Reflective Essay to Discuss the Nursing Process and how it was Applied in the Clinical Area in which I was Placed
This is a reflective essay to demonstrate the nursing process and how it was applied in the clinical area in which I was placed.
Atkinson et al (1983, p2) describes “The nursing process is a system of planning the delivery of nursing care, consisting of four steps: Assessment, Planning, Implementation and Evaluation”.
This is a client focused assignment; therefore I will choose a client whom I have participated in providing nursing care for. I will discuss the nursing process, how it was applied and the context in which it was done. I will use reflection to compare my findings to how literature states it should be done. I plan to show an understanding of holistic care and how it is used in each stage of the nursing process. Holistic care is an approach to healthcare which treats the individual as a whole person in relation to their needs (Hinchliff et al, 1998).
In order to maintain confidentiality I have provided my client with a pseudonym
(Nursing and Midwifery Council, 2002).
I based this assignment on Mary, who is a 72 year old lady and suffers with osteoarthritis which is a degenerative disorder in bone and cartilage (Hinchliff et al, 1996). She had fallen at home and was presented at the Accident and Emergency department by emergency services. After a short stay on Medical Assessment she was transferred to the unit for rehabilitation following her fall. I spent seven weeks on a large intermediate care ward. The ward is nurse led with very little medical intervention.
The NSF for Older People (2001 p.3) defines intermediate care “to provide integrated services to promote faster recovery from illness, prevent unnecessary acute hospital admissions, support timely discharge and maximise independent living”. There is a great deal of input from a large team including physiotherapists, occupational therapists, social workers as well as nurses. Initially an assessment is made through Intermediate Care Assessment Team (ICAT) in order to find whether clients meet criteria to be accepted on this particular unit. Its aim is to provide a multi-agency, integrated service approach to meeting the needs of vulnerable older people who have complex health and social care needs. ICAT follows up referrals from both acute and community settings and assessments are made relating to clients physical, social and mental health. Clients on the unit will be over 65 years and live within the trust area. They will be medically fit for discharge from acute settings, although must have needs which affect their activities of living (AL’s). The unit uses Roper-Logan-Tierney’s (1996) ‘Activities of Living’ model as a basis for assessing and identifying needs.
Mosby’s Nurse’s Pocket Dictionary defines assessment as ‘An appraisal or judgement made about one particular situation or circumstances, A stage of the nursing process involving the collection of information and data relating to patients and their healthcare needs’ (Mosby 2002, p.31). Why do we assess? The purpose of assessment is manifold but is essentially undertaken to identify risk and highlight problem areas in order to provide a platform for possible future intervention (Hinchcliffe et al, 1998). After the decision was made by ICAT and Mary came to the ward, I participated in her admission process. As per trust policy I collected the relevant data collection documents and produced Mary’s folder ensuring each document was in the correct order. My mentor and I referred to the client’s case notes which contained past medical history, investigations and doctors notes etc. We transferred information from recent documents, such as full name, date of birth, address and next of kin. Under supervision of my mentor I was instructed to gather information by assessing Mary based on documents which made her personal file. Both myself and my mentor introduced ourselves to Mary who was sitting at her bed side in a cubicle. In an attempt to establish a therapeutic relationship with my client I firstly orientated her with new surroundings such as visiting times, lounge, dining areas. Involvement and relationship with another is both necessary for the enactment of orientation and development of the therapeutic relationship (Glasser, 1965, cited by Perry et al, 1991). Using an informal manner I went through each part of the assessment. I used skills in observation, open ended questions and listening in an attempt to retrieve as much information possible, particularly in Activities of Living. This helped to build a composite picture of my client and allowed her to introduce new facts that might be pertinent. The questions posed by assessing in the individuality component of the model (such as how, how often, why and when) furnished information not only about the way in which the person carried out each activity of living but also the knowledge and beliefs she held about it (Newton, 1991). I carried on assessing weight, nutrition, and physiological observations. Due to the nature of the ward the new single assessment process has recently been introduced. DoH (2002a) states that “single assessment will provide better and more efficient access to cares services. It will minimise duplication of assessments by agencies and save older people from having to repeat their personal details and needs to a range of professionals. On gathering individualised data, it then must be interpreted. The needs identified were specifically related to mobility and pain, both of which affect AL’s. Strengths identified such as family support are also a valuable resource when proceeding through the next stage of the nursing process which is care planning.
This stage of the nursing process is to develop a plan of care and determine what approach should be used to help with identified problems. During the planning phase, the nurse applies the skill of problem solving and decision making. Setting priorities, writing goals and planning nursing actions also make up this phase (Atkinson et al, 1983). The ward held a care plan file, which held care plans for a range of different problems. These could be used as a guide and had to be individualised relating to each specific client and their needs. On reflection, I felt this was a good idea, particularly for myself as a student to refer to, however it could present an opportunity for care plans to become less individualised should they be used incorrectly, which consequently, could have an adverse effect and defeat its objective. Archibald (2000) explains that Nursing models have been used to provide systematic care delivery stemming from a desire to organise care coherently, enabling the plan of care to be used and continued by others. He goes on to suggest that since the introduction of models, nursing practice has become more patient centred and holistic. Daws (1998) agrees that the nursing care plans play a vital role in promoting a holistic and individualised approach to care delivery and providing an essential tool for documenting needs and preferences. With reference to Mary, goals were set to increase mobility, increase confidence in mobilising and to reduce pain caused by osteoarthritis. Due to the nature of this ward care plans usually determine discharge outcomes. Targets are set for a maximum rehabilitation period of 28 days. Reasons for this are due to the fact that patients are not acutely ill and need very little medical attention. Instead, they have a great deal of input from physiotherapists, occupational therapists who work closely with clients both individually and in small groups. Newton (1996 p.29) states “Goals of Nursing care must be realistic and achievable and reflect the patients goals for living, so they must be set in close partnership with the patient and based on assessment of the individuals AL’s and on the nursing knowledge associated with them”. The care plan is initially implemented by nursing staff who will also take into account client centred outcomes. The easy care (single assessment) document allows the client to say what they would like to achieve. All key players will acknowledge care plans at some point, therefore they must have easy access to the information they need, laws and standards mandate that care plans be specific, clear and legible (Alfaro-LeFevre, 1998). In order to keep Mary involved in her care, goals were agreed with her. This is to ensure patient autonomy but also to give Mary a clear picture of what will be expected of her during her rehabilitation period. It was established that the goal set for pain was highly prioritised and so analgesia was reviewed by a doctor. This ensured Mary could proceed concentrating on client centred outcomes.
The Oxford Dictionary for Nurses (1998, p.313) defines implementation as “the stage of the nursing process in which the patients individual care plan is utilized and executed, in collaboration with other members of the healthcare team” . Hand over was a good source of information used in order to find whether the care being given is right for the patient. The ward used pre written handover sheets which were kept updated by the ward clerk, this allowed more time to write important details in a short space of time. Sometimes nurses do not have enough time to read charts and look up common problems during their shift. When you have time to prepare for the shift, you feel more confident, more competent and can begin giving care in a timely fashion (Alfero-LeFevre, 1998). With reference to Mary care was continued to be monitored and assessed, this mostly happened via handovers but also from every patient encounter. I would see this as an opportunity to assess both physical and mental health, I found that myself as a student could make a valuable contribution to the care being given. All care was documented and signed and Mary’s assessment/care plan file was kept at the foot of the bed. All of the contents are legal documents and can be referred to by health professionals who participate in the care being given but can also be viewed by Mary and her family. DoH highlights this within the essence of care document (benchmarks for record keeping) (2001, p.3) stating that “patients are able to access all their current records if and when they choose to in a format that meets their needs”. It is safe to say that the stages in the nursing process are not in complete isolation from each other, I found from observing care given that each stage overlaps the next. It is at this stage that clear direction is given about what is to be done for the client and by whom it should be done. Since the entire MDT was based in the same unit, the communication was excellent. This ensured a timely advantage for patients and for tasks to be delegated to the correct healthcare professional. Handovers were essential tools in this phase as information could be exchanged between nursing staff and the rest of the MDT, and further strengths and weaknesses could be highlighted. Tasks were allocated to each member of the team on specific days at specific times. The patient was also kept well informed of their care via a board in her room which gave the days and times and activities to be held. All input from therapy staff was documented by form of report and handed over to nurses on completion. Weekly MDT meetings were held, which allowed the team as a whole to discuss plans of care. At this point social workers are updated relating to their area of care and look into the possibility of services post discharge. Mary was kept updated of this information which can only be implemented on her consent.
This is the final stage in the nursing process, which occurs continuously while providing care. Evaluation refers to goals which were set, any reassessment and documentation relating to specific goals. In Mary’s case this was her care plans. Therefore the questions would be asked: Is the client in pain? How well does the client mobilise? Is the client confident in mobilising alone? This phase also involved re-assessing Mary in relation to AL’s, and so by using the Roper, Logan and Tierney (1996) model, a staff nurse updated this information by explaining the process to my client and asking her views on each topic relating to AL’s. Tierney (1998) suggests that this particular model is positively balanced, and has been one of the most popular in the United Kingdom”. Wimpenny (2001) agrees stating “It is certainly the best known and most widely used model in this country”. Generally the model had worked well as a basis for Mary’s care planning, and proved in the evaluation stage that progress was made and the model was excellent in relation to most physical and social aspects of care. It was documented and handed over that my client had appeared to have progressed in all that was set. Newton (1991, p.181) confirms this by stating “Value is also placed on observable behaviour as an indication of the need for nursing and the basis of evaluation of the effects of nursing”.
On reflection, I found that the care plans were maintained well. The intervention of therapy staff and their role in meeting the specific goals was a key factor in Mary’s progression. At this point and in order to encourage a timely discharge my client and her family were informed of a home visit. This would prove to the MDT whether her progression in hospital reflected on her own living environment, therefore determining an expected discharge date and which services/equipment if any are needed to ensure the discharge is safe. Archibald (2000) believes evaluation should take place in collaboration with the patient and family. This happened on the unit via progress reports or case conference which were organised by members of the MDT in a private setting and family were welcomed to be involved on consent of the client. The evaluation of care was fully documented by the nurse and the MDT agreed that goals had been met. Therefore the plans were discontinued as it had been established how my client would manage at home and the only risks identified were eliviated by equipment provided by occupational therapy. After a discharge date was set the nurse made appropriate arrangements for transport via an ambulance and liaised with a family member in order ensure a safe arrival at home.
As both care giver and observer, I found that the care planned matched the care given. Collaboration between the Multidisciplinary Team and working closely with patient and family enabled outcomes to be achieved. This experience has taught me the importance of holistic care in relation to the nursing process and how an effective therapeutic relationship between patient and healthcare professional allows more information to be retrieved, thus creating a more precise and individualised care plan. To care for a person holistically requires ongoing assessments – utilizing knowledge, attitudes and skills. Improving assessments and patient involvement in care is highlighted in the essence of care document (DoH, 2001b). The fact that the MDT were based within the same unit allowed a more timely advantage for both patient and staff , allowed maximum communication to all concerned and worked well in relation to discharge planning. My client had commented how she enjoyed the 4 weeks on the ward. I think that the social aspect of the ward helped a great deal. Mary was encouraged by the whole team and maintained as much independence possible throughout her stay. I have benefited as a result of this placement, as it has taught me the importance of the nursing process. I have become more efficient in collecting information from the client and utilising it appropriately in order to care for the client in a holistic way.
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