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CHAPTER I THE PROBLEM AND ITS BACKGROUND Introduction Nursing is the process of caring for, or nurturing, another individual. In order to render care to an individual, the nurse should apply the art and science of nursing that includes the therapeutic use of self, apply and perform different nursing procedures, critical thinking skills, communication and assessment skills, proper and accurate documentation and most importantly, the practice and use of the nursing process. (Berman, A. , Snyder S. J. , Kozier, B. & Erb, G. (2008). Kozier and Erb’s Fundamentals of Nursing. th Ed. Jurong, Singapore: Pearson Education South Asia Pte Ltd. ) According to Andres (2007) one of the functions of the nurse is the documentation of the client’s health status. Of all the client’s medical attendants, the nurse is with him most of the time. For the reason, the quality of her observations and reports, written and oral are of utmost importance. Moreover, for a documentation to be effective and to be able to solve the client’s potential and actual health problem, critical thinking skills and the use of the nursing process must be used.
It provides a systematic framework in rendering professional and quality nursing care and also the integral part of the nursing practice. Thus, it must be given with utmost attention and should be practiced in the clinical setting. This scientific-based process aims to solve the current and potential health problems of the client leading to individualized, holistic, effective and efficient care to clients. In the Philippine hospital setting, nurses spend more time in doing the charting rather than the ideal that is spending more time together with the client.
In here, if the nursing process is properly utilized in the documentation, there will be more time for the nurse and the client to interact with each other so as the needs of the client be addressed, further quality nursing care will be rendered and the client’s actual or potential health problem will be solved. The said scientific-based process will give the nurse a direction and a systematic framework in attending the needs and problems of the client. However, critical thinking skills must be used in order to follow the nursing process accurately and correctly.
Furthermore, in every area or ward in an institution, there are different types of documentation technique that is being used. Also, it is vital for nurses to use the nursing process since it has been in the nursing curricula and is essential in the standard of the nursing practice. Even if there are certain types of documentation technique, still it must be utilized by the nurses in order to give holistic, individualized and problem-oriented care following the standard of the nursing practice.
With unexpected instances that happened during the course of care of the client, the researchers came up with this study entitled “Extent of Utilization of the Nursing Process in the Documentation of Professional Nurses at Seamen’s Hospital” to figure out if the nurses still apply and follow the nursing process and also, find out the essential role of it in nursing documentation and in the nursing care and its importance in the nursing practice. Background of the Study Nursing profession is a combination of art and science.
Different techniques, skills and knowledge especially the critical thinking skills are required in order to be considered as a competent nurse. However, as a nurse, knowledge on the importance and the use of the nursing process is vital in giving quality nursing care. Moreover, for the professional nurses, in their everyday shift and hours of duty, documentation is a task that must be done correctly, accurately and in an organized manner. With this, in order for them to use and manage their time effectively, the nursing process takes in together with the use of the critical thinking skills that every nurse possesses.
With the use of the said scientific-based process, it follows a systematic and step by step process for which the way of gathering data is in order and it flows following the five phases of the nursing process. These are assessment, diagnosis, planning, implementation and evaluation. Based on Lee’s study entitled “Quality of Nursing care as Perceived by Nurses and Patients in Selected Hospital in Taiwan”, it is found out that nurses perceived themselves to be doing the four phases of nursing process most of the times as well as the patients perceived that nurses do the four phases of nursing process when they administer care to them.
However, presently, the phases of the nursing process has been changed to five and with this, the researchers find this as a gap since Lee used only four while the present phases of the said scientific-based process was already changed to five. In relation to the clinical situation stated above, the researcher find the study to be useful in filling the identified gaps so as the problem in time management, assessment, communication, more time together with clients will be addressed with the use of the five phases of the nursing process.
Furthermore, extent of utilization of the nursing process in the documentation could be assessed. Statement of the Problem This research study aims to assess/examine the Extent of Utilization of the Nursing Process in the Documentation of Professional Nurses at Seamen’s Hospital. 1. What is the extent of utilization of the nursing process in the documentation of professional nurses in your institution in terms of: a. Assessment b. Diagnosis c. Planning d. Implementation e. Evaluation Significance of the Study
This research is one way of determining the essential role of the nursing process in nursing documentation and its importance to the nursing practice. On the other hand, there is a need in this occurrence to find out the level of compliance of nurses in using the nursing process (ADPIE) in their documentation to assess whether the nurses still follow the standard procedure in documenting or charting to achieve and render individualized, holistic, professional and quality nursing care. Registered Nurses This study will enable the nurses to meet the standards of safe practice for which they are accountable.
For the nurses, the utilization of nursing process becomes the vehicle through which they establish rapport with the patient and his family and in providing quality nursing care. The use of various approaches, knowledge, skills, and attitudes is enhanced, thus giving nurses self-confidence and job satisfaction. Also, the nurses will learn more and apply their ideas in the real setting of the nursing profession to boost their therapeutic communication, skills in formulating good plan of care and prevention of errors through the proper documentation of data as evidence-based nursing practice.
Other members of the Healthcare team For other members of the health care team, they will benefit on this as well since accurate nursing documentation of the patient’s changes, reaction and improvement through the proper use of the nursing process are well stated which will be useful in further assessment and interventions that will be done by the said other members of the healthcare team. Clients
For the clients, this study might help them be protected because documentation of the process prevents omissions or duplications in providing care and it also provides individualized, continuous and coordinated nursing care. Significantly, for the clients, this study would aid them in understanding the importance of verbalizing essential facts and what they really feel during nurse’s assessment so as to be provided with priority nursing care. This research may also make patients more cooperative to nurses upon being aware of the hazards that could take place when there is incorrect documentation of information.
Hospital On the other hand, for the hospital as a whole, this study may facilitate in intensifying the responsibility of every staff in each ward to apply accurate documentation and strict conformity to the nursing process so as to heap on the credibility of the institution. Also, this will help the institution in setting standards regarding their nursing practice and will further achieve their goals towards progress and most importantly giving professional, quality nursing care to their clients. Hospital Administrators
This study is probably most beneficial to the hospital administrators because it measures the nurses’ compliance to the step by step method of the nursing process thereby helping them evaluate their nurses’ performance and dedication to their job. Nursing Students Furthermore, for the students, they will benefit in this research because through this, they will be informed well about the importance and the role of nursing process as the integral part of the nursing practice and standards in giving individualized, holistic and quality nursing care to the client.
So as, with this, as students, at this point of their chosen path of career, they will be trained regarding the real practice of nursing in the clinical setting. Nowadays, as students are at the stage of training to learn, they will also gain knowledge regarding the nursing process and with that, the current setting in the hospital which is the nurse consume more time in documentation without considering the importance of the therapeutic effect of nurse-patient interaction.
With this, as student, they will be also educated about an effective yet time-bounded documentation. Furthermore, this study can definitely heighten their skills in using the said scientific-based process competently and familiarize it by heart. Professors and Clinical Instructors This study can be used as a guide in focusing the efforts of the teachers in shaping the student’s mind to recognize the importance of following the nursing process in their documentation. Nursing School Administrators
This study might inspire the nursing school administrators to format their curriculum and teaching plans in incorporating and stressing the weight of the nursing process in the nursing profession and for deeper understanding as well. Nursing Profession To the nursing profession, this study would be beneficial because the utilization of the nursing process establishes that nursing practice is based on a well-defined and well-organized body of special knowledge. Thus it will help people understand what nurses do.
This study would also show that using the nursing process would demonstrate that nurses contribute to better patient outcomes and decreased cost in terms of allocating resources. Future Researchers Lastly, as for the future researchers, this might serve as a tool and reference for their study and assist them for the betterment of their research. Scope and Limitation This study would cover theextent of utilization of assessment, diagnosis, planning, intervention and evaluation in the nursing documentation of professional nurses at Seamen’s Hospital.
The researchers aim to distinguish how often do nurses use and apply the nursing process in their documentation. In the results, the more frequent an item appears would indicate a higher degree of utilization. It would also tackle the different types of nursing documentation for additional information and the different phases of the nursing process stated. This would also discuss the importance of the nursing process in the nursing profession. It involves the staff nurses working in the different wards of the whole institution.
This study was conducted starting from the month of July, wherein the researchers were having their nursing research subject. However, the distribution of questionnaires was done on October 12 -13 2010 after the study was approved by the school and further by the hospital directors. The course of the study ended and was completed on October 14, 2010. This research is limited to 69 respondents only. Mainly, a questionnaire will be used as a survey tool to evaluate and answer the problems regarding this study.
Having limited amount of time to finish their study, the researchers should learn to manage or balance their schedule to attend to their other needs and requirements as well. This study would no longer cover the effect of nursing documentation in rendering quality nursing care based on the extent of use of the nursing process. Also, this study would no longer discuss the step by step process of doing or writing the different types of documentation and as well as it would not include the different relationships or correlations between the different variables.
Conceptual Framework This study was anchored in the Goal Attainment Theory by Imogene King. The said theory was addressed on how nurses interact with clients to achieve goals. With this, a conceptual framework for nursing which later changed to conceptual system was formulated by King which includes the interrelationship between personal, interpersonal and social systems and this also includes the concepts of self, role, perception, communication, interaction, transaction, growth and development, stress, time and personal space as essential knowledge for use by nurses.
Moreover, King defined the personal system as persons and as the basic component of conceptual system. According to the philosophical assumptions of the conceptual system, when personal systems interact, interpersonal systems are formed. Accordingly, it is stated in the goal attainment theory that understanding personal systems is foundational to nursing. She view nursing as scientific and professional discipline. Its structure is identified as an open, interacting framework of personnel, interpersonal and social system.
In here, King stated that nursing process is a strong and consistent element and health is further defined as the goal of nursing. Lastly, critical thinking is a foundational element in King’s conceptual approach to nursing. On the other hand, she developed the Goal-oriented Nursing Record (GONR) wherein the process and outcome of nursing is recorded. In here, its major elements include the database, nursing diagnosis and goal lists, nursing order, flow sheets, progress notes and discharge summary.
With this GONR, she linked the use of it for the continuity of care, systematic data retrieval and quality assurance. However, in relation to the present study, these concepts that King stated play an important role in determining if the nurses still apply and follow the nursing process and also the essential role of it in nursing documentation and in the nursing care and its importance in the nursing practice. The said essential knowledge that a nurse should possess is correlated with the critical thinking skill that basically the nurses have and that being used in taking care of the client.
In every procedure that a nurse performs, the nursing process serves as a guideline in doing it correctly, accurately, effectively and efficiently. By following the said scientific-based process, there will be a systematic flow of nursing care and that professional and quality care which is the goal of nursing according to King will be achieved. Critical thinking in relation to the nursing process is inseparable for which critical thinking is the instrument while the nursing process is the framework itself in giving holistic, individualized and effective care.
On the other hand, first, in assessment, nurse’s communication skill and assessment skill is in utmost importance. If these were possessed by a nurse, the first phase of the nursing process which is the initial phase where the gathering of essential data about the clients, addressing the client’s health problems particularly the actual and potential problem, determining the strengths of the client that may promote treatment and recovery will be properly assessed and prioritized. In this phase as well, the interaction system is established.
However, in the diagnosis phase, the nurse clusters the data according to its significance and then identifies and prioritizes the identified health problem according to its severity or high-impairment effect on the client. Also, making a nursing diagnosis is being made in this phase. In the third phase, the planning phase includes the establishment of priorities by ranking the nursing diagnoses formulated during the diagnosis phase. Also, goals and objectives are set in this phase and formulating different nursing interventions are done as well.
The fourth phase, the implementation phase particularly carry out the formulated nursing interventions in a safe and appropriate manner. Lastly, the evaluation or the last phase involves the evaluation or checking if the applied nursing interventions solves the problem of the client or even lessened it. In the abovementioned steps in the nursing process, it showed how critical thinking is indeed important in using the nursing process therefore agrees that these are the foundational elements in King’s conceptual approach to nursing.
Also, with the use of the nursing process, the goal of nursing according to King which is the quality, professional, individualized and holistic care will be given. It reflected that each problem of each individual is being assessed, diagnosed, planned and then important nursing interventions are rendered and further evaluation is done if it is effective or if it solved or lessened the client’s health problem. Furthermore, the researchers included the concept of personal and interaction systems.
In the present study, the personal systems refer to the nurses and the client as an individual. The study talked about the nursing process where communication between the client and the nurse is one of the essential elements in following the standards of the nursing practice. It was well stated that nurses interact with client where the needs of the client is addressed. However, in relation to the nursing process, ocumentation is also an important part where it serves as the official written record if the nurse applied the said process during the course of care of the client. As two persons interact, King pertained it as the interacting system. Also, before the evidence-based nursing is achieved, the nurse must interact with the patient as well. Thus, it followed the principles of King, which is the nurse-patient interaction. King further added that health is the goal of nursing and nursing is linked to the nursing process for the goal to be achieved.
This statement is related to the study because basically it is all about the extent of use of the nursing process and the researchers will assess if the nursing process is followed and used in each and every type of nursing documentation. Example of which is SOAPIE; This SOAPIE is patterned in the ADPIE or the Assessment, Diagnosis, Planning, Intervention and Evaluation wherein these steps are the same in nature because both are using the nursing process. And with this, effective documentation could be done.
Lastly, the important concepts which are the critical thinking, essential knowledge of nurses, nursing process ??? the ADPIE, the personal and interacting system and the GONR are the important things discussed and correlated with the present study and with these, it will help in determining if the nurses still apply and follow the nursing process and also the essential role of it in nursing documentation and in the nursing care and its importance in the nursing practice. Figure 1. “Goal Attainment Model” ??? Imogene King Figure 1 presents the paradigm of the study. In here, The Personal System [1] represents the nurse ??? in a red oblong shape.
Through documentation, the nurse communicates with the other nurse, the Personal System [2]. So as, These 2 personal systems in 2 red oblong shapes represent the 2 nurses. According to Imogene King, if two personal systems interact with each other, an interaction system is being established as well as in the next frame the Personal System [3] that represents the patient also shows how King explained the interaction system. In relation to the study, when a nurse interact with a client where he/she establish rapport, a connection or relationship is also made which referred to as the nurse-patient interaction.
Broken lines denote relationship with frames where the researchers relate it to King’s Goal attainment theory. In addition, as what the figure shows the personal system [1] is linked critical thinking. According to King, critical thinking is an essential and the integral part to attain the goal of nursing, the quality nursing care. King also linked nursing in the nursing process, where the steps assessment, diagnosis, planning, implementation and evaluation as a vital component to render individualized, holistic and efficient care where it solves the client’s health problems.
By using the step by step nursing process, the nurses will be able to identify the actual and potential health problems of the client. So as, the nurse will have a systematic framework that will help in prioritization of health problems, establish goals and objectives, formulate appropriate nursing interventions and evaluate the effectiveness of such interventions to know if it solved the client’s health problem. When personal system [2] communicates with personal system [3] they will form an interaction system.
As well as in here, the nursing process will take place and is beneficial to attain the goal of nursing according to King because the nurse can only identify problem, formulate and apply intervention and evaluate if the nurse-patient interaction occurred. Also, as nurse assess well the patient, diagnose, and apply intervention, the nurse document the data collected where it serves as a basis for further re-assessment and solve other health problems of the client which are unsolved from previous interventions done.
If there is an excellent nurse-patient interaction then there would be effective documentation which would lead to quality nursing care. Definition of Terms The following terms used in this research were conceptually defined to provide a clearer view and better understanding of the ongoing study. Assessment is an organized systemic process involving documenting the data in a retrievable manner. The profile is called as client database. (Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 4) Charting by Exception (CBE) is a charting method that requires the nurse to document only deviations from pre-established norms per agency guidelines. .(Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 514) Communication is information processing, a change of information from one state to another. (King, 1981). Diagnosis/need identification involves the analysis of collected data to identify the client’s need or problem’s, also known as nursing diagnosis. This step draw conclusion regarding the client’s specific needs or human response of concern so that effective care.. Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 85) Evaluation is the fifth step of the nursing process and isaccomplished by determining the client’s progress toward attaining the identified outcomes and by monitoring the client’s response to/effectiveness of the selected nursing intervention for the purpose of altering the plan as indicated.. (Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 88) Focus charting is a method of identifying and organizing the narrative documentation of client concerns to include data, action, and response.. Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 513) Implementation is the fourth step of the nursing process whichoccurs when the plan of care is put into action, and the nurse performed the planned intervention. Legal and ethical concerns related to interventions also must be considered.. (Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 88) Interaction is the act of two or more persons in mutual presence. (Octaviano, E. F. & Balita, C. E. (2008). Theoretical Foundations of Nursing: The Philippine Perspective).
Interpersonal Systems are interactions between two or more personal systems. (King, 1981) Narrative charting the traditional method of nursing documentation is a story format that describes the client’s status, interventions, treatments, and response to treatments.. (Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 512) Nursing Diagnosis is a statement of a health problem or of a potential problem in the client’s health status that a nurse is licensed and competent to treat.. (Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 5) Nursing Process is the process that serves as an organizational framework for the practice of nursing. It encompasses all of the patient’s assessment, nursing diagnosis, planning, implementation and evaluation.. (Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 83) Objective data is the observable and measurable data obtained through physical examination including inspection, palpation, auscultation and percussion and by laboratory analyses. This is also referred to as signs.. (Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 84)
Planning is the third step of the nursing process whichincludes setting priorities, establishing goals, identifying desired client outcomes, and determining specific nursing intervention. This action is documented as plan of care.. (Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 87) Perception is the process of organizing, interpreting, and transforming information from sense data and memory. (King, 1981) Personal Systems or individuals, are best understood by the concepts of perception, self growth, and development , body image, learning, time, personal space, and coping. King, 1981) PIE Charting is a documentation method using problem, intervention and evaluation (PIE) format. (Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 513) Problem-Oriented Record (POR) is a type of documentation technique that focuses on the problems experienced by the patient as a result of being ill or on the defined nursing diagnoses reflecting those problems. .(Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 513) SOAPIE is a problem-oriented type of charting that includes the subjective and objective cues assessment, planning, intervention and evaluation.
This also refers to progress notes.. (Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 513) Source ??? Oriented charting, is describe as a narrative recording by each member (source) of the health care team on separate records. .(Delaune S. C. Fundamentals of Nursing, Standards and Practice p. 513) Subjective data is the client’s perception, feelings, opinions and concerns regarding his or her health condition. This is also referred to as symptoms; this data cannot be readily observed. (Delaune S. C.
Fundamentals of Nursing, Standards and Practice p. 84) Transaction is a process of interaction in which human beings communicate with environment to achieve goals that are valued. (King, 1981) CHAPTER II REVIEW OF RELATED LITERATURE AND STUDIES This chapter presents related literature and studies that have implications in the present study. Reading materials and results of studies relevant to the present study were taken into consideration has provided a clearer view and insight of the study being undertaken. Local Literature
Documentation is one of the most important nursing functions because it contains the quality of nursing care received by the patients and the standards of nursing practice and it also serves as the legal guideline and basis for the practice of nursing. Furthermore, it includes the patient’s needs, problems, capabilities, and limitations. According to Venzon (2003) the nursing process is a systematic, problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness.
It provides the framework in which nurses use their knowledge and skills to express human caring. It is an orderly, systematic manner of determining the client’s problems, making plans to solve the problems, initiating the plan or assigning others to implement the solution and evaluating the extent to which the plan has effectively resolved the problems identified. Furthermore, it is a method for organizing and delivering nursing care. It provides the creative and organizational structure and framework for nursing care.
It was also stated major purposes of the nursing process is to help identify the client’s health care needs, determine priorities of care goals and expected outcomes, establish a nursing intervention to meet client-centered needs, provide nursing interventions to meet these needs and evaluate the effectiveness of nursing care in achieving client goals. The nursing process involves five steps that are closely interrelated with each other. Nursing assessment involves data collection about the patient from a variety of sources.
Nursing diagnosis allows for the formulation of diagnostic statements that identify the prioritized client’s actual and potential health problems and strengths and the factors contributing to the problem. The planning step involves formulation of the nursing care plan wherein the nurses work with the client to set goals and outcomes and identify the actions for preventing, correcting or relieving health problems and developing specific nursing interventions for each nursing diagnosis. The product of such plan is often a written nursing or interdisciplinary plan. The implementation step is the action stage of the nursing process.
The nurse communicates the plan of care to members of the health team and carries out the interventions as stated in the nursing care plan, or delegates such intervention when indicated. The evaluation step helps to determine the client’s progress towards meeting the expected outcomes and goal. The nurse documents these in the appropriate forms such as the “nursing process. ” In all of these the nurse explains her role to the clients, the families and significant others, demonstrates knowledge, commitment, adaptability, creativity, leadership and a caring attitude that promotes trust and confidence.
Communication of concern establishes rapport with the client and nursing care is thus facilitated. Core competency areas and functions: the competency standards for nursing practice in the Philippines, which was adopted and promulgated pursuance to PRC-BON resolution 112 series of 2005 has 11 core competencyareas such as: (1) safe and quality nursing care (2) managemnt of resources and environment (3) health education (4) legal responsibility (5) ethico-moral responsibility (6) personal and professional development (7) quality improvement (8) research (9) record management (10) communication (11) collaboration and teamwork. De Belen, 2007 Nursing Law, Jursiprudence and Professional Ethics 1st edition) Foreign Literature Nursing process directs nursing activities for health promotion, health protection,and disease prevention and is used by nurses in every practice setting and specialty. The standards of practice published by American Nurses Association (ANA) included eight standards. These standards identified each of the steps of the nursing process. The nursing process is dynamic and requires creativity for its application.
The steps remain the same, but the application and results will be different in each client situation. The nursing process is designed to be used with clients through out the life span and in any setting in which a nurse provides care for clients. (De Laure, 2002 Fundamentals of nursing: Standards and practice 2nd edition) Documentation is the written and legal recording of the interventions that concern the patient and it includes a sequence of processes. It is established with the personal record of the patient, which constitutes a base of information on the situation of his health.
The importance of nursing documentation is neuralgic, provided that without it, there cannot be a complete qualitative nursing intervention and not even an effective care for the patient. (Ioanna, Stiliani, Vasiliki, 2009) Moreover, according to Craven and Hinle (2004), documentation is a written communication that serves as permanent record of client information and care. Client record or chart provides information during the present visit or admission and maybe consulted in the future to review the client’s history or for educational research and legal purposes.
On the other hand, according to Rick Daniels (2004) in Nursing Fundamentals: Caring and Clinical Decision-Making, there are principles that should be followed in order for the documentation to be effective. Documentation requirements will differ depending on the health care facility (hospital, nursing home, home health agency) and the setting within the facility (e. g. emergency room, perioperative, medical-surgical unit) and with specific client populations (e. g. obstetrics, pediatrics, geriatrics). Regardless of what the client care is administered, the documentation of that care must reflect the nursing process.
Nursing notes must be logical, focused and relevant to care, and must represent each phase in the nursing process. Nursing documentation based on the nursing process facilitates effective care because client needs can be traced from assessment, through the identification of the problem, to the care plan, implementation, and evaluation. Brief reminder of the elements of the nursing process includes the first step, Assessment. In this initial step, it must be summarized and without duplication. The assessment data are related to an actual or potential health care need.
With reassessment, highlight any new findings or any changes in the client’s condition. In the second step known as diagnosis, it identifies the clients’ problem or need using NANDA terminology. However, in the outcome identification and planning, the nurse discusses with the client and communicates to members of the multi-disciplinary team the expected outcomes or goals of client care. In implementation, after the intervention has been performed, document on the flow sheet and progress notes observations, treatments, teaching, and related clinical judgments.
Client teaching should include learning needs, teaching plan content, methods of teaching, who was taught, and the client’s response. Moreover, In evaluation, evaluate and document the effectiveness of the intervention in terms of the expected outcomes: progress towards goals, client response to test, treatments, and nursing intervention; client and family response to teaching and significant events; questions, statements, or complaints voiced by the clients or family.
Furthermore, revisions of planned care document the reasons for the revisions with the supporting evidence and the client and family agreement. Charting in accordance with the nursing process ensures thorough documentation in compliance with ANA’s standards of care, practice arts, and reimbursement and accreditation criteria. The guide to effective charting refers to all nursing document, such as flow sheet, progress notes and so on.
Add to the nursing documents when a change occurs in the client’s condition, measuring the client’s response to an intervention or expected outcomes, and the client or family voices a complaint. During the last decade, nurse researchers have observed inadequacies in the clinical record that prevent data collection and comparison among large groups of clients. Problem oriented medical records (POMR) was introduced in 1969 by Lawrence Reed, a physician at case Western Reserve University.
The focus of POMR documentation is on the client’s problem, with a structured, logical format to narrative charting called SOAP which includes the S or the subjective data (what the client or family states); O or the objective data (what id observed/inspected); A or the assessment (conclusion reached on the basis of data formulated as client problems or nursing diagnosis); P or plan (actions to be taken to relieved client’s problem) SOAPIE and SOAPIER refer to formats that add the I or the intervention (measures to achieve an expected outcome); E or the evaluation (effectiveness of interventions) and R or the revision (changes from the original plan of care) The POMR system was modified by nonmedical caregivers and is referred to as problem ??? oriented record (POR). The system is used by hospitals, nursing homes, home care agencies. There are Four critical components of POMR/POR: First is the database that includes the assessment data, representative of all disciplines (history, physical, nursing admit assessment, laboratory findings, educational and discharge needs), which become the basis for a problem list evaluation of the client’s condition. Second is the problem list that is derived from the database; a listing of the client’s problems as identified, with each problem numbered and labeled as acute, chronic, active or inactive.
Nurses use NANDA terminology in writing client problems as nursing diagnosis; the list is revised as new problems arise and others are resolved. Third is the initial plan which is based on problem identification; the starting point on care plan development with client participation in setting goals, expected outcomes and learning needs. Progress notes: charting base on SOAP, SOPIE and SOAPIER format. The POR system uses flow sheets to record routine care and a discharge summary that addresses each problem on the list and notes whether it was resolved. SOAP entries are usually made every 24hours on any unresolved problem or whenever the client’s condition changes.
After SOAP charting gained popularity, the problem, intervention, eveluation, (PIE)charting system was instituted at Craven Regional Medical Center in 1984 to streamline documentation. Whereas SOAP was developed on a medical model PIE charting has a nursing origin. PIE is an acronym for Planning, Intervention, and Evaluation of nursing care. The key component of this system are assessment flow sheets and nurses’ progress notes with an integrated plan of care that eliminates the need for a separate care plan. Each client problem is labeled and numbered for easy reference. When interventions are implemented to manage the client’s problem, the problem number is identified. This system eliminates the traditional care plan by incorporating an ongoing plan of care into the daily documentation.
This article stressed out key factors involved in a successful documentation. First on the list is accuracy and fact. Ideally, a good patient record can be read in 3-5 minutes and you would be able to manage the care of that patient on the information it contains. A good document should identify what the patient’s problems are and what nursing problems are (they are not always the same), what the patient and nurse want to achieve, a plan of care and an evaluation of whether it was effective. All records, be they care plans, assessment forms or incident reports, must be accurate and concise. They should include date and time of each entry and clearly show who’s making it. Stick to the facts rather than subjective, ven judgmental opinion, for example describing a patient as ‘lazy’ when in fact they might be depressed. “Records should be a factual report on patients, not an opinion,” stresses David Bullock, professional advisory service team manager at the NMC. It is also important to record what you failed to do as well as what you did. Second on her list is the relevance of the nursing notes documented. A common fault is not writing too little, but too much. Make sure the nursing notes are relevant, though it is worth including external factors, such as staffing and equipment, which may be significant. And lastly among the list on the key factors would be the ease of reading. Make sure records are legible.
Text should never be erased or painted over with correction fluid ??? instead put a line through the text so that what is written underneath is still legible. Then sign, date and write the time next to your connection. Do the same for each entry. And make sure the signature is legible, not just a scribble or initials. This is crucial in order for others, as well as yourself, to read it at a later date, and also for auditing purposes. (Nursing times vol. 100 no. 38, 2004) Moreover, in a study made by Ellen K. Vasey, RN, MPH documentation is the proof that your patient is receiving quality care. It is significant in providing the data needed to plan the patient’s care and insure continuity of that care.
This furnishes written evidence of why the patient received the medical and nursing care he did, the response he had to that care and what revisions were made in his care plan, if it proved ineffective. One of the widely used systems in documenting patient care is problem-oriented medical record which focuses on the problems of the patient instead of the source of information. Furthermore, POMR system’s well-defined structure and order correspond with the nursing process. (Documenting patient care responsibly, Donna Gane McNeill, RN) ? Local Study ?Since this study is about the utilization of nursing process in nursing documentation, similar or related studies were considered for review from which significant portion have been sited.
According to Lee in her study entitled “Quality of Nursing care as Perceived by Nurses and Patients in Selected Hospital in Taiwan” ,the results of the study show that nurses perceive themselves to be doing most of the time but not always the activity of the four phases of the nursing process in administering nursing care to their patients. The patients, on the other hand also perceive the nurses to be performing most of the time the activity of the four phases of the nursing process. There are no significant differences in the perception of the patients and the nurses. Therefore, it can be concluded that what the patients perceived to be the quality of nursing care rendered to them by the nurses is the same as what the nurses perceived themselves to be doing. Thus, the patients are assured that what they expect to receive from the nurses is what the nurses perceive to be their functions. Andres (2007), in her study entitled “Level of Compliance of Nurses in Nursing Documentation among selected hospitals in the City of Balanga”, stated that when a nurse properly assesses the client, then, he will be correct in charting the record for the doctor’s perusal. This proves the claim of Bose(2001) that nurses whose assessment skills are adequate and correct are more often to elicit good skills in documentation because he knows what to record and what to be considered as vital in the nurse’s records. ?With this, it states that if a nurse has a good skills in assessment and collection of subjective and objective cues, the nurse has the capacity or the knowledge on what needs to be documented and thereby clustering them in an organized related manner as manifested in the documentation. On the other hand, according to Maravilla (2007) in her study entitled “Quality of Nursing care as perceived by the Medical-Surgical patients of Teresita Lopez Jalandoni Provincial Hospital”, she states that the standard fact that a nurse must develop good communication skills toward the client so that the latter’s real condition will be determined especially how the client fells and desires during the time of encounter. Thus, it proves that in the nursing process, if a nurse has a good assessment and communications skills, he will be able to prioritize well and get an accurate subjective and objective cue which will be beneficial for documentation of the patient’s condition. ?Communication of client care information among members of the health care team is a major area of importance to every hospital clinic and other health care delivery site.
This proves the claim of Moller (2000), stated that an ideal good nurse communicator possesses good communication and interpersonal skills in dealing with the client and has the ability to relate to client and other hospital staff by maintaining an open line of communication, incorporates the element of time in directing, discussion-making when critical information is obtained and objectivity when recording data, administration of treatment and results of patient’s response to diagnostic test which is vital in the nursing process application. ? Foreign Study In a study by Reilly, she stated that nurses should be able to write all the data collected about the patient. To do so, nurses must have a complete interview and assessment.
Through this medical record the members of the health care team will be able to communicate with each other. Also, charting/documentation allows us to identify the patient’s problems consistently thus, enabling the nurses and other members of the health care team to appropriately build an effective care plan. Moreover, if all the data or information gathered about a patient wasn’t properly documented then we also could not develop an accurate care plan for the patient. Synthesis of the review: In relation to our study, the extent of utilization of the nursing process, which focuses on the client’s actual and potential health problem, enables nurses to select priorities that correspond with the nursing process.
One way to guarantee effective and quality nursing care is by properly identifying the patient’s problems and needs as well as prioritizing them which could be achieved through excellent communication and interaction. As a part of the nursing process it is necessary for a nurse that one must acquire the assessment skill for them to consider the essential data that must be documented in the nurse’s record. Assessment skill for a nurse is important because it is the initial contact of a nurse to the client. It is the method that is being use by nurses for them to prioritize the problem of the patient. With the use of critical thinking skills, the nurse can prioritize the identified health problem of the client thus, the problem that needs utmost attention and care plan will be attended.
Proper communication between nurses, patients, and other members of the health care team is necessary to have an accurate collection of data needed, thus ensuring correct documentation and fitting care plan. It is likewise important keep good communication skill to create a good rapport and facilitate the work of the nurse easier. And when information about the client is needed, the patient will not doubt about the information that he or she will tell and will have trust to the nurse. Good communication skill in the team is also a vital ability for a nurse to have, and also for other member of the health care team, because this maintain, improve and ensure the quality of the care provided by the health care team.
Open communication is always important in everything that is happening to the patient. However, Andres(2007) said in her study ” Level of compliance of nurses in nursing documentation among selected hospitals in the city of Balanga”, she stated and proves the claim of Bose that it is necessary for a nurse that he or she must acquire the assessment skill for them consider the essential data that must be documented in the nurse’s record. Assessment skill for a nurse is important because it is the initial contact of a nurse to the client. It is the method that is being use by nurses for them to prioritize the problem of the patient and the first part of the nursing process.
In relation to the present study, it is proved that good assessment skills would intensify the following steps of the nursing process having a strong basis coming from the assessment phase. According to Maravilla(2007) in her study ” Quality of nursing care as perceived by the Medical ??? Surgical patients of Teresita Lopez Jalandoni Provincial hospital, it is also important for a nurse that he or she must develop a good communication skill to the patient, for this can create a good rapport and further make the tasks or work easier for the nurses. And when information about the client is needed, the patient will not doubt about the information that he or she will tell and will have trust to the nurse.
As further stated by Maravilla, it simply shows that it corresponds and agree with King’s Goal attainment theory which is used in the present study. This proves that interaction among two personal systems is indeed important for a documentation to be effective and simply, by means of the communication skills, the nursing process will take over by which through this, assessment, diagnosis, planning, implementation and evaluation will flow smoothly. Therefore, utilizing the limited time we have for each patient through exercising the nursing process. Also, with the said scientific-based process, by providing a systematic framework, the goal of nursing according to King which is the professional and quality care will be rendered. CHAPTER III METHODOLOGY
This chapter presents and discusses the locale of the study, the target respondents, the method and techniques used, population and sample of the study, the data gathering instrument, data gathering procedures and the statistical treatment of data gathered. This chapter is also concerned with the development, testing and evaluation of research instrument and methods used. Research Design The paper was classified as descriptive-quantitative design. The purpose of a descriptive study was to observe, describe and document aspects of a situation as it naturally occurs and sometimes to serve as a starting point for hypothesis generation or theory development.
Usually the information gathered in a quantitative study was numeric in information that results from some type of formal measurement and that is analyzed with statistical data procedures. This study was quantitative in nature wherein the results and conclusions were based on a quantitative data. This research collected data based on the samples and questionnaires distributed. In accomplishing the survey, it was conducted under the present situation in which the respondents are those formulating the nursing documentation. Sampling Procedure The researchers used a type of non-probability sampling called convenience sampling wherein the researchers selected respondents who are conveniently available. The process is continued until the desired sample size is obtained.
This is also known as accidental sampling. The researchers used this type of sampling because the Slovin’s formula will yield 83 respondents coming from 10 different areas. This would not be proportional since every area does not have the same number of nurses. The Respondents The target respondents of the study are random registered nurses in every area of Seamen’s Hospital. There are 105 registered nurses and 10 different areas in the said institution. Through the researcher’s statistician, the group took at least 50% of the total population as their respondents. Thus, at least 5 respondents were taken in each area as representative in each shift of duty. Locale of the Study
This study will be conducted in Seamen’s hospital. Criteria used in selecting a hospital for this study were: it must be a tertiary hospital, it must offer general health services, and it must be an affiliate of San Beda College. Guided by the criteria, the hospital chosen was Seamen’s Hospital (AMOSUP) in Intramuros, Manila. Criteria is used in order to choose a hospital that can be easily accessed by the researchers, those with better facility will provide a better result of the present study and understanding and also, those who will benefit also are students of San Beda College aside from the employed nurses, hospital administrators and the institution itself. Research Instrument
The study utilized a questionnaire as its data collection instrument. It addressed the need for a mass coverage of potential respondents as well as uniformity in its selection of answers. The research instrument that the researchers used in the study was the sample survey wherein the respondents are representative sample of a larger population. Questionnaires were distributed to the respondents and wrote their answers to the questions in appropriate spaces provided. The researchers used the Five point Likert scale. With the five-point scale, the points can be labelled: Very Often or Always (5), Often (4), Regularly (3), Sometimes (2) and Never or Very Rarely (1).
The five-point Likert scale had been the approach to get the goal of evaluating the respondents in terms of utilizing the nursing process in documentation. The researchers used a gauge and the questions assessed the extent utilization of the nursing process that comprises five subtypes of questions starting from assessment, diagnosis, planning, intervention and evaluation of patients. With four corresponding questions for each subtype, it aimed to know the extent of use of the nursing process by the professional nurses of Seamen’s Hospital in their documentation. Likert Scale consists of declarative items that express a viewpoint on a topic. Respondents were asked to indicate the degree to which they agree or disagree with the opinion expressed by the statement.
Scoring had been interpreted as follows for the interpretation of the scale as to the awareness of professional nurses: The higher the Likert scale, the higher the extent in use of nursing process in the documentation of professional nurses. The lower the Likert scale, the lower the extent in use of nursing process in the documentation of professional nurses. The responses were assigned with weights as follows: Responses Very often or Always Often Regularly Sometimes NeverWeights 5 4 3 2 1 Interpretation of results was based on the following: 4. 50 ??? 5. 00 – Very Often or Always 3. 50 ??? 4. 49 – Often 2. 50 ??? 3. 49 – Regularly 1. 50 ??? 2. 49 – Sometimes 1. 00 ??? 1. 49 – Never
Validation of research instrument The questionnaire proper made by the researchers was submitted to Ms. Liezel D. Rodriquez, psychometrician for validation. After checking, it was modified and approved as well as discussed with the researchers. On the other hand, the questionnaire was also submitted to Prof. Minerva Serrano, statistician for further checking of the self-made tool. The 28 item questionnaire developed by the researchers underwent a pilot study to test its reliability and validity. As deemed statistically significant by the researchers’ statistician. 15 out of the 105 nurses from the chosen hospital participated in the reliability test.
Upon distribution of the questionnaire, the respondents understood all the contents and answered them without questions. After the test, the questionnaire was found to be reliable and answered what the study wanted to measure. Furthermore, there were no changes done to the questionnaire as it was proven valid and reliable. Data gathering procedure The researchers have conducteda survey to random registered nurses in every area of Seamen’s hospital. The research group have explained diligently all items to be answered by the respondents. To further elaborate and provide adequate data, the group have assisted the respondents in answering the questionnaires that needed clarifications.
Before the study proceeded to the actual data collection phase, a formal letter was submitted to the targeted hospital site, Seamen’s hospital, Manila, requesting permission to conduct the study to their employed nurses. The researchers subjected the data collection instrument to a pretesting in the chosen hospital. An initial sample of 15 nurses randomly selected participated in the pilot study. Testing of the data collection instrument yielded valid and effective results. The finalized questionnaire was distributed to other registered nurses in Seamen’s hospital excluding those who participated in the pilot study. The study proper was conducted on October 12-13, 2010.
The distributed questionnaire was collected and tallied by the researchers for a statistical analysis of data employing for frequency count, weighted mean and overall mean. Having a descriptive-quantitative research design, the kind of information that the researchers would be able to obtain would be expressed in numerical values. The data collected was classified as a primary data wherein information is collected directly from the subjects or the respondents. Statistical treatment The researchers analyzed and interpreted the survey clearly and accurately gathered statistical computations. The data that was gathered were presented through ranking that would create a better understanding to the readers in terms of significance in each data.
The following are statistical tools that were utilized to analyze the gathered data: Frequency distribution table (FDT) A method of tallying and representing how often certain scores occur. In the creation of a frequency distribution, scores were usually grouped into class intervals, or ranges of numbers. Frequency distributions were very important in statistical analysis as they provide the basic representation of information. The frequency distribution was a clear informative chart, providing a way of showing the pattern of the marks obtained: their distribution across the range of possible values. The ranking is based on the scale one (1) to five (5); where one being the lowest and five being the highest.
Weighted mean contributed to a better understanding of the data gathered pertaining to the questionnaire proper. This gives significance to the gathered data for it had determined the relative importance of each quantity on the average results of the survey. The research group had computed for the weighted mean based on the collected data in the Five Point Likert scale. The formula to be used: a. Mean = ? x_ N Where: x = respondents’ rating N = frequency of respondents b. Weighted mean Xw = ? WiXi ? Wi Where: x= assigned weights W= frequency of respondents CHAPTER IV PRESENTATION, INTERPRETATION AND ANALYSIS OF DATA This chapter presents the obtained data which answers the questions posed in Chapter I.
The study aimed to determine the extent of utilization of the nursing process in the nursing documentation of the professional nurses at Seamen’s hospital. Table 1 Frequency and Percentage distribution of respondents according to their Extent of Utilization of the Nursing Process Based on Assessment Extent of utilization of the nursing process Question numberNever or very rarely (1)Some times (2)Regular- ly (3)Often (4)Very often or always (5)Mean responseInter- pretation ASSESSMENT 1. 1 (systematic gathering)00743194. 17Often 1. 2 (verifying data)00728344. 39Often 1. 3 (organizing, clustering, & interpreting)01638244. 23Often 1. 4 (identifying client’s skills)00639244. 26Often 4. 26Often
Table 1 presents the frequency distribution of responses in the assessment phase of the nursing process. It is further categorized into four skills related to nursing assessment. The extent of utilization is rated as Never or Very Rarely, Sometimes, Regularly, Often, and Very Often or Always. The overall mean response yielded 4. 26 which is interpreted as often. For the first category which is the systematic gathering of data, the distributions are as follows: 7 for regularly, 43 for often, and 19 for always. It garnered a mean response of 4. 17 which accounts for often. For verifying the collected subjective and objective data, the mean response is 4. 39.
Majority of the respondents answered very often. 7 of them answered regularly, 28 responded as often and 34 replied as very often. When it comes to organizing, clustering, and interpreting the collected data, the respondents, in general, answered very often with a computed weighted mean of 4. 23. The distributions are as follows: 0=never or very rarely, 1=sometimes, 6=regularly, 38=often, and 24=vey often. In identifying client’s skills to promote treatment and recovery, most of the respondents came back with a response of often with a calculated weighted mean of 4. 26. Distributions are as follows: 6 for regularly, 39 for often, and 24 for very often.
Based from the result, it implies that the nurses apply the assessment phase of the nursing process in their documentation. On the other hand, it is seen that in the utilization of the nursing process, the researchers assessed the five phases. Based from the table above, in the assessment phase, it showed that nurses often use their assessment skills which proves that they do the systematic gathering of subjective and objective data, they verify the collected subjective and objective data for congruence, accuracy and completeness, organize, cluster and interpret the collected data and identify the client’s skills, abilities and behaviours available to promote treatment and recovery.
Therefore, the nurses apply in the nursing practice the first phase of the nursing process. Table 2 Frequency and Percentage distribution of respondents according to their Extent of Utilization of the Nursing Process Based on Diagnosis Extent of utilization of the nursing process Question numberNever or very rarely (1)Some times (2)Regularly (3)Often (4)Very often or always (5)Mean responseInter- pretation DIAGNOSIS 1. 1 (interpreting or drawing conclusion)01834264. 23Often 1. 2 (using critical thinking skill)00829324. 35Often 1. 3 (categorizing client’s needs)01429354. 42Often 1. 4 (matching clustered data & formulating appropriate diagnosis)011029294. 3Often 4. 31Often As observed in table 2, the diagnosis phase is again divided into four activities or skills. The 69 respondents rated their extent of use as Never or Very Rarely, Sometimes, Regularly, Often, Very often or Always. In terms of interpreting or drawing conclusion, the greater part of the respondents said often. 1 answered sometimes while 8 replied as regularly, 34 responded often and the remaining 26 answered always. The computed weighted mean is 4. 23. As per using critical thinking skill 8 said regularly, 29 said often, and 32, which is majority of the respondents said very often or always, yielding 4. 35 in the weighted mean.
In terms of categorizing the client’s needs, the weighted mean computed was 4. 42. The frequency distributions are as follows: 0=never, 1=sometimes, 4= regularly, 29=often, and 35=very often. When it comes to matching the clustered data and formulating appropriate diagnosis, mostly, the respondents answered often and very often both getting an answer of 29. 1 said sometimes, and the remaining 10 of the respondents said regularly. Overall in diagnosis, the computed weighted mean is 4. 31 which are interpreted as often. In the table presented above, it indicates that the nurses utilize the diagnosis phase of the nursing process in their documentation.
In the diagnosis phase, it showed that the extent of use is often thus the nurses interpret or draw conclusion based from the subjective and objective data, use critical thinking skill and prioritize the identified health problem and use the subjective and objective data as basis in constructing nursing diagnosis, categorize the status of the client’s needs as actual or currently existing diagnoses and potential or risk diagnoses and matching the clustered data with the NANDA accepted diagnoses and formulating appropriate diagnosis. Therefore, the nurses also apply in the nursing practice the second phase of the nursing practice. Table 3 Frequency and Percentage distribution of respondents according to their Extent of Utilization of the Nursing Process Based on Planning Extent of utilization of the nursing process Question numberNever or very rarely (1)Some times (2)Regular- ly (3)Often (4)Very often or always (5)Mean responseInter- Pretation PLANNING 1. 1 (establishing priorities)00632314. 36Often 1. 2 identifying desired client outcomes)01834264. 23Often 1. 3 (making specific, measurable, attainable, realistic, and time-bounded [SMART] goals and objectives)01732294. 29Often 1. 4 (developing nursing interventions)01538254. 26Often 4. 28Often As seen on the table above, the planning phase of the nursing process is arranged in four divisions. The respondents were asked to rate their extent of utilization by using the scale of Never, Sometimes, Regularly, Often, and Always. Overall, it garnered a weighted mean of 4. 28 which