seven habits of highly effective people, Covey (2004) observed in habit seven that “to keep progressing, we must learn, commit, and do—learn, commit, and do—and learn, commit, and do again” (p. 306). It is a commitment to personal and professional growth in the process of ongoing learning.

Revisiting Your Transition Plan Recall in Chapter 1, you started developing your transition plan for professional practice. Your plan is specific to you, your situation, and your knowledge, skills, and abilities. These change over time and circumstances. You may have even made subtle changes since the start of this course. Imagine that you are moving forward, driving ahead, and looking through the rear-view mirror. What do you see? Consider the items listed in Box 12–2. Your multiple and competing roles will change. Change is inevitable and can be viewed as a positive. Have you set priorities and are they realistic? Only you can decide this through careful critical reflection. Give yourself permission to make the appropriate 186 Section 3 l Concepts for Your Continuing Journey

BOX 12–2

Considerations in Your Transition Plan

✻ Multiple roles and competing roles ✻ Awareness of knowledge, skills, and abilities ✻ Time commitments ✻ Employment adjustments and the support of peers at work ✻ Additional activities to join a class of students ✻ Finances ✻ Family considerations during the week/weekends, during the semester, and during breaks ✻ Your physical and mental health and wellness ✻ New frames of reference or points of view ✻ Your personal “habits of mind” ✻ Your perception of “the neutral zone”

decisions and seek helpful resources. As the nurse who works with the client to set goals and achievable outcomes in the planning phase of the nursing process, you are now setting your own goals and achievable outcomes for your educational pursuits and your career. However, consider the reality of both short-term and long-term goals and potential revisions to your personal timeline. Seek the resources you will need in this planning period. And then, implement your plan toward your educational objectives. But remember the evaluation phase. Chart your progress and celebrate your achievements what ever the size, from completion of a project, paper, or examination to the accomplishment of a course toward your degree. However, just like a GPS on a car, maps change, new roads are paved, and different directions are taken. New and different challenges will emerge in your life, personal and professional. So, ■ What are your goals? ■ Have you determined long-term versus short-term goals? ■ What are the measurable outcomes for the goals? ■ Have you identified your knowledge, skills, and abilities and what needs to be pursued, refreshed, or expanded upon? Try to be specific. ■ How has your skill with time management changed over the past weeks? Consider how the factors (family, work, school, and personal) will change during breaks, holidays, and semesters. ■ What discoveries have you made concerning your learning style and your learning preferences recently? What do you perceive as helpful versus troublesome? ■ What resources have been useful, difficult to obtain, or “are still on the back-burner”? Try to differentiate among • People to assist you • Things to assist you • Environmental resources to aid in your progress or with your competing roles Chapter 12 l Planning Your Future 187

Now you are looking toward the future and moving along the road ahead. Keep learning. Keep positive and focused despite any negative influences or colleagues. However, when you enter a new situation, you may return to the novice state. Keep moving, growing, and refining practice with clients. In Benner’s (1984) classic work she demonstrated that nurses practice first as novices then as advanced beginners but then move to competent and proficient, and hopefully, to expert. Her domains of nursing practice include many roles and functions in nursing practice. Congratulations and good travels in your career, focused on positive outcomes for the clients of professional nurses.

KEY POINTS • Quality is simply a characteristic but in the context of a profession or

•

•

• •

• • •

• •

• •

service, it adds value and is forward looking to provide a measure of excellence in a service or a product. Quality improvement is the goal of the professionals for making improvements in services or care based on efficacy and demonstrated client outcomes. Continuous quality improvement is an active evaluation process focused on making changes based on data of efficacy and best practices to meet measurable outcomes and the values for excellence by consumers and providers in the system. Leadership involves action, creativity, motivation, and visioning, as viewing the possibilities and motivating others to make things happen. Management involves the coordination of resources to achieve organizational outcomes and requires effective critical thinking, problemsolving, and decision making. Collaboration involves actively working together to meet some identified goal, such as the client’s treatment goals. Collegiality is sharing responsibility and authority to achieve a goal or prescribed outcome. As a provider of care, the nurse actively implements the nursing process to address client needs. As a manager of care, the nurse coordinates resources and directs a specific group to meet the desired outcomes for the client and the organization through thoughtful and careful planning, direction, monitoring, recognition, development, and representation. Client advocacy is focusing on the needs, safety, and best interests of the client or client group. The ANA (2004) Scope and Standards of Nursing Practice specifies nine standards for professional performance for the registered nurse that are both an expectation and a professional responsibility in daily practice and throughout the career. A challenge is an invitation, in this case, an invitation to envision your future and the options and opportunities ahead. Ongoing learning means critically analyzing and reflecting on a situation and applying the positive aspect, based on the data, to a future situation.



1. Compare your reflections on your knowledge, skills, and abilities with those of a classmate. Practice this discussion as one of the professional standards of performance evaluation. 2. Observe for components of collegiality and collaboration in your work setting. What behaviors are effective in promoting a healthy work environment and effective care for clients? 3. Covey (2004) describes the following first three habits of highly effective people as a “private victory”: • Being proactive • Beginning with the end in mind • Putting first things first

Identify how you have been working on these three habits during this course. Be prepared to discuss your examples in a class discussion to be scheduled by your instructor. 4. Evaluate changes in your transition plan over the past weeks. What do you think influenced the changes? 5. Propose what you will be doing in 5 years from now and then 10 years from now. Describe yourself and your professional practice. Contrast your envisioned proposed changes from your present practice.

Go to the Intranet site to complete the interactive exercises provided for this chapter.

REFERENCES American Association of Critical Care Nurses. (2005). AACN’s standards for establishing and sustaining healthy work environments: A journey to excellence. Retrieved March 3, 2008, from http://www.aacn.org/aacn/pubpolcy.nsf/Files/ HWEStandards/$file/HWEStandards.pdf American Nurses Association. (2004). Nursing: Scope and standards of practice (Publication No. 03SSNP). Washington, DC: American Nurses Publishing. American Nurses Credentialing Center (ANCC). (2008). What is the Magnet recognition program. Retrieved March 8, 2008 from, http://www.nursecredentialing.org/ magnet/resources/journey.html Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, Ca: Addison-Wesley. Buckingham, M. (2005). The one thing you need to know . . . about great managing, great leading, and sustaining individual success. New York: Free Press. Covey, S. R. (2004). The seven habits of highly effective people: Restoring the character ethic. New York: Free Press. Dunefsky, F. (2008). Quality health care. In R. Kearney-Nunnery (Ed.), Advancing your career: Concepts of professional nursing (4th ed., pp. 315–333). Philadelphia: F.A. Davis. Greiner, A. C., & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: Institute of Medicine. Mezirow, J. (2000). Learning to think like an adult: Core concepts of transformation theory. In J. Mezirow and Associates, Learning as transformation: Critical perspectives on a theory in progress (pp. 3–33). San Francisco: Jossey-Bass. Page, A. (Ed.). (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press.

BIBLIOGRAPHY American Nurses Association (ANA). (2005). Principles for delegation. Retrieved March 3, 2008, from http://www.nursingworld.org/MainMenuCategories/ HealthcareandPolicyIssues/Reports/ANAPrinciples/PrinciplesofDelegation.aspx


Bridges, W. (2003). Managing transitions: Making the most of change (2nd ed.). Cambridge, MA: DaCapo Press. Deming, W. E. (1986). Out of crisis. Cambridge, MA: Massachusetts Institute of Technology. Juran, J. M. (1988). Juran on planning for quality. New York: Free Press. Koerner, J., & Huber, D. (2006). Communication, persuasion, and negotiation. In D. Huber, Leadership and management in nursing (3rd ed.). Philadelphia: Saunders. Marquis, B. L., & Huston, C. J. (2006). Leadership roles and management functions in nursing: Theory and application (5th ed.). Philadelphia: Lippincott Williams & Wilkins. National Council of State Boards of Nursing. (2006). Joint statement on delegation: American Nurses Association (ANA) and the National Council of State Boards of Nursing. Retrieved March 3, 2008, from https://www.ncsbn.org/ Joint_statement.pdf Sullivan, E. J., & Decker, P. J. (2005). Effective leadership & management in nursing (6th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.

ONLINE RESOURCES American Nurses Association: http://nursingworld.org American Association of Critical Care Nurses: http://www.aacn.org Institute of Medicine: http://www.iom.edu Joint Commission for Accreditation of Healthcare Organizations: http://www.jcaho.org Magnet Recognition Program: http://www.nursecredentialing.org/Magnet.aspx National Council of State Boards of Nursing: http://www.ncsbn.org


APPENDIX A

Dosage and Solution Review and Resources major concern for patient safety involves medication administration. This appendix is to assist in your review of dosage and solutions calculations and a review of recent safety considerations. Demonstration of mastery in calculation of dosages and solutions is an important component in nursing. In your LPN practice, calculation of dosages may have been part of your routine or may have been replaced by unit dose and bar coding. However, your nursing program may require demonstration of mastery in calculations and drug safety. Review the following information and the associated Web sites provided for this content. Different methods of calculation may be used based on preference. However, accuracy is critical. Rounding may also be a consideration. For the purposes of the following practice problems, round only to the second decimal place. In addition, pay particular attention to the recommendations in the Official JCAHO (2007) Do Not Use List, especially

A

■ ■ ■ ■ ■

Do Not abbreviate, write unit or International Unit, daily, or every other day Do not abbreviate drug names that can be misinterpreted Use leading zero with a decimal, as 0.5 mg Do not use a trailing zero with medications, for example use 5 mg Use mL (milliliters) rather than cc

Here is the link again if you wish to refer to the requirements: http://www.jointcommission.org/PatientSafety/DoNotUseList/ On the following pages are sample practice calculations and additional safety information. You may also wish to consult with some of the references listed in the bibliography for additional information and practice opportunities. Have access to current drug resources, those in print and electronic. You may use different calculation methods, depending on preference and accuracy. Two of the popular methods are dimensional analysis (Box A–1) and ratio and proportion (Box A–2). For additional assistance, access the online consult on dosage calculations or a textbook or handbook. Appendix A l Dosage and Solution Review and Resources 191

BOX A–1

Example of Calculation Using Dimensional Analysis

Desired amount ⫽ conversion formula ⫻ factors to convert Examples: Give 750 mg. You have available 250 mg/tablet (your conversion formula) ? tablets ⫽

1 tablet ⫻ 750 mg.

Answer: 3 tablets

250 mg

Give 1.25 grains of aspirin ? tablets ⫽

BOX A–2

1 tablet 62 mg ⫻ ⫻ 1.25 grains Answer: 1 tablet 81 mg 1 grain

Example of Calculation Using Ratio and Proportion

Available dose: Available amount ⫽ Desired Dose: Desired Amount or Available dose Desired Dose ⫽ Available amount Desired Amount Example: Give 750 mg. You have available 250 mg/tablet. 250 mg 750 mg ⫽ 1 tablet X tablets 250 X ⫽ 750 X ⫽ 3 tablets (750 mg)

Abbreviations Recall the need for the use of acceptable and clear abbreviations. What is not correct in each of the following orders? 1. Give 30 U Regular Insulin on a sliding scale 2. Zithromax Z-Pac 250 mg po qd 3. Furosemide 20 mg tablet QOD 4. MS 10 mg IM PRN pain 5. Darvocet-N 50.0 mg q 4 h prn pain

Conversions Periodically review the measurement systems and conversion factors and have a resource readily available in the client care situation. Many dosages will be reflected using the Metric System. Basic Metric System conversions to recall include 1 GM ⫽ 1000 mg 1000 mg ⫽ 1 mcg (microgram) 1 L = 1000 mL

192 Appendix A l Dosage and Solution Review and Resources

We do still use the apothecary system and often these will be needed in discharge planning, especially oral suspensions for children and the elderly. Basic conversions to the metric system include: 1 grain ⫽ 60–62 mg 1 ounce ⫽ 30 mL 1 teaspoon (tsp) ⫽ 5 mL 2 tsp ⫽ 10 mL 3 tsp ⫽ 15 mL ⫽ 1 Tablespoon (TBSP) Try these dosage calculations. The answer key is at the end of the Appendix. 1. Ordered: Supplied: Question: 2. Ordered:

Atropine 0.2 mg IM Stat Atropine 400 mcg/1 mL How much would you administer? Morphine sulfate gr 1⁄4 IM

Supplied: Question: 3. Ordered: Available: Question:

Morphine sulfate 15 mg/mL How much would you administer? Amoxil 1 tsp Amoxil 125 mg/5 mL How much would you administer?

4. Ordered: Aspirin 5 grains Available: Aspirin 325 mg tablets Question: How much would you administer? 5. Ordered: Aspirin 5 grains Available: Aspirin 81 mg tablets Question: How much would you administer?

Oral Dosages 1. Ordered: Supplied: Question: 2. Ordered: Supplied: Question: 3. Ordered: Supplied: Question: 4. Ordered: Supplied: Question:

Dilantin 200 mg TID po Dilantin 100 mg capsules How much would you administer? Paxil 15 mg po daily Paxil 10 mg/5 mL suspension How much would you administer? Colytrol 0.06 mg q 4 h po PRN Colytrol 0.125 mg/mL How much would you administer? Benadryl 50 mg q 6 h PRN pruritus Benadryl 25 mg caplets How much would you administer?

Appendix A l Dosage and Solution Review and Resources 193

5. Ordered: Ceclor 200 mg po q 8 hours Supplied: Ceclor 250 mg/5 mL Question: How much would you administer?

Parenteral Dosages (IM) 1. Ordered: Supplied: Question: 2. Ordered: Supplied: Question: 3. Ordered: Supplied: Question: 4. Ordered: Supplied: Question: 5. Ordered: Supplied:

Compazine 3 mg IM q 3–4 hours PRN nausea Compazine 5 mg/mL vial How much would you administer? Ampicillin 350 mg IM q 6 h times 3 doses then discontinue Ampicillin 500 mg/1 mL vial How much would you administer? Morphine sulfate 8 mg IM Stat Morphine sulfate 15 mg/1 mL vial How much would you administer? Atropine 0.25 mg IM Stat Atropine 0.4 mg/mL vial How much would you administer? Rocephin 600 mg IM q 12 hours Rocephin 1 GM vial with 3.6 mL SW added resulting in 250 mg/mL

Intravenous Medications (IV) The following calculation problems are provided for practice. Many IV medications will be prepared under special safety controls by the pharmacy and come to the unit as an admixture. These examples are provided to demonstrate the considerations with dosage, reconstitution, and administration. 1. Ordered: Levaquin 400 mg in 100 mL D5W IV daily over 60 minutes Supplied: 250 mg per 10 mL in prediluted vials Question: How much would you give and how? 2. Ordered: Oxymorphone HCL 0.5 mg every 4 hours PRN pain IV over 2 minutes Supplied: 1 mg per 1 mL ampule Question: How much would you give and how? 3. Ordered: Lorazepam 1.5 mg STAT in 30 mL D5W Supplied: 2 mg per 1 mL vials Question: How much would you give and how? 4. Ordered: Capreomycin 750 mg IV over 60 minutes in 100 mL NS Supplied: 1 GM vials to be reconstituted with 2 mL SW Question: How much would you give and how? 5. Ordered: Albecet 80 mg in 100 mL D5W over 30 minutes Supplied: 100 mg vials in 20 mL in prediluted vials Question: How much would you give and how? 194 Appendix A l Dosage and Solution Review and Resources

What Is Not Right? Although the advanced practice nurse (APRN) may have prescriptive authority, administration of medications by the registered nurse (RN) is a dependent activity. The order is prescribed by a licensed practitioner but the registered nurse is responsible (6th right) for administration according to the five rights and also ensuring the right documentation on the response by the client to the medication. However, the RN should recognize whether the dose is a safe one. Many medications are prescribed in accordance to a range, as in mg per kilogram of body weight (mg/kg), especially in the case of parental medications. Let’s see whether you can do the math here. Situation: The Pfizer (2006) Pharmaceutical Company has provided professional literature on the drug Amphocin® that warns of the case of cardio-respiratory arrest if the daily dose of 1.5 mg/kg is exceeded (p. 2). Suppose you have two clients who have very severe fungal infections and were prescribed this medication. Decide whether the dosage is within the safe limits for the following two clients. 1. Ms. Holmes who weighs 130 pounds has been prescribed 90 mg IV daily. 2. Mr. Jones weighs 215 pounds and has been prescribed 100 mg IV daily. Are these dosages in the range of safety?

Safety Considerations In addition to the JCAHO (2007) Official Do Not Use List, safety considerations continue to be a major concern with the administration of medications. The electronic medication administration record has helped, but it is not available in all places. Nursing judgment must always be present both in terms of administration and response to medications. For administration, continue to focus on the five rights that are required of the individual nurse administering medications to clients: The RIGHT ■ ■ ■ ■ ■

Medication Dose Route Time Client

However, the “right” actions do not stop with these given reminders. We also are required to use nursing judgment in evaluating and documenting the client’s response. This is the sixth right, the right documentation. In addition, given the research on errors, we need to limit distractions during preparation and promote safety. Interesting, Cook (2007) has also identified nurses’ rights for safety as, the right to ■ ■ ■ ■ ■ ■

A complete and clearly written order Have the correct route and dose dispensed from the pharmacy Have access to current drug information Have organizational policies on medication administration Administer medications safely and to identify problems in the system Stop, think, and be vigilant when administering medications (Cook, 2007, pp. 1–4)

These professional and organizational responsibilities are supported by the Institute for Safe Medication Practice (2008) in addition to the five rights for the individual in their support of a culture of safety in the healthcare environment. Safe administration and Appendix A l Dosage and Solution Review and Resources 195

response to medications must also be including in any client teaching and discharge planning to promote safe medication practices in the home and in the community.

REFERENCES Cook, M. C. (2007). Nurses’ six rights for safe medication administration. Massachusetts Nurses Association. Retrieved on February 25, 2008, from http://www.massnurses.org/nurse_practice/sixrights.htm Institute for Safe Medication Practices. (2008). The five rights: A destination without a map. Retrieved February 25, 2008, from http://www.ismp.org/ newsletters/acutecare/articles/20070125.asp Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). (2007). The official “Do Not Use” List. Retrieved February 25, 2008, from http://www.jointcommission.org/PatientSafety/DoNotUseList/ Pfizer. (2006). Amphocin®: Amphotericin B for injection, USP. Retrieved March 6, 2008, from http://media.pfizer.com/files/products/uspi_amphocin.pdf

BIBLIOGRAPHY Aspden, P., Wolcott, J., Bootman, L., & Cronenwett, L. R. (Eds.). (2006). Preventing medication errors. Washington, DC: National Academies Press. Boundy, P. A., & Stockert, J. F. (2008). Calculation of medication dosages: Practical strategies to ensure safety and accuracy. Philadelphia: Lippincott Williams & Wilkins. DeCastillo, S. L. M., & Werner-McCullough, M. (2007). Calculating drug dosages: An interactive approach to learning nursing math (2nd ed.). Philadelphia: F.A. Davis. Gahart, B. L., & Nazareno, A. R. (2008). Intravenous medications: A handbook for nurses and health professionals (24th ed.). St. Louis: Mosby Elsevier. Mulholland, J. L. (2007). The nurse, the math, the meds: Drug calculations using dimensional analysis. St. Louis: Mosby Elsevier. Ogden, S. J. (2007). Calculation of drug dosages (8th ed.). St. Louis: Mosby Elsevier. Olsen, J. L., Giangrasso, A. P., Shrimpton, D., & Dillon, P. (2007). Medical dosage calculations (9th ed.). Upper Saddle River, NJ: Prentice Hall. Pickar, G., & Abernethy, A. P. (2007). Dosage calculations (8th ed.). Cliffton Park, NY: Cengage Delmar Learning.

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Answer Key JCAHO at http://www.jointcommission.org Med Calc for Nurses http://msumedcalc.com/ MedlinePlus http://www.nlm.nih.gov/medlineplus/ druginformation.html WebMD http://www.webmd.com/drugs/index-drugs.aspx United States Pharmacopia http://www.usp.org

ABBREVIATIONS 1. Do not use “U”—units should be written 2. Do not use “qd”—daily should be written 3. Do not use “QOD”—spell out every other day 4. Do not use MS—spell out Morphine sulfate because it can be confused with other medications 5. Do not use a trailing zero after 50

196 Appendix A l Dosage and Solution Review and Resources

CONVERSIONS 1. Atropine 0.5 mL (0.2 mg) IM Stat 2. Morphine sulfate 1 mL (gr 1/4) IM 3. Amoxil 1 tsp. (125 mg in 5 mL) 4. Aspirin 1 (325 mg) tablet 5. Aspirin 4 (81) tablet ORAL DOSAGES 1. Dilantin 2 capsules orally TID 2. Paxil 7.5 mL po daily 3. Colytrol 0.48 mL q 4 h po PRN 4. Benadryl 2 caplets q 6 h PRN pruritus 5. Ceclor 4 mL po q 8 hours PARENTERAL DOSAGES (IM) 1. Compazine 0.6 mL IM q 3–4 hours PRN nausea 2. Ampicillin 0.7 mL IM q 6 h times 3 then discontinue 3. Morphine sulfate 0.53 mL IM Stat 4. Atropine 0.625 mL IM Stat 5. Rocephin 2.4 mL IM q 12 hours INTRAVENOUS MEDICATIONS (IV) 1. Levaquin 400 mg as total of 16 mL drawn up in two separate syringes and added to 100 mL D5W and infused over 60 minutes. 2. For relief of pain as measured on the pain scale, Oxymorphone hydrochloride (0.5 mg) 0.5 mL slow IV push over 2 minutes every 4 hours, as needed 3. 0.75 mL Lorazepam (1.5 mg) IV in 30 mL D5W given immediately 4. Capreomycin 1.5 mL (750 mg) IV over 60 minutes in 100 mL NS after 1 gm vial reconstituted with 2 mL SW 5. Albecet 16 mL (80 mg) in 100 mL D5W over 30 minutes WHAT IS NOT RIGHT? 1. Ms. Holmes—this is an unsafe overdose. 2. Mr. Jones—this is a high dose but within the safety limit, depending on his response to treatment.

Appendix A l Dosage and Solution Review and Resources 197

APPENDIX B

Nursing Diagnosis complete listing of all NANDA International (2009) Nursing Diagnoses is listed here according to Gordon’s (2006) 11 Functional Health Patterns.

A

Activity/Exercise Activity Intolerance Activity Intolerance, Risk for Bleeding, Risk for Cardiac Output, Decreased Airway Clearance, Ineffective Aspiration, Risk for Breathing Pattern, Ineffective Gas Exchange, Impaired Ventilation, Impaired Spontaneous Ventilatory Weaning Response, Dysfunctional Disuse Syndrome, Risk for Diversional Activity, Deficient Fatigue Impaired Walking Lifestyle, Sedentary Mobility, Impaired Bed Mobility, Impaired Physical Mobility, Impaired Wheelchair Peripheral Neurovascular Dysfunction Risk For Ineffective Gastrointestinal Perfusion Risk For Ineffective Renal Perfusion Risk For Shock Self-Care Deficit, Bathing Self-Care Deficit, Dressing Self-Care Deficit, Feeding Self-Care Deficit, Toileting 198 Appendix B l Nursing Diagnosis

Self-Care, Readiness for Enhanced Tissue Perfusion, Ineffective Peripheral Tissue Perfusion, Risk for Decreased Cardiac Tissue Perfusion, Risk for Ineffective Cerebral Transfer Ability, Impaired Ventilation, Impaired Spontaneous Ventilary Weaning Response, Dysfunctional Walking, Impaired

Sleep/Rest Insomnia Sleep, Readiness for Enhanced Sleep Deprivation Sleep Pattern, Disturbed

Health Perception/Health Management Body Temperature, Risk for imbalanced Contamination Contaminatiiion, Risk for Delayed Surgical Recovery Disturbed Energy Field Health Maintenance, Ineffective Ineffective Family Therapeutic Regimen Management Impaired Home Maintenance Latex Allergy Response Latex Allergy Response, Risk for Protection, Ineffective Readiness for Enhanced Immunization Status Readiness for Enhanced Nutrition Risk for Infection Risk for Aspiration Risk for Falls Risk for Injury Risk For Injury, Suffocation Risk For Injury, Poisoning Risk For Injury, Trauma Risk for Perioperative-Positioning Injury Risk for Sudden Infant Death Syndrome Appendix B l Nursing Diagnosis 199

Self Health Management, Ineffective Self Health Management, Readiness for Enhanced Self-Mutilation Self-Mutilation, Risk for Self Neglect Skin Integrity, Impaired Skin Integrity, Risk for impaired Suicide, Risk for Trauma, Risk for Vascular Viloence, Other-directed Violence, Self-directed

Self Perception and Self Concept Behavior, Risk-Prone Health Body Image, Disturbed Conflict, Decisional Coping, Defensive Coping, Ineffective Coping, Readiness For Enhanced Denial, Ineffective Dignity, Risk for Compromised Human Distress, Moral Hope, Readiness for Enhanced Hopelessness Loneliness, Risk for Personal Identity, Disturbed Power, Readiness for Enhanced Powerlessness Powerlessness, Risk for Self-Concept, Readiness for Enhanced Self-Esteem, Chronic Low Self-Esteem, Situational Low Self-Esteem, Risk for Situational Low

Cognitive/Perceptual Activity Planning, Ineffective Comfort, Impaired Comfort, Readiness for Enhanced

200 Appendix B l Nursing Diagnosis

Communication, Impaired Verbal Communication, Readiness for Enhanced Confusion, Acute Confusion, Risk for Acute Confusion, Chronic Decision Making, Readiness for Enhanced Environmental Interpretation Syndrome, Impaired Knowledge, Deficient Knowledge, Readiness for Enhanced Memory, Impaired Nausea Neglect, Unilateral Pain, Acute Pain, Chronic Sensory Perception, Disturbed (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory) Social Isolation Wandering

Elimination Bowel Incontinence Constipation Constipation, Perceived Constipation, Risk for Diarrhea Dysfuntional Gastrointestinal Mobility Dysfuntional Gastrointestinal Mobility, Risk for Impaired Gas Exchange Urinary Elimination, Impaired Urinary Elimination, Readiness for Enhanced Urinary Incontinence, Functional Urinary Incontinence, Overflow Urinary Incontinence, Reflex Urinary Incontinence, Risk for Urge Urinary Incontinence, Stress Urinary Incontinence, Urge Urinary Retention

Appendix B l Nursing Diagnosis 201

Nutrition/Metabolic Delayed Development, Risk for Delayed Growth and Development Disproportionate Growth, Risk for Dentition, impaired Electrolyte Imbalance, Risk for Failure to Thrive, Adult Fluid Balance, Readiness for Enhanced Fluid Volume, Deficient Fluid Volume, Excess Fluid Volume, Risk for Deficient Fluid Volume, Risk for Imbalanced Hyperthermia Hypothermia Imbalanced Nutrition: Less Than Body Requirements Imbalanced Nutrition: More Than Body Requirements Imbalanced Nutrition: More Than Body Requirements, Risk for Ineffective Infant Feeding Pattern Impaired Swallowing Liver Function, Risk for Impaired Nausea Neonatal Jaundice Nutrition, Readiness for Enhanced Oral Mucous Membrane, Impaired Risk for Unstable Blood Glucose Level Thermoregulation, Ineffective Tissue Integrity, Impaired

Roles Relationship Breastfeeding, Effective Breastfeeding, Ineffective Breastfeeding, Interrupted Caregiver Role Strain Caregiver Role Strain, Risk for Dysfunctional Family Processes Family Processes, Interrupted Family Processes, Readiness for Enhanced Impaired Parenting 202 Appendix B l Nursing Diagnosis

Impaired Parenting, Risk for Impaired Social Interaction Ineffective Role Performance Parental Role Conflict Parenting, Readiness for Enhanced Readiness for Enhanced Relationship Risk for Impaired Attachment

Sexuality Readiness for Enhanced Childbearing Process Risk for Disturbed Maternal/Fetal Dyad Sexual Dysfunction Sexuality Pattern, Ineffective

Coping/Stress Tolerance Anxiety Anxiety, Death Autonomic Dysreflexia Autonomic Dysreflexia, Risk for Coping, Compromised Family Coping, Defensive Coping, Disabled Family Coping, Ineffective Coping, Ineffective Community Coping, Readiness for Enhanced Coping, Readiness for Enhanced Community Coping, Readiness for Enhanced Family Denial, Ineffective Fear Grieving Grieving, Complicated Grieving, Risk for Complicated Infant Behavior, Disorganized Infant Behavior, Readiness for Enhanced Organized Infant Behavior, Risk for Disorganized Intracranial Adaptive Capacity, Decreased Post-Trauma Syndrome Post-Trauma Syndrome, Risk for Rape-Trauma Syndrome Appendix B l Nursing Diagnosis 203

Relocation Stress Syndrome Relocation Stress Syndrome, Risk for Resilience, Impaired Individual Resilience, Readiness for Enhanced Resilience, Risk for Compromised Risk-Prone Health Behavior Sorrow, Chronic Stress Overload

Value/Belief Noncompliance Religiosity, Impaired Religiosity, Readiness for Enhanced Religiosity, Risk for Impaired Spiritual Distress Spiritual Distress, Risk for Spiritual Well-Being, Readiness for Enhanced

REFERENCES Gordon, M. (2006). Manual of nursing diagnosis (11th ed.). Boston: Jones & Bartlett. Herdman, T. H. (Ed.). (2009). NANDA international nursing diagnoses: Definitions and classification, 2009-2011. West Sussex, United Kingdom: John Wiley & Sons.

204 Appendix B l Nursing Diagnosis

APPENDIX C

Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) Systems Nursing Interventions Classification (NIC) Abuse Protection Support Child Domestic Partner Elder Religious Acid-Base Management Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis Acid-Base Monitoring Active Listening Activity Therapy Acupressure

Admission Care Airway Insertion and Stabilization Airway Management Airway Suctioning Allergy Management Amnioinfusion Amputation Care Analgesic Administration Intraspinal Anaphylaxis Management Anesthesia Administration Anger Control Assistance Appendix C l NIC and NOC Systems 205

Animal-Assisted Therapy Anticipatory Guidance Anxiety Reduction Area Restriction Aromatherapy Art Therapy Artificial Airway Management Aspiration Precautions Assertiveness Training Asthma Management Attachment Promotion Autogenic Training Autotransfusion Bathing Bed Rest Care Bedside Laboratory Testing Behavior Management Overactivity/Inattention Self-Harm Sexual Behavior Modification Social Skills Bibliotherapy Biofeedback Bioterrorism Preparedness Birthing Bladder Irrigation Bleeding Precautions Bleeding Reduction Antepartum Uterus Gastrointestinal Nasal Postpartum Uterus Wound Blood Products Administration Body Image Enhancement Body Mechanics Promotion Bottle Feeding Bowel Incontinence Care Encopresis Bowel Irrigation 206 Appendix C l NIC and NOC Systems

Bowel Management Bowel Training Breast Examination Breastfeeding Assistance Calming Technique Capillary Blood Sample Cardiac Care Acute Rehabilitative Cardiac Precautions Caregiver Support Case Management Cast Care Maintenance Wet Cerebral Edema Management Cerebral Perfusion Promotion Cesarean Section Care Chemical Restraint Chemotherapy Management Chest Physiotherapy Childbirth Preparation Circulatory Care Arterial Insufficiency Mechanical Assist Device Venous Insufficiency Circulatory Precautions Circumcision Care Code Management Cognitive Restructuring Cognitive Stimulation Communicable Disease Management Communication Enhancement Hearing Deficit Speech Deficit Vision Deficit Community Disaster Preparedness Community Health Development Complex Relationship Building Conflict Mediation Constipation/Impaction Management

Consultation Contact Lens Care Controlled Substance Checking Coping Enhancement Cost Containment Cough Enhancement Counseling Crisis Intervention Critical Path Development Culture Brokerage Cutaneous Stimulation Decision-Making Support Defibrillator Management External Internal Delegation Delirium Management Delusion Management Dementia Management Bathing Deposition/Testimony Developmental Care Developmental Enhancement Adolescent Child Dialysis Access Maintenance Diarrhea Management Diet Staging Discharge Planning Distraction Documentation Dressing Dying Care Dysreflexia Management Dysrhythemia Management Ear Care Eating Disorders Management Electroconvulsive Therapy (ECT) Management

Electrolyte Management Hypercalcemia Hyperkalemia Hypermagnesemia Hypernatremia Hyperphosphatemia Electrolyte Monitoring Electronic Fetal Monitoring Antepartum Intrapartum Elopement Precautions Embolus Care Peripheral Pulmonary Embolus Precautions Emergency Care Emergency Cart Checking Emotional Support Endotracheal Extubation Energy Management Enteral Tube Feeding Environmental Management Attachment Process Comfort Community Home Preparation Safety Violence Prevention Worker Safety Environmental Risk Protection Examination Assistance Exercise Promotion Strength Training Stretching Exercise Therapy Ambulation Balance Joint Mobility Muscle Control Eye Care Fall Prevention Family Integrity Promotion Childbearing Family Appendix C l NIC and NOC Systems 207

Family Involvement Promotion Family Mobilization Family Planning Contraception Infertility Unplanned Pregnancy Family Presence Facilitation Family Process Maintenance Family Support Family Therapy Feeding Fertility Preservation Fever Treatment Financial Resource Assistance Fire-Setting Precautions First Aid Fiscal Resource Management Flatulence Reduction Fluid/Electrolyte Management Fluid Management Fluid Monitoring Fluid Resuscitation Foot Care Forensic Data Collection Forgiveness Facilitation Gastrointestinal Intubation Genetic Counseling Grief Work Facilitation Perinatal Death Guided Imagery Guilt Work Facilitation Hair Care Hallucination Management Health Care Information Exchange Health Education Health Literacy Enhancement Health Policy Monitoring Health Screening Health System Guidance 208 Appendix C l NIC and NOC Systems

Heat/Cold Application Heat Exposure Treatment Hemodialysis Therapy Hemodynamic Regulation Hemofiitration Therapy Hemorrhage Control High-Risk Pregnancy Care Home Maintenance Assistance Hope Inspiration Hormone Replacement Therapy Humor Hyperglycemia Management Hypervolemia Management Hypnosis Hypoglycemia Management Hypothermia Induction Hypothermia Treatment Hypovolemia Management Immunization/Vaccination Management Impulse Control Training Incident Reporting Incision Site Care Infant Care Infection Control Intraoperative Infection Protection Insurance Authorization Intracranial Pressure (ICP) Monitoring Intrapartal Care High-Risk Delivery Intravenous (IV) Insertion Intravenous (IV) Therapy Invasive Hemodynamic Monitoring Journaling Kangaroo Care Labor Induction Labor Suppression Laboratory Data Interpretation

Lactation Counseling Lactation Suppression Laser Precautions Latex Precautions Learning Facilitation Learning Readiness Enhancement Leech Therapy Limit Setting Lower Extremity Monitoring Malignant Hyperthermia Precautions Massage Mechanical Ventilation Management Invasive Noninvasive Mechanical Ventilator Weaning Medication Administration Ear Enteral Eye Inhalation Interpleural Intradermal Intramuscular Intraosseous Intraspinal Intravenous Nasal Oral Rectal Skin Subcutaneous Vaginal Ventricular Reservoir Medication Management Medication Prescribing Medication Reconciliation Medication Facilitation Memory Training Milieu Therapy Mood Management Multidisciplinary Care Conference

Music Therapy Mutual Goal Setting Nail Care Nausea Management Neurologic Monitoring Newborn Care Newborn Monitoring Nonnutritive sucking Normalization Promotion Nutrition Management Nutrition Therapy Nutritional Counseling Nutritional Monitoring Oral Health Maintenance Oral Health Promotion Oral Health Restoration Order Transcription Organ Procurement Ostomy Care Oxygen Therapy Pacemaker Management Temporary Permanent Pain Management Parent Education Adolescent Childrearing Family Infant Parenting Promotion Pass Facilitation Patient Contracting Patient Controlled Analgesia (PCA) Assistance Patient Rights Assistance Peer Review Pelvic Muscle Exercise Perineal Care Peripheral Sensation Management

Appendix C l NIC and NOC Systems 209

Peripherally Inserted Central (PIC) Catheter Care Peritoneal Dialysis Therapy Pessary Management Phlebotomy Arterial Blood Sample Blood Unit Acquisition Cannulated Vessel Venous Blood Sample Phototherapy Mood/Sleep Regulation Neonate Physical Restraint Physician Support Pneumatic Tourniquet Precautions Positioning Intraoperative Neurologic Wheelchair Postanesthesia Care Postmortem Care Postpartal Care Preceptor Employee Student Preconception Counseling Pregnancy Termination Care Premenstrual Syndrome (PMS) Management Prenatal Care Preoperative Coordination Preparatory Sensory Information Presence Pressure Management Pressure Ulcer Care Pressure Ulcer Prevention Product Evaluation Program Development Progressive Muscle Relaxation Prompted Voiding Prosthesis Care 210 Appendix C l NIC and NOC Systems

Pruritus Management Quality Monitoring Radiation Therapy Management Rape-Trauma Treatment Reality Orientation Recreation Therapy Rectal Prolapse Management Referral Relaxation Therapy Religious Addition Prevention Religious Ritual Enhancement Relocation Stress Reduction Reminiscence Therapy Reproductive Technology Management Research Data Collection Resiliency Promotion Respiratory Monitoring Respite Care Resuscitation Fetus Neonate Risk Identification Childbearing Family Genetic Role Enhancement Seclusion Security Enhancement Sedation Management Seizure Management Seizure Precautions Self-Awareness Enhancement Self-Care Assistance Bathing/Hygiene Dressing/Grooming Feeding IADL Toileting Transfer Self-Efficacy Enhancement Self-Esteem Enhancement

Self-Hypnosis Facilitation Self-Modification Assistance Self-Responsibility Facilitation Sexual Counseling Shift Report Shock Management Cardiac Vasogenic Volume Shock Prevention Sibling Support Skin Care Donor Site Graft Site Topical Treatments Skin Surveillance Sleep Enhancement Smoking Cessation Assistance Social Marketing Socialization Enhancement Specimen Management Spiritual Growth Facilitation Spiritual Support Splinting Sports Injury Prevention: Youth Staff Development Staff Supervision Subarachnoid Hemorrhage Precautions Substance Use Prevention Substance Use Treatment Alcohol Withdrawal Drug Withdrawal Overdose Suicide Prevention Supply Management Support Group Support System Enhancement Surgical Assistance Surgical Precautions Surgical Preparation

Surveillance Community Late Pregnancy Remote Electronic Safety Sustenance Support Suturing Swallowing Therapy Teaching Disease Process Foot Care Group Individual Infant Nutrition 0-3 Months Infant Nutrition 4-6 Months Infant Nutrition 7-9 Months Infant Nutrition 10-12 Months Infant Safety 0-3 Months Infant Safety 4-6 Months Infant Safety 7-9 Months Infant Safety 10-12 Months Infant Stimulation 0-4 Months Infant Stimulation 5-8 Months Infant Stimulation 9-12 Months Preoperative Prescribed Activity/Exercise Prescribed Diet Prescribed Medication Procedure/Treatment Psychomotor Skill Safe Sex Sexuality Toddler Nutrition 13-18 Months Toddler Nutrition 19-24 Months Toddler Nutrition 25-36 Months Toddler Safety 13-18 Months Toddler Safety 19-24 Months Toddler Safety 25-36 Months Toilet Training Technology Management Telephone Consultation Telephone Follow-Up Temperature Regulation Intraoperative Therapeutic Play


Therapeutic Touch Therapy Group Thrombolytic Therapy Management Total Parental Nutrition (TPN) Administration Touch Traction/Immobilization Care Transcutaneous Electrical Nerve Stimulation (TENS) Transfer Transport Interfacility Intrafacility Trauma Therapy: Child Triage Disaster Emergency Center Telephone Truth Telling Tube Care Chest Gastrointestinal Umbilical Line Urinary Ventriculostomy/Lumbar Drain Ultrasonography: Limited Obstetric

Unilateral Neglect Management Urinary Bladder Training Urinary Catheterization Intermittent Urinary Elimination Management Urinary Habit Training Urinary Incontinence Care Enuresis Urinary Retention Care Validation Therapy Values Clarification Vehicle Safety Promotion Venous Access Device (VAD) Maintenance Ventilation Assistance Visitation Facilitation Vital Signs Monitoring Vomiting Management Weight Gain Assistance Weight Management Weight Reduction Assistance Wound Care Burns Closed Drainage Wound Irrigation

NURSING SPECIALTY CORE INTERVENTIONS AREAS Additions Nursing Ambulatory Nursing Anesthesia Nursing Chemical Dependency Nursing Child/Adolescent Psychiatric Nursing College Health Nursing Community Public Health Nursing Correctional Nursing Critical Care Nursing

212 Appendix C l NIC and NOC Systems

Dermatology Nursing Developmental Disability Nursing Emergency Nursing End of Lie Care Nursing Flight Nursing Forensic Nursing Gastroenterological Nursing Genetics Nursing Gerontological Nursing Holistic Nursing

Infection Control/Epidemiological Nursing Intravenous Nursing Medical-Surgical Nursing Midwifery Nursing Neonatal Nursing Nephrology Nursing Neuroscience Nursing Obstetric Nursing Occupational Health Nursing Oncology Nursing Ophthalmic Nursing Orthopedic Nursing Otorhinolaryngology & Head/ Neck Nursing

Pain Management Nursing Parish Nursing Pediatric Nursing Pediatric Oncology Nursing Perioperative Nursing Psychiatric/Mental Health Nursing Radiological Nursing Rehabilitation Nursing School Nursing Spinal Cord Injury Nursing Urologic Nursing Vascular Nursing Women’s Health Nursing

Source: Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (Eds.). (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis: Mosby Elsevier. Reprinted with permission.

Nursing Outcomes Classification (NOC) Abuse Cessation Abuse Protection Abuse Recovery Emotional Financial Physical Sexual Abusive Behavior: Self-Restraint Acceptance: Health Status Activity Tolerance Acute Confusion Level Adaptation to Physical Disability Adherence Behavior Healthy Diet Aggression Self-Control Agitation Level Alcohol Abuse Cessation Behavior Allergic Response Localized Systemic Ambulation Wheelchair

Anxiety Level Anxiety Self-Control Appetite Aspiration Prevention Asthma Self-Management Balance Blood Coagulation Blood Glucose Level Blood Loss Severity Blood Transfusion Reaction Body Image Body Mechanics Performance Body Positioning: Self-Initiated Bone Healing Bowel Continence Bowel Elimination Breast Feeding Establishment Infant Maternal Breastfeeding Maintenance Breastfeeding Weaning Appendix C l NIC and NOC Systems 213

Burn Healing Burn Recovery Cardiac Disease Self-Management Cardiac Pump Effectiveness Cardiopulmonary Status Caregiver Adaptation to Patient Institutionalization Caregiver Emotional Health Caregiver Home Care Readiness Caregiver Lifestyle Disruption Caregiver-Patient Relationship Caregiver Performance Direct Care Indirect Care Caregiver Physical Health Caregiver Role Endurance Caregiver Stressors Caregiver Well-Being Child Adaptation to Hospitalization Child Development 1 Month 2 Months 4 Months 6 Months 12 Months 2 Years 3 Years 4 Years 5 Years Middle Childhood Adolescence Circulation Status Client Satisfaction Access to Care Resources Caring Care Management Communication Continuity of Care Cultural Needs Fulfillment Functional Assistance Pain Management Physical Care Physical Environment 214 Appendix C l NIC and NOC Systems

Protection of Rights Psychological Care Safety Symptom Control Teaching Technical Aspects of Care Cognition Cognitive Orientation Comfort Status Environment Physical Psychospiritual Sociocultural Comfortable Death Communication Expressive Receptive Community Competence Community Disaster Readiness Community Disaster Response Community Health Status Immunity Community Risk Control Chronic Disease Communicable Disease Lead Exposure Violence Community Violence Level Compliance Behavior Prescribed Diet Prescribed Medication Concentration Coordinated Movement Coping Decision-Making Depression Level Depression Self-Control Development Late Adulthood Middle Adulthood Young Adulthood Diabetes Self-Management

Dignified Life Closure Discharge Readiness Independent Living Supported Living Discomfort Level Distorted Thought Self-Control Drug-Abuse Cessation Behavior Electrolyte & Acid/Base Balance Elopement Occurrence Elopement Propensity Risk Endurance Energy Conservation Fall Prevention Behavior Falls Occurrence Family Coping Family Functioning Family Health Status Family Integrity Family Normalization Family Participation in Professional Care Family Resiliency Family Social Climate Family Support During Treatment Fatigue Level Fear Level Child Fear Self-Control Fetal Status Antepartum Intrapartum Fluid Balance Fluid Overload Severity Gastrointestinal Function Grieg Resolution Growth Health Beliefs Perceived Ability to Perform Perceived Control Perceived Resources Perceived Threat

Health Orientation Health Promoting Behavior Health Seeking Behavior Hearing Compensation Behavior Heedfulness of Affected Side Hemodialysis Access Hope Hydration Hyperactivity Level Identity Immobility Consequences Physiological Psycho-Cognitive Immune Hypersensitivity Response Immune Status Immunization Behavior Impulse Self-Control Infection Severity Newborn Information Processing Joint Movement Ankle Elbow Fingers Hip Knee Neck Passive Shoulder Spine Wrist Kidney Function Knowledge Arthritis Management Asthma Management Body Mechanics Breastfeeding Cancer Management Cancer Threat Reduction Cardiac Disease Management Child Physical Safety Conception Prevention Congestive Heart Failure Management Appendix C l NIC and NOC Systems 215

Depression Management Diabetes Management Diet Disease Process Energy Conservation Fall Prevention Fertility Promotion Health Behavior Health Promotion Health Resources Hypertension Management Illness Care Infant Care Infection Management Labor & Delivery Medication Multiple Sclerosis Management Ostomy Care Pain Management Parenting Personal Safety Postpartum Maternal Health Preconception Maternal Health Pregnancy Pregnancy & Postpartum Sexual Functioning Prescribed Activity Preterm Infant Care Sexual Functioning Substance Use Control Treatment Procedure Treatment Regimen Weight Management Leisure Participation Loneliness Severity Maternal Status Antepartum Intrapartum Postpartum Mechanical Ventilation Response: Adult Mechanical Ventilation Weaning Response: Adult Medication Response Memory


Mobility Mood Equilibrium Motivation Multiple Sclerosis: Self-Management Nausea & Vomiting Control Nausea & Vomiting: Disruptive Effects Nausea & Vomiting Severity Neglect Cessation Neglect Recovery Neurological Status Autonomic Central Motor Control Consciousness Cranial Sensory/Motor Function Peripheral Spinal Sensory/Motor Function Newborn Adaptation Nutritional Status Biochemical Measures Energy Food & Fluid Intake Nutrient Intake Oral Hygiene Ostomy Self-Care Pain: Adverse Psychological Response Pain Control Pain: Disruptive Effects Pain Level Parent-Infant Attachment Parenting Adolescent Physical Safety Early/Middle Childhood Physical Safety Infant/Toddler Physical Safety Parenting Performance Parenting: Psychosocial Safety Participation in Health Care Decisions Personal Autonomy Personal Health Status

Personal Resiliency Personal Safety Behavior Personal Well-Being Physical Aging Physical Fitness Physical Injury Severity Physical Maturation Female Male Play Participation Postpartum Maternal Health Behavior Post-Procedure Recovery Prenatal Health Behavior Pre-Procedure Readiness Preterm Infant Organization Psychomotor Energy Psychosocial Adjustment: Life Change Quality of Life Respiratory Status Airway Patency Gas Exchange Ventilation Rest Risk Control Alcohol Use Cancer Cardiovascular Health Drug Use Hearing Impairment Hyperthermia Hypothermia Infectious Process Sexually Transmitted Diseases (STD) Sun Exposure Tobacco Use Unintended Pregnancy Visual Impairment Risk Detection Role Performance Safe Home Environment Safe Wandering Seizure Control

Self-Care Status Self-Care Activities of Daily Living (ADL) Bathing Dressing Eating Hygiene Instrumental Activities of Daily Living (IADL) Non-Parenteral Medication Oral Hygiene Parenteral Medication Toileting Self-Direction of Care Self-Esteem Self-Mutilation Restraint Sensory Function Cutaneous Hearing Proprioception Taste & Smell Vision Sexual Functioning Sexual Identity Skeletal Function Sleep Smoking Cessation Behavior Social Interaction Skills Social Involvement Social Support Spiritual Health Stress Level Student Health Status Substance Addiction Consequences Substance Withdrawal Severity Suffering Severity Suicide Self-Restraint Swallowing Status Esophageal Phase Oral Phase Pharyngeal Phase Symptom Control Appendix C l NIC and NOC Systems 217

Symptom Severity Perimenopause Premenstrual Syndrome (PMS) Systemic Toxin Clearance: Dialysis Thermoregulation Newborn Tissue Integrity: Skin & Mucous Membranes Tissue Perfusion Abdominal Organs Cardiac Cellular Cerebral Peripheral Pulmonary Transfer Performance

Treatment Behavior: Illness or Injury Urinary Continence Urinary Elimination Vision Compensation Behavior Vital Signs Weight: Body Mass Weight Gain Behavior Weight Loss Behavior Weight Maintenance Behavior Will to Live Wound Healing Primary Intention Secondary Intention

CORE OUTCOMES FOR NURSING SPECIALTY AREAS Air and Surface Transport Ambulatory Care Anesthesia Cardiac Rehabilitation Chemical Dependency Community Health Critical Care Dermatology Emergency Care Gastroenterology Genetics Gerontology Home Healthcare Hospice & Palliative Care Intravenous Therapy Medical-Surgical Neonatology Nephrology Neuroscience Nurse Practitioner

Oncology Operating Room Ophthalmology Orthopaedics Otorhinolaryngology & Head-Neck Pain Management Parish Nursing Pediatrics Pediatric Oncology Perianesthesia Postoperative Care Psychiatric-Mental Health Radiology Rehabilitation School Health Spinal Cord Injury Urology Vascular Women’s Health and Obstetrics

Source: Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis: Mosby Elsevier. Reprinted with permission.


REFERENCES Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (Eds.). (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis: Mosby Elsevier Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis: Mosby Elsevier.


APPENDIX D

Your Transition Plan ecall that your transition plan is designed specific to your situation. The plan needs to address your success in the nursing program, on the NCLEX-RN, and your ongoing career goals. So what are the particular factors in your life? Remember, these will change over time.

R

Factors for Efficient Time Management FAMILY ✻ Meals ✻ Homework ✻ Laundry ✻ Relationships ✻ Social obligations WORK ✻ Work schedule ✻ Hours and fatigue ✻ Coworkers & colleagues ✻ Practices to refine ✻ Scope of practice

SCHOOL/COLLEGE ✻ Costs ✻ Transportation ✻ Learning needs ✻ Course requirements ✻ Academic schedule and timeline PERSONAL ✻ Health & fitness ✻ Hope & aspirations ✻ Spirituality ✻ Knowledge, skills, & abilities ✻ Individual needs

So, what changes are needed for your success? ■ ■ ■ ■

Family School/College Work Personal

Have you identified all your “time wasters” and your “time enhancers”?

Your Educational Goals ■ Any changes to your goals or timeline? ■ What adjustments to your work and family schedule will need to be made? ■ Remember, change is positive, not negative. 220 Appendix D l Your Transition Plan

Knowledge, Skills, and Abilities (KSA) ■ Remember to continually evaluate your KSA. ■ What information have you added lately to your knowledge base? ■ What skills do you possess – remember Benner’s (1984) levels from novice to expert? Your place on this continuum may change with new situations or challenges. ■ Your program may also require achievement or assessment tests. What have you discovered? ■ And what about your skills in critical thinking? What have you practiced lately?

Your Support System You are not in this alone. Who are your supporters or challengers? Think about peers, colleagues, family, mentors... Remember: The key word is your SUCCESS!

Appendix D l Your Transition Plan 221

APPENDIX E

Assessment Guidelines The Health History ■ ■ ■ ■ ■ ■ ■ ■

Demographic information Chief Complaint Present Problem Past History Family History Lifestyle habits Social/Experiential or Psychosocial History Review of Systems or Functional Health Patterns ■ Review of Systems • General • Skin • HEENT • Musculoskeletal • Cardiovascular • Respiratory • GI System • GU System • Neurologic ■ Functional Health Patterns • Health perception/health management • Nutritional-metabolic • Elimination • Activity/exercise • Cognitive-perceptual • Sleep/rest • Self-perception/self-concept • Role/relationship • Sexuality/reproductive • Coping/stress tolerance • Value/belief

222 Appendix E l Assessment Guidelines

Physical Assessment (including Skills of Inspection, Auscultation, Palpation and Percussion) ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

General Appearance Skin Head, Eyes, Ears, Nose, Neck, & Mouth/Throat (HEENT) Upper and Lower Extremities Torso and Chest including Heart and Lung Sounds Abdomen Genitourinary and Rectal Extremities and Back Neurological Significant Laboratory Findings Interview with Significant Other(s)

And have you completed a cultural assessment and included this in your assessment?

Appendix E l Assessment Guidelines 223

APPENDIX F

Bridges and Barriers to Communication— A Check Sheet onsider the bridges and barriers for each encounter.

C

Bridges as Therapeutic Communication Techniques ■ ■ ■ ■ ■ ■ ■ ■

Active listening Restatement Reflection Focusing Encouraging elaboration Looking at alternatives Use of silence Appropriate questions

Barriers or Nontherapeutic Communication Techniques ■ ■ ■ ■ ■ ■ ■

False reassurance Giving advice Probing Stereotyping Social comment Changing the subject Use of jargon

224 Appendix F l Bridges and Barriers to Communication—A Check Sheet

Developmental Considerations ■ Incorporate the client’s personality, cognitive, and moral development using a lifespan perspective. ■ Remember, with illness, lower level needs may predominate but we still must focus on developmentally appropriate communication. ■ Consider nonverbal communication • Not “talking down” with a child or the person in bed; be at eye level. • Being respectful for a person’s name or how they wish to be addressed. ■ Consider the individual’s level of cognitive and moral development for understanding and application.

Cultural Considerations ■ Time with clients to become accepted and gain an understanding of their belief system ■ Differences in belief systems among generations and geographic origin ■ Past experiences and current situation ■ Religious influences ■ Familial influences ■ Understanding of advance directives ■ Acceptance of the healthcare services, systems, and practitioners ■ Linguistic issues

Appendix F l Bridges and Barriers to Communication—A Check Sheet 225

APPENDIX G

Theories Used in Nursing Metaparadigm Concepts of Nursing ■ ■ ■ ■

Human beings Environment Health Nursing

Maslow’s (1970) Hierarchy of Needs ■ ■ ■ ■ ■

Physiologic drives Safety Love and belonging Esteem Self-actualization needs

Erikson’s (1963) Eight Ages ■ ■ ■ ■ ■ ■ ■ ■

Basic Trust versus Mistrust Autonomy versus Shame and Doubt Initiative versus Guilt Industry versus Inferiority Identity versus Role Confusion Intimacy versus Isolationism Generativity versus Stagnation Ego Integrity versus Despair

Piaget’s Theory of Cognitive Development ■ Sensorimotor stages (reflexive, primary circular reactions, secondary circular reactions, coordination of secondary schema, tertiary circular reactions, representational thought) ■ Preoperational ■ Concrete operations ■ Formal operations

226 Appendix G l Theories Used in Nursing

Nursing Models ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Johnson’s Behavioral System with eight associated subsystems King’s (1981) Theory of Goal Attainment Leininger’s (2006) Culture Care Diversity and Universality Neuman’s (2002) Systems Model Newman’s (1994, 2007) Expanding consciousness Orem’s (2001) Self-care as a human regulatory function Parse’s (1998, 1999) Theory of Human Becoming Pender’s Health Promotion Model” (Pender, Murdaugh, & Parsons, 2006) Rogers’ (1989) Science of Unitary Human Being Roy’s Adaptation System (Roy & Andrews, 1991) Watson’s (1999) Theory of Caring where clients co-participate in ongoing change

REFERENCES Erikson, E. H. (1963). Childhood and society (2nd ed.). New York: W. W. Norton. Johnson, D. E. (1990). The behavioral system model for nursing. In M. E. Parker (Ed.), Nursing theories in practice (pp. 23–32). New York: National League for Nursing. King, I. M. (1981). A theory for nursing: Systems, concepts, process. New York: John Wiley & Sons. Leininger, M. M. (2006). The culture care theory. In M. Leininger & M. R. McFarland (Eds.), Culture care diversity and universality: A worldwide nursing theory (2nd ed., pp. 1–41). Boston: Jones and Bartlett. Maslow, A. H. (1970). Motivation and personality (2nd ed.). New York: Harper & Row. Newman, M. A. (1994). Health as expanding consciousness (2nd ed.). New York: National League for Nursing. Newman, M. A., & Jones, D. A. (2007). Experiencing the whole: Health as expanding consciousness. In C. Roy & D. A. Jones (Eds.), Nursing knowledge development and clinical practice (pp. 119–128). New York: Springer. Nightingale, F. (1859). Notes on nursing: What it is, and what it is not. In Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.). St. Louis: Mosby. Parse, R. R. (1998). The human becoming school of thought. Thousand Oaks, CA: Sage. Parse, R. R. (1999). Nursing science: The transformation of nursing practice. Journal of Advanced Nursing, 30(6), 1383–1387. Pender, N. J. (2006). Expressing health through lifestyle patterns. In W. K. Cody (Ed.), Philosophical and theoretical perspectives for advanced nursing practice (4th ed., pp. 143–153). Boston: Jones and Bartlett. Rogers, M. E. (1989). Nursing: A science of unitary human beings. In J. Riehl-Sisca (Ed.), Conceptual models for nursing practice (3rd ed., pp. 181–188). Norwalk, CT: Appleton & Lange. Roy, C., & Andrews, H. A. (1991). The Roy adaptation model: The definitive statement. Norwalk, CT: Appleton and Lange. Watson, J. (1999). Nursing: Human science and human care, a theory of nursing. Boston: Jones and Bartlett.

Appendix G l Theories Used in Nursing 227

APPENDIX H

Concept Mapping: A Tool FHP FHP

FHP

FHP

FHP

Dx: COPD FHP

FHP

List your nursing diagnoses according to NANDA specifications:

Identify Goals and Outcomes:

Specify Nursing Interventions:

And, how will you evaluate the client’s responses?

228 Appendix H l Concept Mapping: A Tool

INDEX Page numbers followed by an f refer to illustrations, pages followed by b refer to boxes, pages followed by t refer to tables.

A Abbreviations dosage, 192, 196 Abdominal assessment, 100, 100f Ability, 7, 13 Accountability for plan of care, 112, 125 as practice parameter, 24, 128, 143 Active euthanasia, 51, 56 Active listening, 66 Actual nursing diagnoses, 115t, 116–118 Adaptation model, 39t Adult learners, 3, 134–135 Advance directives, 50–53, 56 Advanced placement considerations, 8 Advanced practice nurse, 16–18, 18t Affective learning domain, 7, 136, 136t, 144, 152 Agency for Healthcare Research and Quality, 172–173 Alternative and complementary medicine, 106 American Association of Critical Care Nurses, 183 American Nurses Association code of ethics of, 21, 24, 47b, 47–49, 51, 55, 128 genetic competencies and, 54–55 nursing process defined by, 86 Nursing’s Social Policy Statement of, 24–25 overview of, 23t plan of care defined by, 87 professional performance standards of, 184b, 184–185, 188 research guidelines and expectations of, 165, 168 safety and, 83–84 standards of care of, 49 standards of practice of, 20–21, 147, 158 Analogy in diagnosis, 113–115, 114f Analysis in diagnosis, 110 Andragogical model, 134 APRN nursing boards for, 16–18, 18t Assessment, 94–107 case study of, 96, 97t, 98–102, 101b–102b, 103t–104t cultural influences in, 104–106, 105b data collection in, 94–96, 96b, 97t, 98b, 98–102, 99f–100f, 101b–102b, 103t–104t findings in, 102, 104

functional health patterns in, 102, 102b, 103t–104t guidelines for, 222–223 health history in, 95–96, 96b, 97t, 222 information sources in, 95 key points in, 106–107 key terms in, 94 knowledge deficit and, 133, 133b physical, 96, 98b, 98–101, 99f–100f, 101b–102b, 223 scope of practice in, 18t–19t, 18–20, 20b types of, 94–95 Assignment in implementation, 128 preparation of, 11–12 Asthma case study, 174 Auditory learning style, 10 Auscultation in physical assessment, 96, 99f–100f, 99–100 Authority, 16 Autonomy, 24, 26, 44–45, 55

B Barriers to communication, 66, 66t, 75, 224–225 Basic concepts, 1–56 ethics as, 44–56, 47b multiple roles as, 3–13, 4b, 5f, 6b, 9b–10b overview of, 1–2 professional practice parameters as, 15–26, 18t–19t, 20b, 23b, 23t theory as, 28–41, 32f–33f, 34t–35t, 35f, 37t–39t Basic human rights in research, 164, 164b Behavioral system model, 37t Beneficence, 44–45, 49, 55 Berlo’s communication theory, 62–63 Boards of nursing, 16–17 Bridges’ stages for managing transition, 4, 4b, 5f Bridges to communication, 66, 66t, 224–225

C Caring model, 39t Change defined, 138, 144 of healthcare landscape, 182–184 process of, 138–140, 139f transition and, 4b, 4–5, 5f Chief complaint, 96, 96b Children communication with, 67–68

229

Chronic obstructive pulmonary disease evaluation of, 150t–151t, 150–151, 153–155, 155t physical assessment in, 96, 97t, 98–102, 101b–102b, 103t–104t Client advocacy, 184, 188 Client teaching, 135–143 change process in, 138–140, 139f evaluation of, 151–153 learning domains and, 136t, 136–137 principles of, 135–136 readiness and motivation in, 137–138 strategies for, 142t, 142–143 tools for, 140–142 Cloning, 54 Code of ethics, 21, 24, 47b, 47–49, 51, 55 Cognitive critical thinking skills, 72 Cognitive development theory, 33–34, 34t, 226 Cognitive learning domain, 7, 136, 136f, 144, 152 Collaboration, 181–182, 185, 188 Collaborative nursing diagnoses, 115t Colleague communication, 73–74 Collegiality, 182, 188 Communication, 61–76 bridges and barriers to, 66, 66t, 224–225 clinical decision making and, 75 with colleagues, 73–74 critical thinking in, 70, 72b, 72–73 cultural considerations in, 68–70, 71f defined, 61, 75 developmental considerations in, 67–68 key points in, 75–76 key terms in, 61 models and theories of, 62–63 process of, 61–65, 66t therapeutic nurse–client, 66, 67t variables in, 65 Communication channel, 62 Community service, 24 Complementary and alternative medicine, 106 Comprehensive assessment, 95, 106 Concept, 30, 41 Concept mapping, 87, 124, 124f, 129b, 129–132, 130f–131f, 144 tool for, 228 Conceptual framework, 29 Conceptual model, 29 Confidentiality, 45–46, 55 Confirmation, 65–66 Continuing competency, 19 Continuing practice considerations evidence–based practice as, 162–175, 163f, 164b–165b, 167f future planning as, 178–188, 179f, 183f, 184b, 185f, 187b overview of, 161

230 Index

Continuous quality improvement, 179, 188 Control, 65 Conversions dosage, 192, 197 Coordination of care, 129, 143–144 Core competencies, 22–24, 23b, 26 Costs educational goals and, 7–8 Crackles, 100 Critical analysis, 7 Critical thinking communication and, 70, 72b, 72–73 defined, 76 in nursing, 72b, 72–73 skills and disposition in, 72, 72b taking examinations and, 12 Cultural competence, 68–70, 75 Cultural considerations in assessment, 104–106, 105b, 107 in communication, 68–70, 71f, 225 in research, 173 Culture care diversity and universality model, 37t Culture of blame, 81, 89 Culture of safety, 78–81, 79b, 89 Curtain’s ethical decision making model, 49

D Data collection, 94–96, 96b, 97t, 98b, 98–102, 99f–100f, 101b–102b, 103t–104t Decision making communication and, 75 ethics in, 46–47, 49–55 Delegation, 128–129, 129b, 143, 180–181 Demographic information, 96, 96b Deontology, 46–47 Dependent nursing actions, 131–132 Developmental theories, 32–35, 33f, 34t–35t, 35f communication and, 67–68, 225 defined, 32–33, 41 Diagnosis and planning, 109–125 analysis and outcome identification in, 110–111, 121, 122t concept maps in, 124, 124f holistic planning considerations in, 120–121 interventions and, 122–123 key points in, 125 key terms in, 109 nursing diagnoses in, 111–120, 114f, 118t overview of, 109–110, 110b planning goals in, 121 reference books for, 123–124, 126 RN’s responsibilities in, 109–110, 125 Do Not Use list, 82, 191 Documentation, 156–157, 159 Domains of care, 88 Domains of learning, 7, 136t, 136–137, 144

Dosage and solution review, 191–197 abbreviations in, 192, 196 calculations in, 191, 192b conversions in, 192–193, 197 intravenous, 194, 197 No Not Use list in, 191 oral, 193–194, 197 parenteral, 194, 197 safety and, 195–197 Driving forces in change, 139f, 140

E Education. See also Client teaching nursing, 21 Educational goals transition and, 7–8, 220 Eight ages of man theory, 33f, 33–34, 226 Empathy, 65 Empirical research, 165b, 165–166, 175 Empowerment, 6–7 Encoding and decoding, 62–63 Environment learning, 137 in systems theory, 35f, 35–36 Erikson’s eight ages of man theory, 33, 33f, 226 Ethical, Legal, and Social Implications Research Program, 54 Ethics, 44–56 advance directives in, 50–52 decision making in, 49–55 decision systems in, 46–47 in evidence–based practice, 164b, 164–165, 175 genomics in, 53–55 informed consent in, 49–50 key points in, 55–56 key terms in, 44 nursing code of, 47b, 47–49 organ procurement in, 53 overview of, 44 persistent vegetative state and, 52–53 as practice parameter, 21, 24–25 principles of, 44–46 Web sites relevant to, 48, 52–53 Euthanasia, 51, 56 Evaluation, 147–159 case study of, 150t–151t, 150–151, 154–155, 155t of client education, 134, 151–153 of client outcomes, 148–151, 149b, 150t–151t defined, 147, 158 documentation of, 156–157 key points in, 158–159 key terms in, 147 nursing classification systems in, 154–156, 155t overview of, 147–148 of professional performance, 157–158 Evidence–based practice, 162–175 case study of, 173, 174b

defined, 25, 162, 174 eliminating barriers to, 173–174 key points in, 174–175 key terms in, 162 literature in, 165–166, 169b, 169–172, 175 nursing research in, 163–164 overview of, 162–163 research ethics in, 164b, 164–165, 175 research methods in, 165b, 165–168, 175 use of, 168–169, 169f, 172–173, 175 Examination taking, 12 Expanding consciousness model, 38t Experience in critical thinking, 73 Expert, 17 Extremity assessment, 98–99 Eye contact, 98

F Family history, 96, 96b Family roles, 6, 6b, 8 Fidelity, 44–45, 49, 55 Focused assessment, 95, 106 Frame of reference, 10 Framework, 29, 41 Full disclosure, 45, 50, 55 Functional health patterns in assessment, 102, 102b, 103t–104t, 107 concept mapping and, 131, 131f NANDA nursing diagnoses and, 112 Future career planning, 178–188 collaboration and collegiality in, 181–182 healthcare changes and, 182–184 key points in, 188 key terms in, 178 leadership and management in, 180–181 options in, 185–186 performance standards and, 184b, 184–185 professional practice in, 178–179, 184–185 transition plan and, 186–188, 187b

G Garnering resources for learning, 11–12 Genetic mapping, 53–54 Genomics, 53–55 Giger and Davidhizar transcultural assessment model, 105, 105b, 107 Goals educational, 7–8, 220 Gordon’s functional health patterns, 102, 102b, 107 Graduate nursing education, 186 Grand theory, 30, 41

H Habits of mind, 72–73 Head and neck assessment, 98

Index 231

Health communication, 65 model of, 63, 75 Health history, 95–96, 96b, 97t, 107, 222–223 Health promotion model, 38t–39t Healthcare agency culture, 74 Heart sounds, 99, 99f Henderson’s nursing philosophy, 36 Hierarchy of needs theory, 31–32, 32f, 41, 226 Holistic healthcare model, 69 Holistic issues, 111 Hospital safety, 82, 83b, 84 Human becoming model, 38t Human Genome Project, 53, 55–56 Human rights, 44–45, 55, 164, 164b

I Implementation, 127–144 adult learning theories and, 134–135 client teaching in, 135–143, 136t, 139f, 142t. See also Client teaching concept mapping in, 129b, 129–132, 130f–131f key points in, 143–144 key terms in, 127 knowledge deficit and, 132–134, 133b overview of, 127–128 Independent nursing actions, 131–132 Informed consent, 45, 49–50, 55 Inspection, 96, 98b, 98–101, 101b–102b Institute for Healthcare Improvement, 84 Institute of Medicine core competencies defined by, 22–23, 23b safety and, 78–82, 79b Instruments research, 171 International Council of Nurses, 47–48 Intervention planning and, 122–123 requirements of, 127–128 Intravenous dosages, 194, 197

J Joint Commission on Accreditation of Healthcare Organizations, 82–83, 89 Justice, 44–45, 49, 55

K Kinesics, 64 Kinesthetic learning style, 10 Knowledge in critical thinking, 73 defined, 7, 13 educational goals and, 7–8 Knowledge deficit, 132–134, 133b Knowledge transformation, 168, 175 Knowles’ andragogical model, 134 Kohlberg’s theory of moral development, 34, 35t

232 Index

L Laboratory findings, 101, 102b Leadership, 178–179, 188 Leapfrog Group, 84 Learning changing environment of, 10 defined, 13, 136, 144 domains of, 7, 136t, 136–137, 144 as empowerment, 6–7 options for future, 185–186 transformative, 5 Learning environment, 137 Learning styles, 9–11, 10b, 13 Letting go, 4, 4b, 5f Lewin’s change model, 139f, 139–149 Licensed practical nurse, 3–6, 16–17, 18t–19t, 19 Licensed vocational nurse, 16, 18t–19t Licensure, 17–18, 26 Lifestyle, 96, 96b Literature reading and review, 165–166, 169b, 169–172, 175 LPN/LVN multiple roles of, 5–6, 6b nursing assessment scope of, 19, 19t nursing boards for, 16–17 scope of practice of, 18t transition to registered nurse of, 3–4

M Magnet recognition program, 183–184 Management, 180–181, 188 Manager of care, 184, 188 Maslow’s human motivation and hierarchy of needs theory, 31–32, 32f, 41, 226 Medical diagnosis, 112, 117–118 Medical healthcare model, 69 Medication errors, 80–81 Message, 62, 74 Metacommunication, 64, 75 Metaparadigm concepts, 28–29, 40, 226 Mezirow’s transformative learning, 5, 13 Middle–range nursing theories, 30–31 Model. See also specific models and types of model defined, 29, 41 Motivation to learn, 138, 144 Multiple roles, 3–13, 4b, 5f, 6b, 9b–10b competing roles and, 5–6, 6b key points of, 12–13 key terms in, 3 learning and, 6–13, 9b–10b overview of, 3 rationale for return to school and, 4–5 transition and, 4b, 4–5, 5f, 7–8 Myers–Briggs inventory, 9, 10b

N NANDA nursing diagnoses, 87, 90, 198–204 evolution of, 87 formulation of, 112–117, 114f, 118t reference books for, 123, 126 National Council Licensing Examination. See NCLEX National Council of State Boards of Nursing. See NCSBN National League for Nursing, 23t National Quality Forum, 84 NCLEX, 17 NCLEX–PN and RN, 17 NCSBN delegation rights of, 128–129, 129b overview of, 23t regulations of, 17–18 scope of practice defined by, 18t–19t, 18–19, 20b Neurological assessment, 100–101 Neutral zone, 4, 4b, 5f New beginning in transition, 4, 4b, 5f NIC taxonomy, 88, 90, 159, 205–213 Nightingale as nursing researcher, 163 nursing theory of, 36 NOC taxonomy, 88, 90, 159, 213–218 Noise, 62 Nonmaleficence, 45 Nontherapeutic communication techniques, 67t Nonverbal communication, 64, 68, 75 North Atlantic Nursing Diagnosis Alliance. See NANDA nursing diagnoses Northouse and Northouse communication model, 63–65 Notes on Nursing, 36 Novice, 17 Nurse–client communication, 66, 67t Nurse–nurse communication, 73–74 Nursing actions, 131–132 Nursing assessment. See Assessment Nursing classification systems, 154–156, 155t Nursing code of ethics, 47b, 47–49. See also Ethics Nursing diagnoses analysis of, 110 defined, 110, 110b evaluation and, 149b, 150, 150t–151t formulation of, 111–115, 114f, 118t medical diagnoses versus, 112, 117–118 NANDA, 87, 112, 198–204 prioritizing of, 120 reference books for, 123–124, 126 types of, 115t, 115–120, 125 Nursing education programs of, 21 returning to, 1, 3–13, 4b, 5f, 6b, 9b–10b Nursing interventions classification. See NIC

Nursing Licensure Compact, 19–20 Nursing models, 227 Nursing Outcomes Classification. See NOC Nursing practice acts, 17–19, 18t–19t Nursing process assessment in, 94–107, 95f, 96b, 97t, 98b, 99f–100f, 101b–102b, 103t–104t, 104f client teaching in, 135–143, 136t, 139f, 142t communication skills in, 61–76, 66t–67t, 71f, 72b defined, 86, 90 diagnosis and planning in, 109–125, 110b–111b, 110f–111f, 113f–114f, 117f, 118t evaluation in, 147–159, 148f, 149b, 150t–151t, 153f–154f, 155t, 158f implementation in, 127–144, 128f, 129b, 130f, 132f, 133b, 134f, 136t, 139f, 142t overview of, 59–60 phases of, 86–89 safety in, 78–90, 79b, 83b Nursing research, 163–164 Nursing theory, 30–31 Nursing’s Social Policy Statement, 24–25

O Objective data, 95, 104, 107 Oral dosages, 193–194, 197 Organ procurement and donation, 53 Outcomes in care planning, 111, 121, 122t criteria for, 148, 158 evaluation of, 148–151, 149b, 150t–151t in implementation, 134

P Palpation, 96, 99 Paradigm, 29, 41 Parameter, 16 Parenteral dosages, 194, 197 Past health history, 96, 96b Perception and learning, 6 Percussion, 96, 98b, 99 Persistent vegetative state, 52–53 Personal attributes, 72b Personal roles, 6, 6b PES diagnostic system, 117 Physical assessment, 96, 98b, 98–101, 99f–100f, 101b–102b, 223 Physician–assisted suicide, 51 Piaget’s theory of cognitive development, 33–34, 34t, 226 Plan for transition, 220–221 Planning of care. See also Diagnosis and planning defined, 87, 110, 111b diagnosis and, 109–125

Index 233

implementation of, 88 overview of, 109–110, 110b Pleural friction rubs, 100 Possible nursing diagnoses, 115t Power of learning, 6–7 Practice parameters, 16–22, 18t–19t, 20b, 25. See also Professional practice parameters Preparation of assignments, 11–12 Present problem in health history, 96, 96b Prevention levels of, 85–86, 89, 112 of medication errors, 80–81 RN’s role in, 112 Primary prevention, 85, 89, 112 Privacy, 45–46, 55 Profession, 15–16 Professional culture, 21–22, 23t Professional nursing practice. See also specific aspects future planning and, 178–179, 184–185 overview of, 1–2 Professional organizations, 22, 23t. See also specific organizations Professional performance evaluation of, 157–158 standards of, 184b, 184–185, 188 Professional practice parameters, 15–26, 18t–19t, 20b, 23b, 23t code of ethics in, 21 community service in, 24 core competencies in, 22–24, 23b key points in, 25–26 overview of, 15–16 professional culture in, 22, 23t professional education in, 21 standards of practice in, 20b, 20–21 terminology in, 15–20, 18t–19t theory and, 24–25 Propositions, 30, 41 Provider of care, 184, 188 Psychomotor learning domain, 7, 136, 136t, 144, 152–153 Psychosocial history, 96, 96b Pulmonary status assessment, 99–100, 100f Purnell cultural competence model, 70, 71f

Q Qualitative research, 167–168, 175 Quality, 179, 188 Quality chasm, 78–81, 79b Quality improvement, 179, 188 Quantitative research, 165b, 165–166, 175

R Rales, 100 Reaction in learning, 6

234 Index

Readiness to learn, 137–138, 144 Reading the literature, 169b, 169–172 Recall of information, 6 Receiver, 62 Reference books, 123–124, 126 Registered nurse. See RN Regulations as professional parameter, 16–18, 18t Relationships, 63, 65–66 Research, 163, 165b, 165–168, 174–175 Resources, 11–3 Responsibility, 24, 26, 128, 143 Restraining forces, 139f, 140 Returning to school, 1–8, 4b, 5f, 6b Review of literature, 170 Review of systems, 96, 96b, 97t Rhonchi, 100 Rights defined, 44, 55 of delegation, 128–129, 129b Risk factor identification, 112 Risk nursing diagnoses, 115t, 118–120 RN competency levels of, 17 diagnosis and planning scope of, 109–110, 112, 125 nursing assessment scope of, 19, 19t nursing boards for, 16–17 research expectations of, 168 scope of practice of, 18t, 20b transition from LPN to, 3–4 Role–relationship functional health pattern, 119–120 Roles, 5–8, 6b, 13 Root cause analysis, 82, 89

S Safety, 78–90 culture of, 78–81, 79b goals for, 81–85, 83b Institute of Medicine quality chasm and, 78–81, 79b key points in, 89–90 key terms in, 78 nursing process and, 86–89 nursing risk factors and, 80 prevention levels in, 85–86 rules for, 78–79, 79b Sampling in research, 171 Schedule educational goals and, 7–8 Schiavo Terri, 52–53 School returning to, 1–8, 4b, 5f, 6b Science of unitary human beings model, 39t

Scientific healthcare model, 69 Scope of practice determinants of, 17–20, 18t–19t, 20b in diagnosis and planning, 109–110, 125 Secondary prevention, 85, 89, 112 Self–care model, 38t Self–determination, 44–45, 50, 55 Self–regulation, 24 Sender, 62 Sentinel event, 82, 83b, 89 Shannon’s communication model, 62 Skill, 7, 13 Social history, 96, 96b Standards of care defined, 48, 55 ethics and, 48–49 evaluation and, 148 Standards of nursing practice evaluation and, 147, 158 as practice parameter, 20b, 20–21 Statistics, 171 Studying, 11 Subjective data, 95, 102, 104, 106 Support system, 221 Syndrome nursing diagnoses, 115t Systems model, 37t Systems theory, 30, 35f, 35–36, 41

T Taking examinations, 12 Taxonomy NANDA nursing diagnoses as, 112, 116, 154 NIC, 88, 90, 159, 205–213 NOC, 88, 90, 159, 213–218 Teaching, 135–143, 136t, 139f, 142t, 144. See also Client teaching Technology, 74 Terminology. See also Taxonomy domains of care, 88 Tertiary prevention, 85, 89, 112 Theory, 28–41, 32f–33f, 34t–35t, 35f, 37t–39t of adult learning, 134–135 of change, 139 communication, 62–63 defined, 41 development and application of, 29–36, 32f, 33t–35t, 35f developmental, 32–35, 33f, 34t–35t, 35f Erikson’s eight ages of man, 33f, 33–34 of goal attainment, 37t, 63 impact on practice of, 40

key points in, 40–41 key terms in, 28 Kohlberg’s moral development, 34, 35t levels of, 30–31 Maslow’s human motivation and hierarchy of needs, 31–32, 32f nursing models and, 36, 37t–39t overview of, 28–29, 226–227 Piaget’s cognitive development, 33–34, 34t as practice parameter, 15, 24–25 systems, 35f, 35–36, 41 use of, 24 Therapeutic communication, 66, 67t, 75 Thriving and learning, 12 Time management, 9, 9b Transcultural assessment model, 105, 105b, 107 Transformative learning, 5 Transition educational goals and, 7–8 phases of, 4b, 4–5, 5f plan for, 186–188, 187b, 220–221 Trust and communication, 65, 67

U UAP nursing boards, 16–17P Understanding and learning, 7 Unfreezing in change process, 140 Uniform Rights of the Terminally Ill Act, 50 Unlicensed assistive personnel, 16–17 Utilitarianism, 46, 55

V Value system, 7 Variables in research, 171 Veracity principle, 45, 55 Verbal communication, 64, 67–68, 75 Visual learning style, 10

W Wellness nursing diagnoses, 115t Wheezes, 100 Work environment and schedule client safety and, 80, 83–84 educational goals and, 7–8 safety and, 80, 83–84 standards for healthy, 183

Index 235

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