problem solving approach in nursing research

What is Problem-Solving in Nursing? (With Examples, Importance, & Tips to Improve)

Whether you have been a nurse for many years or you are just beginning your nursing career, chances are, you know that problem-solving skills are essential to your success. With all the skills you are expected to develop and hone as a nurse, you may wonder, “Exactly what is problem solving in nursing?” or “Why is it so important?” In this article, I will share some insight into problem-solving in nursing from my experience as a nurse. I will also tell you why I believe problem-solving skills are important and share some tips on how to improve your problem-solving skills.

What Exactly is Problem-Solving in Nursing?

5 reasons why problem-solving is important in nursing, reason #1: good problem-solving skills reflect effective clinical judgement and critical thinking skills, reason #2: improved patient outcomes, reason #3: problem-solving skills are essential for interdisciplinary collaboration, reason #4: problem-solving skills help promote preventative care measures, reason #5: fosters opportunities for improvement, 5 steps to effective problem-solving in nursing, step #1: gather information (assessment), step #2: identify the problem (diagnosis), step #3: collaborate with your team (planning), step #4: putting your plan into action (implementation), step #5: decide if your plan was effective (evaluation), what are the most common examples of problem-solving in nursing, example #1: what to do when a medication error occurs, how to solve:, example #2: delegating tasks when shifts are short-staffed, example #3: resolving conflicts between team members, example #4: dealing with communication barriers/lack of communication, example #5: lack of essential supplies, example #6: prioritizing care to facilitate time management, example #7: preventing ethical dilemmas from hindering patient care, example #8: finding ways to reduce risks to patient safety, bonus 7 tips to improve your problem-solving skills in nursing, tip #1: enhance your clinical knowledge by becoming a lifelong learner, tip #2: practice effective communication, tip #3: encourage creative thinking and team participation, tip #4: be open-minded, tip #5: utilize your critical thinking skills, tip #6: use evidence-based practices to guide decision-making, tip #7: set a good example for other nurses to follow, my final thoughts, list of sources used for this article.

• Faye Abdellah: 21 Nursing Problems Theory

Faye Abdellah is a celebrated nurse theorist, military nurse, and leader in nursing research. Get to know the major concepts of her “ 21 Nursing Problems ” nursing theory, its application, and its impact on nursing.

Table of Contents

Early life of faye abdellah, as an educator, as a researcher, established nursing standards, military nursing service, abdellah’s typology of 21 nursing problems, awards and honors, assumptions, nursing problems, problem solving, basic needs, sustenal care needs, remedial care needs, restorative care needs, patient-centered approaches to nursing, 21 nursing problems and the nursing process, recommended resources, external links, biography of faye glenn abdellah.

Faye Glenn Abdellah (March 13, 1919 – present) is a nursing research pioneer who developed the “Twenty-One Nursing Problems.” Her nursing model was progressive for the time in that it refers to a nursing diagnosis during a time in which nurses were taught that diagnoses were not part of their role in health care.

She was the first nurse officer to rank a two-star rear admiral, the first nurse, and the first woman to serve as a Deputy Surgeon General.

On March 13, 1919, Faye Abdellah was born in New York to a father of Algerian heritage and a Scottish mother. Her family subsequently moved to New Jersey, where she attended high school.

Years later, on May 6, 1937, the German hydrogen-fueled airship Hindenburg exploded over Lakehurst.

Abdellah and her brother witnessed the explosion, destruction, and fire after the ignited hydrogen killed many people. That incident became the turning point in Abdellah’s life. It was that time when she realized that she would never again be powerless to assist when people were in such a dire need of assistance. It was at that moment she vowed that she would learn to nurse and become a professional nurse.

Faye Abdellah earned a nursing diploma from Fitkin Memorial Hospital’s School of Nursing, now known as Ann May School of Nursing.

It was sufficient to practice nursing during her time in the 1940s, but she believed that nursing care should be based on research, not hours of care.

Abdellah went on to earn three degrees from Columbia University: a bachelor of science degree in nursing in 1945, a master of arts degree in physiology in 1947, and a doctor of education degree in 1955.

With her advanced education, Abdellah could have chosen to become a doctor. However, as she explained in one of her interviews that she wanted to be an M.D. because she could do all she wanted to do in nursing, which is a caring profession.

Career and Appointments

In her early twenties, Faye Abdellah worked as a health nurse at a private school, and her first administrative position was on the faculty of Yale University from 1945-1949. At that time, she was required to teach a class called “120 Principles of Nursing Practice,” using a standard nursing textbook published by the National League for Nursing. The book included guidelines that had no scientific basis, which challenged Abdellah to explain everything she called the “brilliant” students.

After a year, Abdellah became so frustrated that she gathered her colleagues in the Yale courtyard and burned the textbooks. The next morning the school’s dean told her she would have to pay for the destroyed texts. It took a year for Abdellah to settle the debt, but she never regretted her actions because it started her on the long road to pursue the scientific basis of the nursing practice .

In 1949, she met Lucile Petry Leone, the first Nurse Officer, and decided to join the Public Health Service. Her first assignment was with the division of nursing that focused on research and studies. They performed studies with numerous hospitals to improve nursing practice .

Abdellah was an advocate of degree programs for nursing. Diploma programs, she believes, were never meant to prepare nurses at the professional level. Nursing education, she argued, should be based on research; she herself became among the first in her role as an educator to focus on theory and research. Her first studies were qualitative; they simply described situations. As her career progressed, her research evolved to include physiology, chemistry, and behavioral sciences.

In 1957, Abdellah spearheaded a research team in Manchester, Connecticut, that established the groundwork for what became known as progressive patient care . In this framework, critical care patients were treated in an intensive care unit, followed by a transition to immediate care and then home care. The first two segments of the care program proved very popular within the caregiver profession. Abdellah is also credited with developing the first nationally tested coronary care unit as an outgrowth of her work in Manchester.

Home care, which is the third phase of the progressive patient care equation, was not widely accepted in the mid-twentieth century. Abdellah explained that people at the time kept saying home care would mean having a maid or a nurse in everyone’s home. They could not figure out that home care with nurses teaching self-care would help patients regain independent function. Forty years later, home care had become an essential part of long-term health care.

In another innovation within her field, Abdellah developed the Patient Assessment of Care Evaluation (PACE), a system of standards used to measure the relative quality of individual health-care facilities that were still used in the healthcare industry into the 21st century. She was also one of the first people in the healthcare industry to develop a classification system for patient care and patient-oriented records.

Classification systems have evolved in different ways within the health-care industry, and Abdellah’s work was foundational in developing the most widely used form: Diagnostic related groups, or DRGs. DRGs, which became the standard coding system used by Medicare, categorize patients according to particular primary and secondary diagnoses. This system keeps health-care costs down because each DRG code includes the maximum amount Medicare will payout for a specific diagnosis or procedure while also taking into account patient age and length of stay in a healthcare facility. Providers are given an incentive to keep costs down because they only realize a profit if costs are less than the amount specified by the relevant DRG category.

During her 40-year career as a Commissioned Officer in the U.S. Public Health Service from 1949 to 1989, Abdellah was assigned to work with the Korean people during the Korean War. As a senior officer, she was alternatively assigned to Japan, China , Russia, Australia, and the Scandinavian countries to identify the Public Health Service’s role in dealing with various health problems. She was able to assist and initiate, in an advisory role, numerous studies in those countries.

She served as Chief Nurse Officer from 1970 to 1987 and was the first nurse to achieve the rank of a two-star Flag Officer named by U.S. Surgeon General C. Everett Koop as the first woman and nurse Deputy Surgeon General from 1982 to 1989. After retirement, Abdellah founded and served as the first dean in the Graduate School of Nursing, GSN, Uniformed Services University of the Health Sciences (USUHS).

Faye Abdellah is well known for developing the “Twenty-One Nursing Problems Theory” that has interrelated the concepts of health, nursing problems, and problem-solving.

She views nursing as an art and a science that molds the attitude, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help individuals cope with their health needs, whether they are ill or well.

She used Henderson’s 14 basic human needs and nursing research to establish the classification of nursing problems.

Faye Abdellah’s theory is further discussed below.

As a consultant and educator, Faye Abdellah shared her nursing theories with caregivers around the world. She led seminars in France, Portugal, Israel, Japan, China, New Zealand, Australia, and the former Soviet Union. She also served as a research consultant to the World Health Organization. From her global perspective, Abdellah learned to appreciate nontraditional and complementary medical treatments and developed the belief such non-Western treatments deserved scientific research.

Also, she has been active in professional nursing associations and is a prolific author, with more than 150 publications. Her publications include Better Nursing Care Through Nursing Research and Patient-Centered Approaches to Nursing . She also developed educational materials in many areas of public health, including AIDS , hospice care , and drug addiction.

Abdellah considers her greatest accomplishment being able to “play a role in establishing a foundation for nursing research as a science.” Her book, Patient-Centered Approaches to Nursing , emphasizes nursing science and has elicited changes throughout nursing curricula. Her work, which is based on the problem-solving method, serves as a vehicle for delineating nursing (patient) problems as the patient moves toward a healthy outcome.

Faye Abdellah is recognized as a leader in nursing research and nursing as a profession within the Public Health Service (PHS) and as an international expert on health problems. She was named a “living legend” by the American Academy of Nursing in 1994 and was inducted into the National Women’s Hall of Fame in 2000 for a lifetime spent establishing and leading essential health care programs for the United States. In 2012, Abdellah was inducted into the American Nurses Association Hall of Fame for a lifetime of contributions to nursing.

Her contributions to nursing and public health have been recognized with almost 90 professional and academic honors, such as the Allied Signal Achievement Award for pioneering research in aging and Sigma Theta Tau’s Lifetime Achievement Award.

Abdellah’s leadership , her publications, and her lifelong contributions have set a new standard for nursing and health care. Her legacy of more than 60 years of extraordinary accomplishments lives nationally and globally.

Aside from being the first nurse and the first woman to serve as a Deputy Surgeon General, Faye Glenn Abdellah also made a name in the nursing profession to formulate her “21 Nursing Problems Theory.” Her theory changed the focus of nursing from disease-centered to patient-centered and began to include the care of families and the elderly in nursing care. The Patient Assessment of Care Evaluation developed by Abdellah is now the standard used in the United States.

Abdellah’s 21 Nursing Problems Theory

According to Faye Glenn Abdellah’s theory, “Nursing is based on an art and science that molds the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people, sick or well, cope with their health needs.”

The patient-centered approach to nursing was developed from Abdellah’s practice, and the theory is considered a human needs theory. It was formulated to be an instrument for nursing education , so it most suitable and useful in that field. The nursing model is intended to guide care in hospital institutions but can also be applied to community health nursing, as well.

The assumptions Abdellah’s “21 Nursing Problems Theory” relate to change and anticipated changes that affect nursing; the need to appreciate the interconnectedness of social enterprises and social problems; the impact of problems such as poverty, racism, pollution, education, and so forth on health and health care delivery; changing nursing education ; continuing education for professional nurses; and development of nursing leaders from underserved groups.

• Learn to know the patient.
• Sort out relevant and significant data.
• Make generalizations about available data concerning similar nursing problems presented by other patients.
• Identify the therapeutic plan.
• Test generalizations with the patient and make additional generalizations.
• Validate the patient’s conclusions about his nursing problems.
• Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting this behavior.
• Explore the patient’s and family’s reaction to the therapeutic plan and involve them in the plan.
• Identify how the nurse feels about the patient’s nursing problems.
• Discuss and develop a comprehensive nursing care plan .

Major Concepts of 21 Nursing Problems Theory

The model has interrelated concepts of health and nursing problems and problem-solving, which is inherently logical in nature.

She describes nursing recipients as individuals (and families), although she does not delineate her beliefs or assumptions about the nature of human beings.

Health, or the achieving of it, is the purpose of nursing services. Although Abdellah does not define health, she speaks to “total health needs” and “a healthy state of mind and body.”

Health may be defined as the dynamic pattern of functioning whereby there is a continued interaction with internal and external forces that results in the optimal use of necessary resources to minimize vulnerabilities.

Society is included in “ planning for optimum health on local, state, and international levels.” However, as Abdellah further delineates her ideas, the focus of nursing service is clearly the individual.

The client’s health needs can be viewed as problems, overt as an apparent condition, or covert as a hidden or concealed one.

Because covert problems can be emotional, sociological, and interpersonal in nature, they are often missed or misunderstood. Yet, in many instances, solving the covert problems may solve the overt problems as well.

Quality professional nursing care requires that nurses be able to identify and solve overt and covert nursing problems. The problem-solving process can meet these requirements by identifying the problem, selecting pertinent data, formulating hypotheses, testing hypotheses through collecting data, and revising hypotheses when necessary based on conclusions obtained from the data.

Subconcepts

The following are the subconcepts of Faye Abdellah’s “21 Nursing Problems” theory and their definitions.

The 21 nursing problems fall into three categories: physical, sociological, and emotional needs of patients; types of interpersonal relationships between the patient and nurse; and common elements of patient care . She used Henderson’s 14 basic human needs and nursing research to establish the classification of nursing problems. Abdellah’s 21 Nursing Problems are the following:

• To maintain good hygiene and physical comfort .
• To promote optimal activity: exercise, rest, sleep
• To promote safety by preventing accidents, injuries, or other trauma and preventing the spread of infection .
• To maintain good body mechanics and prevent and correct the deformity.
• To facilitate the maintenance of a supply of oxygen to all body cells.
• To facilitate the maintenance of nutrition for all body cells.
• To facilitate the maintenance of elimination.
• To facilitate the maintenance of fluid and electrolyte balance.
• To recognize the physiologic responses of the body to disease conditions—pathologic, physiologic, and compensatory.
• To facilitate the maintenance of regulatory mechanisms and functions.
• To facilitate the maintenance of sensory function.
• To identify and accept positive and negative expressions, feelings, and reactions.
• To identify and accept interrelatedness of emotions and organic illness.
• To facilitate the maintenance of effective verbal and nonverbal communication .
• To promote the development of productive interpersonal relationships.
• To facilitate progress toward achievement and personal spiritual goals.
• To create or maintain a therapeutic environment.
• To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs.
• To accept the optimum possible goals in the light of limitations, physical and emotional.
• To use community resources as an aid in resolving problems that arise from an illness.
• To understand the role of social problems as influencing factors in the cause of illness.

Moreover, patients’ needs are further divided into four categories: basic to all patients , sustenance care needs , remedial care needs , and restorative care needs .

The basic needs of an individual patient are to maintain good hygiene and physical comfort ; promote optimal health through healthy activities, such as exercise, rest, and sleep ; promote safety through the prevention of health hazards like accidents, injury , or other trauma and the prevention of the spread of infection; and maintain good body mechanics and prevent or correct deformity.

Sustenal care needs to facilitate the maintenance of a supply of oxygen to all body cells; facilitate the maintenance of nutrition of all body cells; facilitate the maintenance of elimination; facilitate the maintenance of fluid and electrolyte balance; recognize the physiological responses of the body to disease conditions; facilitate the maintenance of regulatory mechanisms and functions, and facilitate the maintenance of sensory function.

Remedial care needs to identify and accept positive and negative expressions, feelings, and reactions; identify and accept the interrelatedness of emotions and organic illness; facilitate the maintenance of effective verbal and non- verbal communication ; promote the development of productive interpersonal relationships; facilitate progress toward achievement of personal spiritual goals; create and maintain a therapeutic environment; and facilitate awareness of the self as an individual with varying physical, emotional, and developmental needs.

Restorative care needs include the acceptance of the optimum possible goals in light of limitations, both physical and emotional; the use of community resources as an aid to resolving problems that arise from an illness; and the understanding of the role of social problems as influential factors in the case of illness.

Abdellah’s work, based on the problem-solving method, serves as a vehicle for delineating nursing (patient) problems as the patient moves toward a healthy outcome. The theory identifies ten steps to identify the patient’s problem and 11 nursing skills to develop a treatment typology.

The ten steps are:

• Validate the patient’s conclusions about his nursing problems.
• Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his or her behavior.
• Explore the patient and their family’s reactions to the therapeutic plan and involve them in the plan.
• Identify how the nurses feel about the patient’s nursing problems.

The 11 nursing skills are:

• observation of health status
• skills of communication
• application of knowledge
• the teaching of patients and families
• planning and organization of work
• use of resource materials
• use of personnel resources
• problem-solving
• the direction of work of others
• therapeutic uses of the self
• nursing procedure

Abdellah also explained nursing as a comprehensive service, which includes:

• Recognizing the nursing problems of the patient
• Deciding the appropriate course of action to take in terms of relevant nursing principles
• Providing continuous care of the individual’s total needs
• Providing continuous care to relieve pain and discomfort and provide immediate security for the individual
• Adjusting the total nursing care plan to meet the patient’s individual needs
• Helping the individual to become more self- directing in attaining or maintaining a healthy state of body and mind
• Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations
• Helping the individual to adjust to his limitations and emotional problems
• Working with allied health professions in planning for optimum health on local, state, national, and international levels
• Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet people’s health needs

Faye Abdellah’s work is a set of problems formulated in terms of nursing-centered services used to determine the patient’s needs. The nursing-centered orientation to client care appears to be contradicting the client-centered approach that Abdellah professes to support. This can be observed by her desire to move away from a disease-centered orientation.

In her attempt to bring the nursing practice to its proper relationship with restorative and preventive measures for meeting total client needs, she seems to swing the pendulum to the opposite pole, from the disease orientation to nursing orientation, while leaving the client somewhere in the middle.

The nursing process in Abdellah’s theory includes assessment , nursing diagnosis , planning, implementation , and evaluation.

In the assessment phase , the nursing problems implement a standard procedure for data collection . A principle underlying the problem-solving approach is that for each identified problem, pertinent data is collected. The overt or covert nature of problems necessitates a direct or indirect approach, respectively.

The outcome of the collection of data in the first phase concludes the patient’s possible problems, which can be grouped under one or more of the broader nursing problems. This will further lead to the nursing diagnosis .

After formulating the diagnosis, a nursing care plan is developed, and appropriate nursing interventions are determined. The nurse now sets those interventions in action, which complete the implementation phase of the nursing process .

The evaluation takes place after the interventions have been carried out. The most convenient evaluation would be the nurse’s progress or lack of progress toward achieving the goals established in the planning phase.

With Faye Abdellah’s aim in formulating a clear categorization of patient’s problems as health needs, she rather conceptualized nurses’ actions in nursing care, which is contrary to her aim. Nurses’ roles were defined to alleviate the problems assessed through the proposed problem-solving approach.

The problem-solving approach introduced by Abdellah has the advantage of increasing the nurse’s critical and analytical thinking skills since the care to be provided would be based on sound assessment and validation of findings.

One can identify that the framework is strongly applied to individuals as the focus of nursing care. The inclusion of an aggregate of people such as the community or society would make the theory of Abdellah more generalizable since nurses do not only provide one-person service, especially now that the community healthcare level is sought to have higher importance than curative efforts in the hospital.

The following are the strengths of Faye Abdellah’s “21 Nursing Problems” theory.

• The problem-solving approach is readily generalizable to the client with specific health needs and specific nursing problems.
• With the model’s nature, healthcare providers and practitioners can use Abdellah’s problem-solving approach to guide various activities within the clinical setting. This is true when considering a nursing practice that deals with clients with specific needs and specific nursing problems.
• The language of Faye Abdellah’s framework is simple and easy to comprehend.
• The theoretical statement greatly focuses on problem-solving, an activity that is inherently logical in nature.

The following are the limitations of Faye Abdellah’s “21 Nursing Problems” theory.

• The major limitation to Abdellah’s theory and the 21 nursing problems is their robust nurse-centered orientation. She rather conceptualized nurses’ actions in nursing care which is contrary to her aim.
• Another point is the lack of emphasis on what the client is to achieve was given in client care.
• The framework seems to focus quite heavily on nursing practice and individuals. This somewhat limits the generalizing ability, although the problem-solving approach is readily generalizable to clients with specific health needs and specific nursing.
• Also, Abdellah’s framework is inconsistent with the concept of holism. The nature of the 21 nursing problems attests to this. As a result, the client may be diagnosed with numerous problems leading to fractionalized care efforts. Potential problems might be overlooked because the client is not deemed to be in a particular illness stage.

Abdellah’s typology of 21 nursing problems is a conceptual model mainly concerned with patient’s needs and nurses’ role in problem identification using a problem analysis approach.

According to the model, patients are described as having physical, emotional, and sociological needs. People are also the only justification for the existence of nursing. Without people, nursing would not be a profession since they are the recipients of nursing.

Patient-centered approaches to nursing health are described as a state mutually exclusive of illness. Abdellah does not define health but speaks to “total health needs” and “a healthy state of mind and body” in her nursing description.

However, Abdellah rather conceptualized nurses’ actions in nursing care, contrary to her aim of formulating a clear categorization of patients’ problems as health needs. Nurses’ roles were defined to alleviate the problems assessed through the proposed problem-solving approach.

As a whole, the theory is intended to guide care not just in the hospital setting but can also be applied to community nursing, as well. The model has interrelated concepts of health and nursing problems and problem-solving, which is inherently logical in nature.

Furthermore, the 21 nursing problems progressed to a second-generation development referred to as patient problems and patient outcomes . Abdellah educated the public on AIDS , drug addiction, violence, smoking, and alcoholism. Her work is a problem-centered approach or philosophy of nursing.

Recommended books and resources to learn more about nursing theory:

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

• Nursing Theorists and Their Work (10th Edition) by Alligood Nursing Theorists and Their Work, 10th Edition provides a clear, in-depth look at nursing theories of historical and international significance. Each chapter presents a key nursing theory or philosophy, showing how systematic theoretical evidence can enhance decision making, professionalism, and quality of care.
• Knowledge Development in Nursing: Theory and Process (11th Edition) Use the five patterns of knowing to help you develop sound clinical judgment. This edition reflects the latest thinking in nursing knowledge development and adds emphasis to real-world application. The content in this edition aligns with the new 2021 AACN Essentials for Nursing Education.
• Nursing Knowledge and Theory Innovation, Second Edition: Advancing the Science of Practice (2nd Edition) This text for graduate-level nursing students focuses on the science and philosophy of nursing knowledge development. It is distinguished by its focus on practical applications of theory for scholarly, evidence-based approaches. The second edition features important updates and a reorganization of information to better highlight the roles of theory and major philosophical perspectives.
• Nursing Theories and Nursing Practice (5th Edition) The only nursing research and theory book with primary works by the original theorists. Explore the historical and contemporary theories that are the foundation of nursing practice today. The 5th Edition, continues to meet the needs of today’s students with an expanded focus on the middle range theories and practice models.
• Strategies for Theory Construction in Nursing (6th Edition) The clearest, most useful introduction to theory development methods. Reflecting vast changes in nursing practice, it covers advances both in theory development and in strategies for concept, statement, and theory development. It also builds further connections between nursing theory and evidence-based practice.
• Middle Range Theory for Nursing (4th Edition) This nursing book’s ability to break down complex ideas is part of what made this book a three-time recipient of the AJN Book of the Year award. This edition includes five completely new chapters of content essential for nursing books. New exemplars linking middle range theory to advanced nursing practice make it even more useful and expand the content to make it better.
• Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice This book offers balanced coverage of both qualitative and quantitative research methodologies. This edition features new content on trending topics, including the Next-Generation NCLEX® Exam (NGN).
• Nursing Research (11th Edition) AJN award-winning authors Denise Polit and Cheryl Beck detail the latest methodologic innovations in nursing, medicine, and the social sciences. The updated 11th Edition adds two new chapters designed to help students ensure the accuracy and effectiveness of research methods. Extensively revised content throughout strengthens students’ ability to locate and rank clinical evidence.

Recommended site resources related to nursing theory:

• Nursing Theories and Theorists: The Definitive Guide for Nurses MUST READ! In this guide for nursing theories, we aim to help you understand what comprises a nursing theory and its importance, purpose, history, types or classifications, and give you an overview through summaries of selected nursing theories.

Other resources related to nursing theory:

• Betty Neuman: Neuman Systems Model
• Dorothea Orem: Self-Care Deficit Theory
• Dorothy Johnson: Behavioral System Model
• Florence Nightingale: Environmental Theory
• Hildegard Peplau: Interpersonal Relations Theory
• Ida Jean Orlando: Deliberative Nursing Process Theory
• Imogene King: Theory of Goal Attainment
• Jean Watson: Theory of Human Caring
• Lydia Hall: Care, Cure, Core Nursing Theory
• Madeleine Leininger: Transcultural Nursing Theory
• Martha Rogers: Science of Unitary Human Beings
• Myra Estrin Levine: The Conservation Model of Nursing
• Nola Pender: Health Promotion Model
• Sister Callista Roy: Adaptation Model of Nursing
• Virginia Henderson: Nursing Need Theory
• Abdellah, F.G. The federal role in nursing education. Nursing outlook. 1987, 35(5),224-225.
• Abdellah, F.G. Public policy impacting on nursing care of older adults. In E.M. Baines (Ed.), perspectives on gerontological nursing. Newbury, CA: Sage publications. 1991.
• Abdellah, F.G., & Levine, E. Preparing nursing research for the 21st century. New York: Springer. 1994.
• Abdellah, F.G., Beland, I.L., Martin, A., & Matheney, R.V. Patient-centered approaches to nursing (2nd ed.). New York: Mac Millan. 1968.
• Abdellah, F.G. Evolution of nursing as a profession: perspective on manpower development. International Nursing Review, 1972); 19, 3..
• Abdellah, F.G.). The nature of nursing science. In L.H. Nicholl (Ed.), perspectives on nursing theory. Boston: Little, Brown, 1986.
• Craddock, J. (2013). Encyclopedia of world biography supplement. Detroit, Mich.: Gale. https://www.encyclopedia.com/doc/1G2-3435000010.html
• Better Patient Care Through Nursing Research
• Preparing Nursing Research for the 21st Century: Evolution, Methodologies, Challenges

With contributions by Wayne, G. (for Biography), Vera, M. 

6 thoughts on “Faye Abdellah: 21 Nursing Problems Theory”

Thank you for sharing Angelo

I mean no disrespect to RADM Abdellah’s service to our nation, but the USPHS is not part of the military. It is part of the Uniformed Services, but not in the Dept of Defense.

Oh! Good to know! Thanks for clarifying :)

An insightful information 👌

I was a brand new lieutenant US Army and just graduated from college to become a nurse. I had used Faye Abdellah’s Theories as the rationale for nursing care plans in school papers, so I was very familiar. A big professional regret was I had the opportunity to meet Faye at a nursing conference in Germany. I was a timid young nurse and somewhat shy and saw her in one of the conference sessions sitting by herself. I wish I introduced myself and talked to her. I really respected her as a pioneer in nursing theory.

thanks for sharing.

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Problem Solving for Better Health Nursing: a working approach to the development and dissemination of applied research in developing countries

Affiliation.

• 1 Dreyfus Health Foundation of The Rogosin Institute, affiliated with New York-Presbyterian Hospital and Weill Medical College of Cornell University, New York, NY 10021, USA. [email protected]
• PMID: 16728296
• DOI: 10.1016/j.apnr.2005.12.001

This article describes the international component of the Problem Solving for Better Health Nursing (PSBHN) program initiated by the Dreyfus Health Foundation (DHF) in 2002. PSBHN is operational in 14 countries in addition to the United States. A PSBHN initiative is described, and attention is given to lessons learned and plans for the future.

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• The effectiveness of empathy training on the empathy skills of nurses working in intensive care units. Mirzaei Maghsud A, Abazari F, Miri S, Sadat Nematollahi M. Mirzaei Maghsud A, et al. J Res Nurs. 2020 Dec;25(8):722-731. doi: 10.1177/1744987120902827. Epub 2020 Oct 12. J Res Nurs. 2020. PMID: 34394695 Free PMC article.
• The Relationship between Self-Directed Learning and Problem-Solving Ability: The Mediating Role of Academic Self-Efficacy and Self-Regulated Learning among Nursing Students. Hwang Y, Oh J. Hwang Y, et al. Int J Environ Res Public Health. 2021 Feb 11;18(4):1738. doi: 10.3390/ijerph18041738. Int J Environ Res Public Health. 2021. PMID: 33670105 Free PMC article.
• The effect of web quest and team-based learning on students' self-regulation. Badiyepeymaie Jahromi Z, Mosalanejad L, Rezaee R. Badiyepeymaie Jahromi Z, et al. J Adv Med Educ Prof. 2016 Apr;4(2):80-7. J Adv Med Educ Prof. 2016. PMID: 27104202 Free PMC article.
• Professional practice models for nurses in low-income countries: an integrative review. Ng'ang'a N, Byrne MW. Ng'ang'a N, et al. BMC Nurs. 2015 Aug 21;14:44. doi: 10.1186/s12912-015-0095-5. eCollection 2015. BMC Nurs. 2015. PMID: 26300694 Free PMC article.
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Nurse leaders as problem-solvers

Addressing lateral and horizontal violence.

Anthony, Michelle R. PhD, RN; Brett, Anne Liners PhD, RN

Michelle R. Anthony is a program coordinator at Columbia (S.C.) VA Health Care System. Anne Liners Brett is doctoral faculty at the University of Phoenix in Tempe, Ariz.

Acknowledgment: The authors acknowledge the support of the University of Phoenix Center for Educational and Instructional Technology Research.

The contents of this article do not represent the views of the US Department of Veterans Affairs or the United States Government.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

For more than 126 additional continuing-education articles related to management topics, go to NursingCenter.com/CE .

Earn CE credit online: Go to http://nursing.ceconnection.com and receive a certificate within minutes .

Read about a qualitative, grounded theory study that looked to gain a deeper understanding of nurse leaders' perceptions of their role in addressing lateral and horizontal violence, and the substantive theory developed from the results.

The issue of lateral and horizontal violence (LHV) has plagued the nursing profession for more than 3 decades, yet solutions remain elusive. The significance of LHV isn't lost on nurse leaders because it creates an unhealthy work environment. Research literature worldwide has continued to report the prevalence of disruptive behaviors experienced by nursing students, novice nurses, and seasoned nurses in the workforce. The World Health Organization, International Council of Nurses, and Public Services International have recognized this issue as a major global public health priority. 1

LHV, also called nurse-on-nurse aggression, disruptive behavior, or incivility, undermines a culture of safety and negatively impacts patient care. 2,3 This experience, known to nurses as “eating their young,” isn't only intimidating and disruptive, it's also costly and demoralizing to the nursing profession and healthcare organizations. 4,5 Although the impact of LHV can be dreadful for both the institution and its staff, little is known about the reasons for these behaviors among nursing professionals. 2

LHV encompasses all acts of meanness, hostility, disruption, discourtesy, backbiting, divisiveness, criticism, lack of unison, verbal or mental abuse, and scapegoating. 6 The sole intent of bullying behaviors is to purposefully humiliate and demean victims. Bullying behaviors also taint healthcare organizations; cause irreparable harm to workplace culture; breakdown team communication; and severely impact the quality of the care provided, thereby jeopardizing patient safety. 7,8 Researchers have reported that acts of LHV are used to demonstrate power, domination, or aggression; for retribution; to control others; and to enhance self-image. 9-12

Previous studies have shown that the frequency of LHV in healthcare organizations is quite severe, with about 90% of new nurses surveyed reporting acts of incivility by their coworkers. 13 Sixty-five percent of nurses in one survey reported witnessing incidents of despicable acts, whereas another 46% of coworkers in the same survey reported the issue as “very serious” and “somewhat serious.” 13

LHV poses a significant challenge for nurse leaders who are legally and morally responsible for providing a safe working environment. 2,6 The purpose of this qualitative, grounded theory study was to gain a deeper understanding of nurse leaders' perceptions of their role in addressing LHV and develop a substantive theory from the results.

Literature review

A paucity of evidence exists in the literature regarding how nurse leaders perceive their role in addressing LHV. 14 Studies have shown that this phenomenon is attributed to heavy workloads, a stressful work environment, and lack of workgroup cohesiveness, as well as organizational factors such as misuse of authority and the lack of organizational policies and procedures for addressing LHV behaviors. 15

In one study, one-third of the nurses reported that they had observed emotional abuse during several of their work shifts. 16 Another study indicated that 30% of survey respondents (n = 2,100) stated LHV occurs weekly. 17 A third study revealed that 25% of participants noted LHV happened monthly, and a fourth study of ED nurses reported that about 27.3% of the nurses had experienced LHV perpetrated by nursing leadership (managers, supervisors, charge nurses, and directors), physicians, or peers in the last 6 months. 18

In a survey completed by members of the Washington State Emergency Nurses Association, 27% of respondents experienced acts of bullying in the past 6 months. 19 Another study reported that 27% to 85% of nurse respondents had experienced some form of uncivil behavior. 20 Other data have shown that those more vulnerable to violent, disruptive, and intimidating behaviors are newly licensed nurses beginning their careers. 21

Although nurse leaders can be perpetrators of LHV, they play an essential role in addressing LHV behaviors and creating a safe work environment. 22 The literature suggests that, in many cases, a lack of awareness and response by nurse leaders adds to the prevalence of LHV. 23 This may be due, in part, to nurse leaders being aligned with the perpetrators who are creating the toxic work environment. 6 The literature suggests that an environment where staff members feel safe to practice results in a culture that decreases burnout and promotes nurse retention and quality outcomes. 24,25

This qualitative, grounded theory study focused on nurse leaders' perception of their role in breaking the cycle of LHV for staff members whom they supervise. Two research questions guided the study: 1. How do nurse leaders perceive their role in addressing LHV among nursing staff members under their supervision? 2. What substantive theory may emerge from the data collected during interviews with nurse leaders?

A grounded theory methodology was used to explore the nurse leader's role in addressing LHV with the intent of developing a substantive theory through the meaningful organization of data themes to provide a framework to address the phenomenon of LHV. Purposive sampling was used to recruit a total of 14 participants for this study from a large healthcare system in the Southeastern US. The participants were chosen because of their experience with LHV and their ability to discuss and reflect on those experiences. Informed consent was obtained before the start of the study, which included explaining the reason for the study and what to expect. In addition, permission was obtained from the Institutional Review Board.

Data collection and analysis

Demographic data collected to describe the sample included gender, age range, number of years holding a management position, supervisory responsibility, and highest degree obtained. (See Table 1 .)

Semistructured, in-depth interviews were the primary mode of data collection. The recorded interviews were conducted face-to-face and lasted about 60 minutes. Data collection continued until saturation was achieved. Data saturation occurred when no new descriptive codes, categories, or themes were emerging from the analyzed data. The interviews were transcribed verbatim and verified through a member check process.

During the data analysis process, themes and patterns were identified. Data from each participant's interview were examined to determine if the responses were aligned with the identified themes. Analysis of the data included coding at increasingly abstract levels and constant comparison. Qualitative software assisted in coding the information and uncovering subtle trends.

Four themes emerged from core categories developed during the qualitative data coding process.

Theme 1: Understanding/addressing LHV . In question one, participants were asked to describe their understanding of LHV. Five subthemes emerged from the data collected with this question. (See Table 2 .)

Theme 2: Experience addressing LHV . In the second question, participants were asked about their experience with addressing incidents of LHV. Six subthemes were identified. (See Table 3 .)

Theme 3: Role perception in addressing LHV . In the third question, participants were asked what they perceive their role to be in addressing LHV. Six subthemes resulted from this question. (See Table 4 .)

Theme 4: Organizational impediment to addressing LHV . In question four, participants were asked to describe the factors within the organization that influence or impede their role in addressing LHV. This question yielded nine subthemes. (See Table 5 .)

Substantive theory

As a result of the themes that emerged from the data, a substantive theory was developed. This is especially important for the nursing profession to develop as a scientifically based practice. Theories help guide research and provide the expansion, generation, and validation of the science of nursing knowledge. 26 The substantive theory will help nurse leaders become more cognizant of the role that effective leadership plays in preventing or intervening in incidents of LHV in the workplace. The analysis revealed that nurse leaders are aware that the quality of patient care and staff well-being can be adversely affected by the impact of LHV.

Data themes were used to formulate the following theory: Nurse leaders address LHV affecting their staff members by solving problems, creating a safe work environment, and reducing institutional barriers that impede addressing LHV in a timely fashion. Nurse leaders perceive their role as a problem-solver, which is a necessary step in advocacy. 27 Problem-solving is a process that contains the elements of decision-making and critical thinking. 28

The theory that emerged from the core categories explicitly focused on the central phenomenon of LHV in the nursing work environment. Figure 1 shows the interrelatedness of the themes to the resultant substantive theory.

Discussion and implications

The study results have several implications for both the nursing profession and nurse leaders. The nursing profession requires decisive and robust leadership, and the role of the nurse leader is to be a combination of nurturer, investigator, and judge to examine incidents of LHV. 26,29-32 Nurse leaders are responsible for setting the tone and expectations for a safe work environment. This includes modeling the expected ethical behaviors; for example, doing the right things for the right reasons, being collegial toward each other, and being respectful of other's differences. One participant remarked, “This is a different world based on how I was raised. I was raised to be respectful to people.”

In addition, nurse leaders are responsible for enforcing policies created to address disruptive behaviors and working with the administration as soon as an incident occurs. Past research indicates that a healthy and collaborative work environment fosters nurse engagement and patient safety. 25,30 Staff members and patients need a leader to protect them when necessary; thus, the nurse leader needs to “walk the walk” in providing a safe environment for all. Nurse leaders engaged in these kinds of behaviors are providing strong leadership and practicing strong decision-making, thus ensuring the continued robustness of their organizations.

Recommendations and limitations

Future research could replicate this study in a different geographic region to explore the causes of LHV by soliciting the views of nursing students, new graduate nurses, and nurse educators from unionized and nonunionized hospital systems and comparing the results to further understand this phenomenon. Additionally, developing a tool to test the substantive theory could substantiate the nurse leader's role as a problem-solver to address incidence of LHV in the workplace.

The decision to conduct this study in one type of healthcare organization limits the ability to compare the interviewed nurse leaders' experiences with nurse leaders in other healthcare organizations. The experiences of nurses in other healthcare organizations may be different; thus, overall generalizability of the study may be limited.

Say “no” to the status quo

The results of this study support the findings of previous researchers. 23,31,33,34 Accepting the status quo is unacceptable and can cause irreparable harm to organizational well-being if LHV isn't addressed. Collaboration between nurse leaders and administrators is essential to successfully reduce institutional obstacles that prevent the timely handling of LHV incidents. The role of the nurse leader as a problem-solver should be clear, defined, and well supported to seek resolutions to toxic behaviors that are hurting the work environment. But we must remember that creating a policy doesn't equal change. Every employee from the lowest level in the organization to the highest ranks of administration must model civil behaviors.

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Home > Online Programs > EVIDENCE-BASED PRACTICE (EBP): THE PROBLEM-SOLVING APPROACH

EVIDENCE-BASED PRACTICE (EBP): THE PROBLEM-SOLVING APPROACH

• Published On: January 10, 2012

As the nursing profession continues to evolve, the educational focus is also changing. One of the most significant emerging trends in healthcare today is the focus on evidence-based practice, also known as EBP.

Evidenced-based practice is often described as an approach to patient care that involves considering the best available research and practice guidelines associated with a specific clinical situation. Key elements in the successful implementation of evidence-based practice in nursing include:

• Reviewing research and studies that examine the best practices in clinical nursing.
• Interactive decision-making regarding care and treatment planning which integrates care team members, as well as the opinion of the patient and his or her family.
• Ongoing professional development education of nurses, including pursuit of advanced degree programs when available.
• Addressing clinical issues and critically examining possible practice changes.
• Strong emphasis on problem-solving skills, clinical judgment and the use of sound evidence to support clinical decisions based on research, experience and the environment.

Challenges to Evidence-Based Practice

Some of the impediments to evidence-based practice include a resistance to change practice and habits within the nursing community, the lack of ongoing education programs and poor administrative support. Although barriers exist, the successful patient outcomes from evidence-based practice have helped win support for this model of care among the medical profession as a whole.

Increased Responsibilities for Nurses Today

Because evidence-based practice places an emphasis on the knowledge, skills and experience of nurses, today’s nurses are being given more responsibility and respect than ever before. EBP focuses on specific nursing skills including critical decision-making founded in evidence and research, with a move away from traditional treatment regimes and habits that had been the hallmark of nursing for generations. Registered nurses now need strong analytic and academic research skills to complement clinic skills and hands-on patient care.

Options for Evidence-Based Practice Education

Nurses who are seeking to improve their clinical skills and expand both their knowledge base and career options should consider obtaining additional nursing education in programs that focus on EBP. Professional nursing today demands that nurses have a solid understanding of how to conduct research, critically review studies and medical reviews, and an EBP-focused education program will teach nurses these vital skills.

Some of the most accessible educational programs that include an emphasis on EBP the knowledge are the online nursing programs offered at the University of Texas at Arlington, including an RN to BSN and a Master of Science in Nursing Administration . The University of Texas at Arlington’s College of Nursing and Health Innovation, named one of the “Best of the West” by Princeton Review , offers a specialized program to allow RNs to obtain their BSN in just over a year. By pursuing an advanced nursing degree with a focus on evidence-based practice, working nurses will have access to a variety of career options in both clinical and administrative roles.

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Problem Solving in Nursing: Strategies for Your Staff

4 min read • September, 15 2023

Problem solving is in a nurse manager’s DNA. As leaders, nurse managers solve problems every day on an individual level and with their teams. Effective leaders find innovative solutions to problems and encourage their staff to nurture their own critical thinking skills and see problems as opportunities rather than obstacles.

Health care constantly evolves, so problem solving and ingenuity are skills often used out of necessity. Tackling a problem requires considering multiple options to develop a solution. Problem solving in nursing requires a solid strategy.

Nurse problem solving

Nurse managers face challenges ranging from patient care matters to maintaining staff satisfaction. Encourage your staff to develop problem-solving nursing skills to cultivate new methods of improving patient care and to promote  nurse-led innovation .

Critical thinking skills are fostered throughout a nurse’s education, training, and career. These skills help nurses make informed decisions based on facts, data, and evidence to determine the best solution to a problem.

Problem-Solving Examples in Nursing

To solve a problem, begin by identifying it. Then analyze the problem, formulate possible solutions, and determine the best course of action. Remind staff that nurses have been solving problems since Florence Nightingale invented the nurse call system.

Nurses can implement the  original nursing process  to guide patient care for problem solving in nursing. These steps include:

• Assessment . Use critical thinking skills to brainstorm and gather information.
• Diagnosis . Identify the problem and any triggers or obstacles.
• Planning . Collaborate to formulate the desired outcome based on proven methods and resources.
• Implementation . Carry out the actions identified to resolve the problem.
• Evaluation . Reflect on the results and determine if the issue was resolved.

How to Develop Problem-Solving Strategies

Staff look to nurse managers to solve a problem, even when there’s not always an obvious solution. Leaders focused on problem solving encourage their team to work collaboratively to find an answer. Core leadership skills are a good way to nurture a health care environment that supports sharing concerns and  innovation .

Here are some essentials for building a culture of innovation that encourages problem solving:

• Present problems as opportunities instead of obstacles.
• Strive to be a positive role model. Support creative thinking and staff collaboration.
• Encourage feedback and embrace new ideas.
• Respect staff knowledge and abilities.
• Match competencies with specific needs and inspire effective decision-making.
• Offer opportunities for  continual learning and career growth.
• Promote research and analysis opportunities.
• Provide support and necessary resources.
• Recognize contributions and reward efforts .

Embrace Innovation to Find Solutions

Try this exercise:

Consider an ongoing departmental issue and encourage everyone to participate in brainstorming a solution. The team will:

• Define the problem, including triggers or obstacles.
• Determine methods that worked in the past to resolve similar issues.
• Explore innovative solutions.
• Develop a plan to implement a solution and monitor and evaluate results.

Problems arise unexpectedly in the fast-paced health care environment. Nurses must be able to react using critical thinking and quick decision-making skills to implement practical solutions. By employing problem-solving strategies, nurse leaders and their staff can  improve patient outcomes  and refine their nursing skills.

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Evidence-based practice, from  encyclopedia of nursing research.

Keywords: evidence-based practice, health care delivery, nursing, Delivery of Health Care, Evidence-Based Practice, Nursing

Evidence-based practice (EBP) is the conscientious use of current best evidence in making decisions about patient care ( Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000 ). It is a problem-solving approach to the delivery of health care that integrates the best evidence from research with a clinician's expertise and a patient's preferences and values ( Melnyk & Fineout-Overholt, 2015 ). When delivered in a context of caring and in an organizational culture that supports EBP, the best patient outcomes are achieved. Although it is well recognized that EBP improves the quality and safety of health care as well as decreases hospital costs and patient morbidities, evidence-based care is not consistently implemented by point-of-care clinicians and health care systems across the United States. Unfortunately, it typically takes well over a decade to translate findings from research into clinical practice to improve care and patient outcomes. Recognition of the long research–practice time lag resulted in the Institute of Medicine setting a goal that by the year 2020, 90% of clinical decisions will be supported by the best available evidence ( Institute of Medicine, 2008 ).

For clinicians to use evidence to make daily decisions about patient care, there must be an understanding of the two types of evidence in EBP: (a) external evidence that is generated through rigorous research and (b) internal evidence that is generated through quality improvement, outcomes management, and EBP-implementation projects within clinicians’ own practice settings. Internal evidence is important in evidence-based decision making to demonstrate outcomes from evidence-based interventions as well as when rigorous studies do not exist to guide best practices. Evidence for interventions is leveled from level 1 (i.e., systematic reviews of randomized controlled trials), which is the strongest level of evidence to guide clinical practice, to level 7 (i.e., evidence from expert opinion). The level of the evidence plus the quality of that evidence as determined from critical appraisal determines the strength of the evidence, which provides clinicians the confidence to act on the evidence and implement best practices ( Melnyk & Fineout-Overholt, 2015 ).

Dr. Archie Cochrane, a British epidemiologist, is credited with starting the EBP movement when he challenged the public to pay only for health care that had been supported as efficacious through research ( Enkin, 1992 ). In 1972, he criticized the medical profession for not providing rigorous systematic reviews of evidence so that organizations and policy makers could make decisions about health care. He contended that thousands of low-birth-weight premature infants had died needlessly because the results of several randomized controlled trials were not synthesized into a systematic review to support the practice of routinely providing corticosteroid injections to high-risk women in preterm labor to halt the premature birth process. Archie Cochrane considered systematic reviews to be the strongest level of evidence to guide practice decisions ( Cochrane Collaboration, 2001 ). Although he died in 1988, Dr. Cochrane's influence was responsible for the launching of the Cochrane Center in Oxford, England, in 1992 and the founding of the  Cochrane Collaboration (2001)  a year later. The purpose of the Cochrane Collaboration is to provide and routinely update rigorous systematic reviews of health care interventions to guide best practices.

In the United States, the U.S. Preventive Services Task Force, an independent panel of 16 experts in primary care, research, and prevention, systematically reviews the evidence of effectiveness and develops gold standard recommendations for clinical preventive services that include screening, counseling, and preventive medications. The U.S. Preventive Services Task Force produces a Guide to Clinical Preventive Services every year that includes its updated evidence-based recommendations for primary care providers (see  www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/guide/index.html ).

In EBP there are seven steps, which include the following:

Cultivate a spirit of inquiry

Ask the burning clinical question in PICOT (P = patient population, I = intervention or area of interest, C = comparison intervention or group, O = outcome, and T = time) format

Search for and collect the most relevant evidence

Critically appraise the evidence (i.e., rapid critical appraisal, evaluation, and synthesis)

Integrate the best evidence with one's clinical expertise and patient preferences and values in making a practice decision or change

Evaluate outcomes of the practice decision or change based on evidence

Disseminate the outcomes of the EBP decision or change ( Melnyk & Fineout-Overholt, 2015 )

Without a spirit of inquiry, nurses and other clinicians may find it challenging to ask burning clinical questions about their practices (e.g., In intensive care unit patients, how does early ambulation compared with delayed ambulation affect the number of ventilator days? In orthopedic patients, how does analgesia administered by the triage nurse compared with waiting for physician-ordered analgesia affect pain and length of time in the emergency department?). Asking questions in PICOT (population/patient problem, intervention, comparison, outcome, time) format leads to a more time efficient and effective search for evidence. Articles from the search are then rapidly critically appraised, evaluated, and synthesized to determine whether a practice change on the basis of the best evidence is indicated. Relevant, reliable evidence is then integrated with the clinician's expertise and patient preferences and values in making a practice decision or change. Clinician expertise involves health care provider skills and interpretation of patient assessment data, internal evidence, use of health care resources, and other important information that is relevant to the clinical decision and outcome. Once an evidence-based change is made in clinical practice, measurement of key outcomes is necessary to demonstrate that the impact expected of the change indeed occurred in a clinician's own practice setting. The final step in EBP is disseminating the outcomes of the evidence-based change so that others might benefit from the process.

Although EBP produces better outcomes than care that is steeped in tradition and a known process exists for implementing evidence-based care, there are multiple barriers that exist within individuals and institutions that are slowing the widespread adoption of evidence-based care. Barriers in individuals include (a) the perception that EBP takes too much time, (b) the inadequate knowledge and skills in EBP, and (c) a lack of confidence to implement change. System barriers include (a) contextual environment and culture that does not support EBP, (b) lack of resources required for EBP, (c) lack of EBP mentors who can assist with EBP implementation at point of care, and (d) nurse leaders and managers who do not model EBP ( Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012 ). Conversely, there are a number of factors that facilitate the implementation of EBP, including (a) EBP knowledge and skills, (b) beliefs about the value of EBP and the ability to implement it, (c) a context and culture that supports EBP and provides the necessary tools to support evidence-based care (e.g., time to search for evidence, access to computer databases at point of care), (d) EBP mentors (i.e., typically advanced practice nurses with expertise in EBP as well as organizational and individual behavior change strategies) who work directly with clinicians at the point of care in implementing EBP, and (e) supportive leadership behaviors ( Melnyk, 2014 ;  Melnyk & Fineout-Overholt, 2015 ;  Stetler, Ritchie, Rycroft-Malone, & Charns, 2014 ).

EBP competencies for practicing nurses and advanced practice nurses now exist. These competencies were generated by a panel of national experts in EBP and validated through research by conducting two rounds of a Delphi survey with EBP mentors throughout the country ( Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014 ). All health care systems should require that nurses and advanced practice nurses meet these EBP competencies as doing so should greatly enhance the quality and safety of health care. In addition, all nursing and other health sciences students should be taught EBP in their academic programs so that they are meeting these competencies on graduation.

There are several conceptual models that have been developed to facilitate a change to EBP in individuals and health care systems. These models include (a) the EBP decision-making model by DiCenso, Ciliska, and Guyatt; (b) the Stetler model of EBP; (c) the Iowa model of EBP to promote quality care created by Marita Titler and colleagues; (d) the model for EBP change by Rosswurm and Larabee; (e) the Advancing Research and Clinical Practice Through Close Collaboration model by Melnyk and Fineout-Overholt; (f) the Promoting Action on Research Implementation in Health Services framework by Rycroft-Malone, Kitson, and colleagues; (g) the clinical scholar model by Schultz; and (h) the Johns Hopkins nursing EBP model by Newhouse and colleagues ( Dang et al., 2015 ). It is increasingly recognized that efforts to change practice should be guided by conceptual models ( Graham, Tetroe, & the KT Theories Research Group, 2007 ). As these models are supported by evidence from research, they will become even more valuable in helping clinicians deliver evidence-based care.

In summary, EBP is necessary to ensure the highest quality of cost-effective care and the best patient outcomes. Nurses must ensure that their patients are receiving the highest quality of care by consistently ensuring the delivery of evidence-based care in their practices. Efforts in the future must be accelerated and placed on (a) educating both practicing clinicians and health professional students in the EBP process with emphasis on the building of EBP skills; (b) creating cultures of EBP that provide resources, EBP mentors, and support to clinicians to engage in and sustain evidence-based care; (c) providing incentives for EBP; and (d) establishing evidence-based clinical practice guidelines and policies that are incorporated into technology (e.g., electronic health records) to facilitate best practice by clinicians at the point of care ( Melnyk & Williamson, 2010 ). More implementation research is needed to determine the best strategies for accelerating the speed at which research is translated into real-world practice settings to improve care and people's health outcomes.

• Cochrane Collaboration. (2001). Retrieved from  http://www.cochrane.org/cochrane/cc-broch.htm#cc .
• Dang, D.; Melnyk, B. M.; Fineout-Overholt, E.; Ciliska, D.; DiCenso, A.; Cullen, L.; Stevens, K. (2015). Models to guide implementation of evidence-based practice. In B. M. Melnyk; E. Fineout-Overholt (Eds.), Evidence-based practice in nursing & healthcare. A guide to best practice (3rd ed., pp. 235-247). Wolters Kluwer/Lippincott Williams & Wilkins Philadelphia PA.
• Enkin, M. (1992). Current overviews of research evidence from controlled trials in midwifery obstetrics. Journal of the Society of Obstetricians and Gynecologists of Canada, 9, 23-33.
• Graham, I. D.; Tetroe, J.; KT Theories Research Group. (2007). Some theoretical underpinnings of knowledge translation. Academic Emergency Medicine, 14(11), 936-941.
• Institute of Medicine. (2008). Evidence-based medicine and the changing nature of health care: 2007 IOM annual meeting summary. National Academies Press Washington, DC.
• Melnyk, B. M. (2014). Building cultures and environments that facilitate clinician behavior change to evidence-based practice: What works? Worldviews on Evidence-Based Nursing, 11(2), 79-80.
• Melnyk, B. M.; Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare. A guide to best practice (3rd ed.). Wolters Kluwer/Lippincott Williams & Wilkins Philadelphia PA.
• Melnyk, B. M.; Fineout-Overholt, E.; Gallagher-Ford, L.; Kaplan, L. (2012). The state of evidence-based practice in US nurses: Critical implications for nurse leaders and educators. Journal of Nursing Administration, 42(9), 410-417.
• Melnyk, B. M.; Gallagher-Ford, L.; Long, L. E.; Fineout-Overholt, E. (2014). The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings: Proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence-Based Nursing, 11(1), 5-15.
• Melnyk, B. M.; Williamson, K. (2010). Using evidence-based practice to enhance organizational policies, healthcare quality and patient outcomes. In A. S. Hinshaw; P. Grady (Eds.), Shaping health policy through nursing research (pp. 87-98). Springer Publishing New York NY.
• Sackett, D. L.; Straus, S. E.; Richardson, W. S.; Rosenberg, W.; Haynes, R. B. (2000). Evidence-based medicine: How to practice and teach EBM. Churchill Livingstone London UK.
• Stetler, C. B.; Ritchie, J. A.; Rycroft-Malone, J.; Charns, M. P. (2014). Leadership for evidence-based practice: Strategic and functional behaviors for institutionalizing EBP. Worldviews on Evidence-Based Nursing, 11(4), 219-226.

Bernadette Mazurek Melnyk Ellen Fineout-Overholt

Evidence Pyramid

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• Published: 05 September 2024

Breaking the taboo of using the nursing process: lived experiences of nursing students and faculty members

• Amir Shahzeydi   ORCID: orcid.org/0000-0001-9095-2424 1 , 2 ,
• Parvaneh Abazari   ORCID: orcid.org/0000-0003-4024-2867 3 , 4 ,
• Fatemeh Gorji-varnosfaderani   ORCID: orcid.org/0000-0001-6830-982X 5 ,
• Elaheh Ashouri   ORCID: orcid.org/0000-0002-7566-6566 6 ,
• Shahla Abolhassani   ORCID: orcid.org/0000-0002-5191-7586 6 &
• Fakhri Sabohi   ORCID: orcid.org/0000-0003-1448-6606 6  

BMC Nursing volume  23 , Article number:  621 ( 2024 ) Cite this article

Metrics details

Despite the numerous advantages of the nursing process, nursing students often struggle with utilizing this model. Therefore, studies suggest innovative teaching methods to address this issue. Teaching based on real clinical cases is considered a collaborative learning method that enhances students’ active learning for the development of critical thinking and problem-solving skills. In this method, students can acquire sufficient knowledge about patient care by accessing authentic information.

The aim of the present study was to investigate the experiences of nursing students and faculty members regarding the implementation of nursing process educational workshops, based on real case studies.

A qualitative descriptive study.

Participants

9 Nursing students and 7 faculty members from the Isfahan School of Nursing and Midwifery who attended the workshops.

This qualitative descriptive study was conducted from 2021 to 2023. Data was collected through semi-structured individual and focus group interviews using a qualitative content analysis approach for data analysis.

After analyzing the data, a theme titled “Breaking Taboos in the Nursing Process” was identified. This theme consists of four categories: “Strengthening the Cognitive Infrastructure for Accepting the Nursing Process,” “Enhancing the Applicability of the Nursing Process,” “Assisting in Positive Professional Identity,” and “Facilitating a Self-Directed Learning Platform.” Additionally, thirteen subcategories were obtained.

The data obtained from the present study showed that conducting nursing process educational workshops, where real clinical cases are discussed, analyzed, and criticized, increases critical thinking, learning motivation, and understanding of the necessity and importance of implementing the nursing process. Therefore, it is recommended that instructors utilize this innovative and effective teaching method for instructing the nursing process.

Peer Review reports

Introduction

The nursing process is a systematic and logical method for planning and providing nursing care [ 1 ] that provides an opportunity for nurses to efficiently and dynamically utilize their knowledge and expertise. It also creates a common language, known as nursing diagnosis, which facilitates action, promotes creative solutions, and minimizes errors in patient care [ 2 ]. Clinical education, based on the nursing process, provides an appropriate setting for nursing students to gain clinical experiences and foster professional development [ 3 ].

Despite the numerous advantages, nursing students face difficulties in implementing this model in various countries [ 4 , 5 ], lack of appropriate knowledge, lack of clinical practice, and insufficient learning are among the most significant obstacles to the implementation of the nursing process by students. This can be attributed to the poor quality of education regarding this important nursing care model. Therefore, it is necessary for educators in this field to use innovative and participatory teaching methods [ 3 , 6 ]. According to research conducted in Iran, 72% of nursing faculty members use passive teaching methods. Meanwhile, 92% of nursing students prefer active and innovative learning methods over traditional and passive methods [ 7 ]. Therefore, the use of modern methods, which aim to stimulate students’ thinking and enhance their responsiveness in acquiring and applying knowledge, can be effective [ 6 ].

Case-based learning is a collaborative learning method that aims to develop and enhance critical thinking and problem-solving skills [ 8 ]. Teaching the nursing process based on clinical and real cases can be very important in terms of promoting critical thinking, simulating real experiences, enhancing clinical judgment, and ultimately improving the quality and effectiveness of education [ 8 , 9 ]. In this method, students gain sufficient knowledge about patient care by accessing real information, improving their skills in patient assessment, and gaining personal nursing experience. This leads to a better understanding of comprehensive care and prepares individuals for future professional roles [ 9 ].

Very few studies have been conducted on teaching methods and their impact on the quality of nursing process [ 10 , 11 ]. In Iran, case-based trainings have mostly focused on hypothetical cases [ 1 , 12 ]. In other countries, most studies conducted on the case-based educational method have not focused on the nursing process. The few studies that have been conducted on the nursing process have either not been based on real clinical cases [ 13 ] or, if clinical cases have been researched, the studies have been conducted quantitatively [ 8 , 9 ] While qualitative research provides researchers with more opportunities to discover and explain the realities of the educational environment and gain a better understanding of many challenging aspects related to the nursing education process. Researchers are able to provide a practical model that helps improve and enhance the current process by gaining insight and a deep understanding of what is happening in the field of study [ 14 ]. This study represents the first qualitative research that describes the lived experiences of nursing students and faculty members regarding the teaching of the nursing process through real-based case workshops.

Study design

This qualitative descriptive study was conducted from 2021 to 2023. Qualitative descriptive studies typically align with the naturalistic inquiry paradigm, which emphasizes examining phenomena in their natural settings as much as possible within the context of research. Naturalistic inquiry, rooted in a constructivist viewpoint, enables a deeper understanding of phenomena by observing them within the authentic social world we inhabit [ 15 ]. In this type of study, researchers provide a comprehensive summary of an extraordinary occurrence or circumstance of interest and its related factors, but they do not delve into deep interpretation [ 16 ]. This study was undertaken to explore students and faculty members perceptions of the effect of the educational workshops on knowledge, skills and attitudes of students to the nursing process.

Setting and sample

Participants were selected from nursing students and faculty members who participated in nursing process workshops (Table  1 ). The criteria for entry into the study included volunteering to participate in the study and attending at least 3 sessions of the workshops.

Workshop details

The workshops were held in the conference hall of the Nursing and Midwifery Faculty. They consisted of 9 sessions, each lasting 2 h, from 16:00 to 18:00. Students from terms 2 to 8 and faculty members participated in these workshops. Each session was attended by an average of 60 members. Despite the inconvenience of scheduling the sessions outside of the official class hours, all the members stayed until the end of the meeting, showing a keen interest in the material and actively participating in discussions. Attendance was open to all students and faculty members, and participants in each of the workshop sessions were not the same.

It should be noted that all workshops were accompanied by a specialized instructor in the field of the nursing process, as well as a specialized instructor in the field of the specific disease being discussed. The details of these workshops are summarized in three stages:

First Stage

Step 1 . The researcher visited one of the inpatient clinical wards of the hospital based on the assigned topic for each workshop. They selected a patient, conducted a comprehensive assessment, and recorded the information using Gordon’s assessment form. This included the patient’s current and past medical history, paraclinical tests, physical examinations, medications, and information gathered from credible sources such as interviews with the patient and their family, medical records, and the patient’s treatment and care interventions documented in their medical file and Cardex.

Step 2 . Preparing the presentation file, which includes the following items:

Writing the comprehensive patient assessment based on step one.

Writing actual and at-risk nursing diagnoses according to PES (Problem/ Etiology/ Signs and Symptoms) and PE (Problem/ Etiology) rules, as well as collaborative problems, and then prioritizing them based on Maslow’s Hierarchy of Needs.

Writing objectives and outcomes for each nursing diagnosis based on the SMART (Specific/ Measurable/ Attainable/ Realistic/ Time Bound).

Writing nursing interventions (based on objectives and outcomes), along with the rationales according to evidence-based, up-to-date, and reliable sources for each intervention.

Step 3 . Sending the presentation file to an expert professor in the field of nursing process for review and implementing her comments.

Second stage

Step 1 . Announcing the date and time of the workshop session to students and faculty members.

Step 2 . Providing students and faculty members with a comprehensive patient assessment.

Third stage (workshop implementation)

Step 1. Presenting all stages of the nursing process based on the case study:

Providing a comprehensive assessment of the patient’s condition. (Giving time for students, faculty members, and presenters to discuss with each other, express their comments, and summarize)

Presenting diagnoses along with the objectives and expected outcomes. (Giving time for students, faculty members, and presenters to discuss with each other, express their comments, and summarize)

Presentation of nursing interventions. (Giving time for students, faculty members, and presenters to discuss with each other, express their comments, and summarize)

Presentation on assessing the level of achievement of expected outcomes and evaluating interventions. (Giving time for students, faculty members, and presenters to discuss with each other, express their comments, and summarize)

Data Collection Tools

Demographic questionnaire.

It included age, gender, Position, degree and number of sessions attended in the workshop.

Semi-structured interview

It included the following questions:

What was your motivation to attend these meetings?

Before entering the nursing process meetings, what did you expect from the meeting?

How many of your expectations were met by participating in the meetings?

How much did these meetings help you in applying the nursing process in the clinical setting?

What do you think about the continuation of such meetings?

Data collection

After obtaining official permission from the university in 2021, the phone numbers of students and faculty members who participated in more sessions of the workshop were collected in 2023. A specific time and location were subsequently arranged to contact and interview participants who had indicated their willingness to take part in the study. Approximately 40 individuals expressed their consent to participate; however, data saturation was achieved after interviewing 16 participants. It is important to note that interviews were conducted through both individual sessions and focus groups. Individual interviews were carried out with 3 faculty members, while two focus groups were conducted separately with 9 students and 4 faculty members.

Individual Interviews

The interviews were conducted in a semi-structured manner and began with a general question to establish initial and closing communication. These interviews were conducted by one of the researchers who holds a PhD in nursing and has published several qualitative articles in reputable journals. In each of these sessions, the interviewer introduced themselves and welcomed the participants. The goals of the session were discussed, and participants were given complete freedom to express their opinions. The interviewer refrained from interfering or reacting to their opinions, and the information discussed was kept completely confidential under the guise of a code. Participants were subsequently asked to provide consent for voice recording during the interviews. Once consent was obtained from the participants, their voices were recorded. Each individual interview lasted between 30 and 45 min.

Focus Group Interviews

All the conditions of these interviews were similar to individual interviews. However, in focus group sessions, an additional researcher acted as an assistant to the main interviewer. The assistant’s role was to determine the order of speaking based on the participants’ requests, observe their facial expressions while speaking, and take necessary notes. Each of the focus group sessions lasted approximately 5 h. It should be noted that participant selection and sampling continued until data saturation was achieved. Saturation of data refers to the repetition of information and the confirmation of previously collected data.

Data analysis

The qualitative content analysis approach proposed by Graneheim and Lundman was used for data analysis [ 16 ]. The recorded interviews were transcribed verbatim (The transcripts were sent to the participants for feedback and were approved by them), and then each word was carefully examined to identify codes Two independent individuals encoded the data. Words that accurately represented thoughts or concepts within the data were highlighted. Then, the researcher added her own notes about his thoughts, interpretations of the text, and initial analysis of the text. With the progression of this process, appropriate names for the codes emerged, and the codes were organized into subcategories. These subcategories were created to organize and categorize the codes within clusters. The researcher reorganized the subcategories based on their relationships, condensing them into a smaller number of organizational categories. And then the concepts of each category, subcategory, and code were developed.

Trustworthiness

Data was managed using the Lincoln and Guba criteria. These criteria include acceptability, which is equivalent to internal validity; transferability, which is equivalent to external validity; similarity, which is equivalent to reliability; and verifiability, which is equivalent to objectivity [ 17 ]. The use of member checks by participants is considered a technique for exploring the credibility of results. In this regard, the interview text and the primary codes extracted from it were made available to several participants to verify the accuracy with their experiences. External supervision was employed to ensure that the criterion of internal consistency was met. For this purpose, the data was given to a researcher who did not participate in the study. If there was agreement in the interpretation of the data, it confirmed the presence of internal consistency. Finally, an audit or verification inquiry was conducted. The researcher accurately recorded and reported all stages and processes of the research from beginning to end. This allows external supervisors to conduct audits and assess the credibility of the findings.

Data analysis resulted in the emergence of 13 subcategories, 4 categories, and 1 theme (Table  2 ).

Strengthening the intellectual infrastructure of accepting the nursing process

Subcategories such as “improving nursing perception,” “strengthening critical thinking,” “evidence-based nursing practice,” and “filling an educational gap” contributed to the emergence of the category “Strengthening the intellectual infrastructure of accepting the nursing process.”

Improving nursing perception

Participants’ experiences indicate the significant positive impact of the workshop on improving students’ perception of the nursing process. Most nurses in departments do not provide patient care based on the nursing process. As a result, students do not have the opportunity to practically experience the real application of the nursing process in the department. Instead, they only perceive the nursing process as a written task.

For me, it was a question of what the nursing process is, for instance. How difficult is it?” and it really helped me overcome my fear in a way. (P3 student) Usually, they would explain the nursing process to us, but it was not practical or based on real cases, like this. (P1 Student)

Strengthening critical thinking

Critical thinking is a fundamental skill in the nursing process that involves various stages and activities. These include questioning to gather adequate information, validating and analyzing information to comprehend the problem and its underlying factors, evaluating interventions, and making appropriate decisions for effective problem-solving. The experiences of the participating students clearly reflected the formation of these stages during the workshop sessions.

I learned in the workshop about the importance of using critical thinking to successfully connect knowledge and practice. It’s a shame that critical thinking has not been cultivated in the minds of students, and these workshops have laid the foundation for it in our minds. (P6 student) Students often come across hypothetical cases in textbooks, but when they are confronted with real cases, the circumstances are different… This is when critical thinking becomes crucial and the art of nursing is demonstrated… These sessions have made a significant contribution to this subject. (P15 Faculty member)

Evidence-based nursing practice

One of the features of the sessions was that in introducing the case from assessment to evaluation, to justify the rationale and process of collecting and formulating nursing diagnoses, establishing expected outcomes, and providing reasons for each intervention, relied on up-to-date and reliable nursing and medical resources

It had a strong scientific foundation, consistently emphasizing the importance of evidence-based practices and a scientific approach, effectively communicating this perspective to audience. (P2 Student). I became familiar with the book ‘Carpenito,’ and it helped me a lot in understanding my shortcomings. (P3 student). In my opinion, one of the factors that contributed to the effectiveness of the work was consulting the references. They emphasized that as a nurse, I should not solely rely on my personal opinion but should instead base my actions on the reference materials (P14 Faculty member).

Filling an educational gap

From the perspective of workshop participants, the workshop has increased their awareness of their limited knowledge about the application of the nursing process. It has also helped them recognize their shortcomings, and motivated them to pursue additional studies in this field.

Exactly, there was a vacant spot for this educational program in our classes. And there should have been sessions that would prove to us that nursing is not just about the theoretical concepts that faculty members teach in class. (P5 Student) The nursing process has a theoretical aspect that students learn, but when they attempt to apply it in practice, they often encounter difficulties. These sessions helped to fill the gap between theory and practice. (P15 Faculty member)

Practicality of the nursing process

Subcategories of “linking the nursing process with team care,” “demonstrating the role of the nursing process in improving care quality,” “comprehensive view in care,” and “student’s guiding light in the clinic,” Created the category “Practicality of the Nursing Process”.

Linking the nursing process with team care

Participants’ experiences indicated that participating in nursing process sessions helped them realize that the nursing process is a model that will lead to collaborative team care. Prior to attending these sessions, nursing students like nurses considered their duty to be solely executing medical orders under the supervision of clinical faculty members and staff nurses.

I realized that in certain situations, I am able to confidently express my opinion to the doctor. For instance, if I believe that a particular course of action would yield better results, I can easily communicate this and provide reasons to support my viewpoint (P7 Student). Teaching the pathway when it’s categorized with knowing what we’re assessing… Let’s go up to the patient; our confidence can really guide them along with us as we progress step by step and systematically. Often, the patient accompanies us, and sometimes they voice their unspoken concerns, which helps improve their care. It means the patient themselves are partnering with us. (P6 student)

Demonstrating the role of the nursing process in improving care quality

Strengthening the attitude and belief in the role and application of the nursing process in improving the quality of care was another concept that emerged from the experiences of the students. Presenting reports on the implementation of the nursing process on real cases led them to believe that providing care based on the nursing process results in organized care planning and enhances the quality of care.

In these workshops, the needs of patients were prioritized, documented, and then organized systematically. This concept remains ingrained in a person’s mind and enables us to deliver comprehensive care to the patient without overlooking any aspect. This has been very helpful for me, and now it greatly assists me in the clinic. (P4 Student) Another great aspect of these sessions was the emphasis they placed on the nurse-patient relationship. I could see that the students had been following up with patients for a while and implementing the process. This was very helpful to me. For instance, diagnosing based on the patient’s current health status was an ongoing process. In my opinion, the connection between the patient and nurse was more important and practical for me.(P1 Student).

Comprehensive view in care

Attention to the patient’s care needs went beyond focusing solely on physiological aspects. It involved a holistic approach that addressed the patient’s needs related to all aspects of biology, psychology, society, spirituality, and economics. This was clearly reflected in the students’ experiences during the nursing process sessions.

…I paid attention to all aspects of the patient. For example, perhaps I overlooked her anxiety issue and never took it into consideration. However, I eventually came to realize that addressing anxiety is crucial, as it is one of the primary concerns and needs of patients. (P2 Student) …that the students had a holistic view of the patient (they had examined the patient thoroughly, including the patient’s skin, etc.) and had compiled a list of the patient’s issues, paying attention to all aspects of the patient (P14 Faculty member).

Student’s guiding light in the clinic

One of the significant accomplishments of nursing process sessions, as evidenced by the students’ experiences, was the role of these sessions in assisting students in overcoming confusion and uncertainty during their internships. These sessions enabled them to establish a mental connection between the theoretical knowledge learned in the classroom and its application in the real clinical setting, also helped them understand how to effectively utilize their theoretical knowledge in a clinical learning environment.

.I was feeling incredibly lost and confused. I didn’t know what steps to take next. Many of us find ourselves in this situation, unsure of what to do. At least for me, as someone who grasps concepts better through examples, the case-based studies conducted during the workshop had a significant impact. (P6 Student)

Supporting a positive professional identity

Two subcategories, “highlighting the importance of nursing science” and “reforming the perception of nursing nature,” have contributed to the development of the category “supporting a positive professional identity.”

Highlighting the importance of nursing science

Based on students’ experiences, the nursing process sessions have been able to answer an important question. Why should they be bombarded with information and expected to possess extensive knowledge in the field of disease recognition, pathophysiology, diagnosis, treatment, and nursing care during their studies? The students believed that the content of the nursing process sessions clarified the necessity and importance of nursing knowledge for them. In these sessions, they came to believe that providing care based on the nursing process requires extensive nursing knowledge.

. In my opinion, this work showcases a significant strength by highlighting the importance of working scientifically as a nurse. Personally, I feel its impact on myself is profound. (P2 Student) In my opinion, it was very touching and captivating because it accurately portrayed the immense power of a nurse. However, amidst the demanding and difficult nature of the job, what specific details should a nurse pay attention to? and it is precisely these details that shape the work of a nurse. It was very interesting and beneficial for me. (P5 student)

Reforming the perception of nursing nature

The student is seeking ways to comprehend and value the practical aspects of nursing as a genuine science, assuming that nursing is indeed regarded as a science. Participants’ experiences have shown that nursing process sessions have been able to address this identity challenge and modify and enhance students’ understanding of the nature of nursing.

I used to believe that nursing was primarily an art complemented by science until I entered term 2 and participated in these workshops. And now I realize that it has the scientific foundation that I expected from an evidence-based practice. (P5 student). . The important point was that lower-term students, who sometimes lacked motivation and thought nursing had nothing to offer, gained motivation and had a change in perspective by attending these sessions. (P2 faculy members)

Self-directed learning facilitator

Subcategories of “stimulating a thirst for learning,” “creating a stress-free learning atmosphere,” and “teaching fishing,” formed the category of “self-directed learning facilitator.”

Stimulating a thirst for learning

Participants’ experiences indicated that the format of conducting sessions, ranging from step-by-step training to training accompanied by multiple examples, had a significant impact on creating a sense of necessity and stimulating learners’ motivation to learn.

First of all, the challenges that you yourself raised (faculty member) for example, why did you make this diagnosis?” Why did you include this action? Why is this a priority? Really, it shook me and made me think that maybe there is more to this, maybe there is more to the nursing process that I haven’t understood yet…. That’s why it became my motivation. (P3 student) …But these sessions helped me a lot. At least, they sparked my curiosity and motivated me to delve deeper into the subject. I began actively participating in these sessions and found them to be highly effective for my personal growth. (P6 student) In my opinion, one of the things that empowered the work was the act of seeking references. They emphasized that as a nurse, I should not solely rely on my personal opinion but should instead base my actions on credible sources. (P14 Faculty member)

Creating a stress-free learning atmosphere

Students believed that the absence of a legal requirement to attend these workshops, coupled with the understanding that their participation or non-participation would not be evaluated for grading purposes, would enable them to engage in these sessions without concern for their academic performance and in accordance with their own volition.

I was more scared… In my internships, for example, we would sit and talk with the instructor. However, the discussions primarily revolved around grades and other academic matters, which created a stressful environment where students were hesitant to freely express their thoughts. But the sessions here are very relaxed, and students no longer have the fear of grades. (P7 student) The essence of these sessions was that they came from the heart and inevitably touched the heart. The beauty of this program was that it was built on love. (P10 Faculty member)

Teaching fishing

Direct reference to teaching fishing in the participants’ experiences points to one of the very important features that effectively prepares the way for self-guided learning. The term “teaching fishing” was repeatedly mentioned in the participants’ experiences. They believed that these sessions served as a roadmap to easily enhance their knowledge and skills in the field of nursing process application.

.And actually, teaching fishing, as mentioned by other students, is important. In my opinion, it has a positive impact both professionally and in terms of the effectiveness of the nursing process. (P2 student) The important aspect was the involvement and full participation of the students, who prepared the materials themselves… The meaning and concept of being a student were more evident, and the talents of the students flourished. They actively participated in discussions about learning and education. (P15 Faculty member)

Planners, in their efforts to help students gain a better understanding of the nature and application of the nursing process, are constantly striving to innovate in teaching this model. The aim of the present study was to describe and explain the experiences of nursing students and faculty during clinical-based nursing process workshops involving real cases.

Hanisch et al. (2020) recommend using data from actual patients [ 18 ], and Yilmaz et al. (2015) suggest providing nursing students with opportunities to apply the nursing process in diverse patient populations during clinical training [ 19 ]. The study conducted by Karimi et al. (2011) demonstrated that organizing nursing process classes as workshops stimulated a sense of competition and superiority both among and within groups. This approach also enhanced participants’ concentration on learning the content of each session. In addition, the workshop fostered a sense of cooperation and cohesion among the students, which was evident in their increased interest and excitement [ 1 ]. The importance of utilizing workshop-based training with real clinical cases is clearly evident. When students receive data related to a real patient, they directly experience the clinical environment. This, in turn, leads to an improvement in their critical thinking and decision-making skills when they encounter similar cases. For this purpose, nursing educators can present the rich clinical cases they encounter during their internships in theory classes based on the stages of the nursing process. They can also ask students to present these cases for their peers to comment on and critique the care provided, in order to stimulate discussion.

The category of " Strengthening the intellectual infrastructure of accepting the nursing process " indicates that the teaching method used in this study has been able to help students better understand and recognize the nature and improvement of insight into the nursing process. In the study by Thuvaraka et al. (2018), 52% of participants strongly agreed on the necessity of having a positive attitude and insight towards the nursing process for its proper implementation [ 20 ]. According to the study by Mert et al. (2020), a lack of insight into the nursing profession and process can even lead students to consider dropping out of their studies [ 21 ]. The importance of reviewing the nursing education process to enhance this perception has been emphasized in various studies. Zamanzadeh et al. (2015) discuss several challenges in the implementation of the nursing process. These challenges include a lack of clarity regarding its meaning, differences in perspectives, and insufficient training leading to a lack of awareness on how to properly implement it [ 22 ]. More than 90% of students (93.5%) in the study conducted by Rajabpoor et al. (2018) [ 4 ] and over two-thirds (75.6%) of students in the study conducted by Sharghi et al. (2015) identified lack of proper training and insufficient time allocated for teaching as the most significant barriers to implementing the nursing process. They attributed this to traditional and routine teaching methods [ 23 ]. This causes students to undervalue the nursing process, perceiving it only at a theoretical level rather than practical. As a result, they become overwhelmed by the routine when working as clinical nurses [ 7 ]. Therefore, by teaching the case method based on real clinical cases, nursing instructors can strengthen students’ positive outlook and ability to apply the nursing process. This increases the percentage of students implementing the nursing process in clinical wards.

Strengthening critical thinking is one of the concepts derived from analyzing the experiences of the students and faculty who participated in the present study. Based on a review study by Carvalho et al. (2017), the utilization of the nursing process, particularly the stage of nursing diagnosis formulation, enables nurses to employ critical thinking in making judgments and providing clinical care [ 24 ]. This process also helps ensure the delivery of high-quality care [ 25 ]. But if the nursing process is presented in an undesirable manner, it suppresses critical thinking. According to Heidari et al. (2016), the nursing process resulted in students relying on copying from books, which led to a decline in creativity and an increase in their dissatisfaction [ 26 ]. According to the study conducted by Ghanbari et al. (2017), the implementation of collaborative workshops focused on the nursing process resulted in an improvement in critical thinking skills among nursing students [ 3 ]. Therefore, nursing instructors can teach theoretical classes based on the clinical cases they have experienced in the hospital. By doing so, students can immerse themselves in the clinical environment during theoretical classes, which significantly enhances their critical thinking skills.

The evidence-based nursing display was one of the achievements of nursing process educational workshops, which were based on real cases. Mackey et al. (2017) consider evidence-based practice as a means to bridge the gap between theory and practice in nursing education for undergraduate and graduate students [ 27 ]. And likewise, Sin et al. (2017) believe that nursing faculties are obligated to enhance the competence and knowledge of students for evidence-based practice by employing innovative methods [ 28 ]. Therefore, it is recommended that nursing instructors use up-to-date scientific references for nursing interventions when teaching about the nursing process of diseases. This practice helps students feel that the care they provide is supported by scientific evidence and motivating them to carry out nursing care more effectively.

One of the emerging concepts in this study was the focus on the practicality of the nursing process. In the study conducted by Agyeman-Yeboah et al. (2017), participants reported that new students and nurses tend to neglect the implementation of the nursing process when they observe experienced nurses failing to apply it in a scientific and systematic manner [ 5 ]. The lack of implementation of the nursing process by nurses is due to a lack of knowledge and a negative attitude towards it. Zerihun Adraro and Adugna Cherkos (2021) conducted a study in Ethiopia and found that the majority of nurses had inadequate knowledge, and half of them lacked a positive attitude towards the implementation of the nursing process [ 29 ]. In the study by Thuvaraka et al. (2018), only 17% of nurses had sufficient knowledge about the nursing process and implemented it [ 20 ]. One of the important experiences for students in the “Practicality of the Nursing Process” category is the development of their participatory and interprofessional spirit. They are encouraged to express their opinions about the care and treatment process of patients, rather than blindly following the doctor’s orders. According to a systematic review study, the level of physicians’ proficiency in their management systems is a significant issue for the healthcare system [ 22 ]. According to the study conducted by Nakhaee et al. (2017), doctors are the ones responsible for making decisions regarding all patient matters, while the efforts of nurses often go unappreciated. This lack of recognition can result in a decline in their self-esteem [ 30 ]. While according to Adamy et al. (2019), the implementation of the nursing process at a professional level is highly effective in creating an independent nursing role, rather than just serving as assistants to physicians. This implementation also enhances the credibility of the nursing profession [ 31 ]. The recommendation of the present researchers to nursing instructors is to take a significant step in enhancing the knowledge and independent spirit of nursing students by basing their teaching on real clinical cases. When students perceive that they have independence and are not merely following doctors’ orders, their engagement in operationalizing the nursing process and evidence-based care will increase.

Strengthening the holistic perspective was one of the positive experiences for students and faculty members who attended these workshops. According to the study by Hackett et al. (2017), physical problems can result in mental stress among patients. Therefore, it is essential to consider all dimensions of care [ 32 ]. According to Ericsson (1995), humans should be considered as a whole, and nursing care should be tailored to address biological, psychological, social, and spiritual aspects [ 33 ]. The importance of holistic care has been emphasized by Florence Nightingale, who encouraged caregivers to practice it [ 34 ]. Holistic care emphasizes partnership and dialogue between nurse and patient about health care needs [ 35 ]. Adequate training is crucial in ensuring that nurses and nursing students are well-prepared to meet the diverse needs of patients and deliver comprehensive care [ 36 ]. It is recommended for nursing instructors to focus on the mental aspect in addition to the physical aspect when teaching the nursing process and encourage students to apply this approach during clinical internships.

Another advantage of these sessions was the successful implementation of the nursing process in apprenticeship. Work disorder and confusion in implementing the nursing process are significant challenges. According to the study by Korkut et al. (2021), students were unable to collect appropriate data from their patients and were confused when formulating and prioritizing nursing diagnoses, determining goals, and planning care. However, due to the fear of receiving a low grade, they were compelled to present fabricated data [ 37 ]. Therefore, nursing instructors should incorporate real clinical cases encountered during internships into their theoretical classes. This simulation helps students perform better in implementing the nursing process in the hospital environment later on.

During these workshop sessions, the students’ awareness of the professional identity of nursing was heightened. They came to understand that this professional identity is a crucial principle that underpins their comprehension of nursing and scientific care. As a result, they recognized the significance of studying pathophysiology and the fundamental principles of scientific care for different diseases. Professional identity is described as a person’s perception of themselves within a profession or the collective identity of the profession [ 38 ]. In nursing, professional identity plays a crucial role in delivering high-quality services to patients [ 39 ] because it effectively enhances clinical competence, self-assurance, self-esteem, and interpersonal communication skills [ 40 , 41 ]. In this regard, the study by Sun et al. (2016) found that professional identity and education level had the greatest impact on the stress levels of nursing students. The results of that study showed that developing and enhancing professional identity could be beneficial for nursing students in managing stress [ 42 ]. Similarly, according to the study by Sabanciogullari et al. (2015), there was a positive and significant correlation between nurses’ job satisfaction and professional identity. This study found that 15.5% of nurses who intended to leave their profession had insufficient professional identity and lower job satisfaction. Professional identity is a significant factor in job satisfaction [ 41 ]. According to the study by Van der Cingel et al. (2021), a lack of attention to the professional identity of nursing contributes to the departure of nursing students and young nurses from the nursing profession [ 43 ]. Therefore, focusing on professional identity in nursing education is crucial and should be a primary objective [ 38 ], despite findings from Haghighat et al. (2019) indicating that nursing education programs in Iran have not effectively nurtured nursing students [ 44 ]. This highlights a greater focus on teaching based on real clinical cases, which enhances the professional identity of nursing and facilitates the implementation of the nursing process.

“Self-directed learning facilitator” is one of the important categories identified in the present study. It encompasses three crucial concepts: “stimulating a thirst for learning”, “creating a stress-free learning atmosphere”, and “teaching fishing”. The students’ experiences indicated that engaging in discussions, asking questions, and providing answers had a significant impact on motivating them to study and enhancing their motivation for learning. This learning took place in a calm and stress-free environment. Participants were able to analyze the content calmly, as grades were not involved. As a result, they were able to diagnose what to prioritize in a clinical setting, even without the assistance of a clinical instructor. In fact, during these sessions, the instructors focused on teaching the students how to fish instead of simply giving them fish. As a result, the students’ spirit of independent learning increased. Kholmuratovich et al. (2020) stated in their study that independent learning helps students to learn effectively and efficiently [ 45 ]. It increases their independence and critical thinking skills, while also effectively enhancing their self-esteem and motivation [ 46 ]. For this reason, Lau et al. (2017) recommend promoting this teaching method in their study [ 47 ]. Based on the aforementioned studies, independent and self-directed learning leads to improved comprehension and learning, increased motivation, enhanced self-confidence, and critical thinking among students. Consequently, it can be argued that teaching based on clinical cases and workshop-based approaches, beyond aiding students in better understanding and applying the nursing process, has the potential to transform students’ overall learning approach.

Teaching the nursing process through workshops based on clinical cases has broken the taboo surrounding the application of the nursing process. The organization of these workshops in a friendly and stress-free environment, where real clinical cases were discussed, analyzed, and criticized, motivated the students to apply the nursing process in clinical setting. This approach led to a correction in their perception that they considered the implementation of the nursing process as time-consuming and unnecessary, and it also increased the students’ critical thinking abilities. The nature and process of conducting the workshops proved to be beneficial in implementing the theoretical standards in practical settings. The nursing interventions program was evidence based. This approach not only fostered students’ motivation for self-directed learning but also heightened their curiosity for acquiring knowledge. In these sessions, the approach involved teaching students how to fish rather than simply giving them fish. On the other hand, one of the significant challenges in the application of the nursing process in clinical practice by students is the lack of knowledge and skills among nurses to provide care based on the nursing process, it is recommended that these workshops also be conducted for nurses. Furthermore, action research should be employed to evaluate the role of this educational approach in enhancing the knowledge and skills of clinical nurses.

Limitations

Considering that the workshops had to be held outside of the regular class hours of the faculty, which is at 16:00, and taking into account the transportation issues of the students, the workshops could only continue until 18:00. The limitations of this study include the restricted hours and duration of these workshops. Another limitation of this study is the lack of implementation of nursing interventions by the researchers for the patient and subsequently the real evaluation of the interventions performed, due to ethical considerations. In fact, considering that the biggest problem for students is the application of the nursing process related to assessment, diagnosis, and planning, the focus of the workshops was on these stages. However, it seems that by covering all stages of the nursing process in educational workshops, the challenges faced by students in the implementation and evaluation stages can also be addressed.

Data availability

The data that support the findings of this study are available from the cor - responding author upon reasonable request.

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Acknowledgements

The researchers would like to express their gratitude to the students and professors who participated in the workshops and Student Research Committee of Isfahan University of Medical Sciences.

This study was financed by the Student Vice Chancellor for Research of Isfahan University of Medical Sciences (Project number 1400254).

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Parvaneh Abazari

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Faculty of Nursing and Midwifery, Qom University of Medical Sciences, Qom, Iran

Fatemeh Gorji-varnosfaderani

Nursing and Midwifery Care Research Center, Department of Adult Health Nursing, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

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ASH, PA, FG designed the study. ASH, PA, FG, EA, SHA, FS helded the Workshops. PA interviewed the participants. ASH and FG wrote the interviews. PA, EA and SHA analyzed the interviews. ASH, PA and FS prepared the manuscript, and all authors read and approved the final manuscript.

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This study has been approved by the ethics committee of Isfahan University of Medical Sciences (IR.MUI.NUREMA.REC.1400.139) in 2021. Initially, the research purpose was explained to the patients and their caregivers. They were informed that participation in the research is entirely voluntary and free of charge. Not participating in the research would not affect their care and treatment interventions. They were assured that they could withdraw from the research at any time. Furthermore, it was emphasized that their information would be presented in the workshop in a strictly confidential manner, without disclosing their names, photos, file numbers, etc. Subsequently, both oral and written consent were obtained from them. After that, the study’s purpose was also explained to nursing students and faculty members, and informed oral and written consent was obtained from them. Numeric codes were used instead of personal names to ensure the confidentiality of the interviews. The participants were free to withdraw from the study at any time. All methods were conducted following the applicable guidelines and regulations.

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Shahzeydi, A., Abazari, P., Gorji-varnosfaderani, F. et al. Breaking the taboo of using the nursing process: lived experiences of nursing students and faculty members. BMC Nurs 23 , 621 (2024). https://doi.org/10.1186/s12912-024-02233-z

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Nursing Research: What It Is and Why It Matters

When people think about medical research, they often think about cutting-edge surgical procedures and revolutionary new medications. As important as those advancements are, another type of research is just as vital: nursing research.

This type of research informs and improves nursing practice. In many cases, it’s focused on improving patient care. Experienced nurses who have advanced nursing degrees and training in research design typically conduct this research.

Nurse research can explore any number of topics, from symptomology to patient diet. However, no matter the focus of a research project, nurse research can improve health care in an impressive number of ways. As experts in their field, nurse researchers can pursue a wide range of unique career advancement opportunities .

Why Nursing Research Matters: Examples of Research in Action

Research drives innovation in every industry. Given that nurses are on the front line of the health care industry, the research they do can be particularly impactful for patient outcomes. 

It Can Improve Patients’ Quality of Life

Patients diagnosed with life-threatening chronic diseases often undergo intense treatments with sometimes debilitating side effects. Nursing research is vital to helping such patients maintain a high quality of life.

For example, a 2018 study led by a nurse scientist explored why cancer patients undergoing chemotherapy frequently experience severe nausea. While the physical toll of chemotherapy contributes to nausea, the study found that patients who have factors such as children to take care of, high psychological stress, and trouble performing day-to-day tasks are often much more likely to experience nausea.

By identifying the root causes of nausea and which patients are more likely to experience it, this research allows health care professionals to develop evidence-based care practices . This can include prescribing anti-nausea medications and connecting patients to mental health professionals.

It’s Central to Making Health Care More Equitabl

A Gallup survey reports that about 38% of Americans put off seeking medical treatment due to costs. Unfortunately, cost is only one factor that prevents people from seeking treatment. Many Americans don’t live close to medical providers that can meet their needs, aren’t educated about health, or encounter discrimination.

As complex as this issue is, the National Institute of Nursing Research (NINR) asserts that the country’s nurse researchers can lead the charge in tackling it. In its strategic plan for 2022 to 2026, the institute highlights the following:

• Nursing has long been one of the most trusted professions in the country.
• Nurses often interact with patients, patients’ families, and communities more frequently than other health care professionals.
• The care that nurses provide must often take environmental and social factors into account.

These traits put nurses in the position to not only research health inequity but also put their research to work in their organizations. To help make that happen, NINR often funds nurse-led research projects focused on equity and social determinants of health. With that kind of backing, the field may become more transformative than ever.

It Can Strengthen the Health Care Workforce

While nursing research can be used to improve patient care, it can also be leveraged to solve issues health care professionals face daily. Research about the state of the health care workforce during the COVID-19 pandemic is a perfect illustration.

In 2022, a team of nurse researchers published a report called Nursing Crisis: Challenges and Opportunities for Our Profession After COVID-19 in the International Journal of Nursing Practice . In it, the authors provided concrete statistics about the following:

• Mental and physical health issues many nurses encountered
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• How many nurses were planning to leave the profession altogether

As nurses themselves, the authors also offer actionable, evidence-based solutions to these issues, such as streamlining patient documentation systems and implementing employee wellness programs.

However, this type of research isn’t just important to solving workforce issues stemming from specific emergencies, such as the COVID-19 pandemic. By publishing quantifiable data about the challenges they face, nurse researchers empower other nurses and professional nursing organizations to advocate for themselves. This can help employers enact effective policies, support their nursing staff, and draw more talented people into the profession.

Career Opportunities in Nursing Research

Nurse researchers can work in any number of administrative, direct care, and academic roles. However, because nurse research often requires clinical care and data analysis skills, jobs in this field typically require an advanced degree, such as a Master of Science in Nursing (MSN).

While many more nurse research career opportunities exist, here are four career paths nurses with research experience and advanced degrees can explore.

Nurse Researcher

Nurse researchers identify issues related to nursing practice, collect data about them, and conduct research projects designed to inform practice and policy. While they often work in academic medical centers and universities, they can work for any type of health care provider as well as health care advocacy agencies.

In addition to conducting research, these professionals typically provide direct patient care. Many also write papers for peer-reviewed journals and make presentations about their work at conferences.

Clinical Research Nurse

Despite having a similar title to nurse researchers, clinical research nurses have slightly different responsibilities. These professionals are usually in charge of providing care to patients participating in medical research projects, including clinical trials and nursing research initiatives. They also typically collect data about patient progress, coordinate care between different team members, and contribute to academic papers.

Occupational Health Nurse

Also referred to as environmental health nurses, occupational health nurses serve specific communities, such as professionals in a particular industry or people who live in a particular area. They often educate their communities about relevant health risks, advocate for stronger health and safety regulations, and run wellness programs.

To carry out their duties, occupational and environmental health nurses must typically research health trends about the people they serve, including living and working conditions that put them at risk for illness or injury. They can work for private companies and government agencies.

Nurse Educator

Nurse educators prepare new nurses to enter the workforce or train experienced nurses in more advanced techniques. This can include teaching classes and providing on-the-job training. They often work for colleges, universities, and large health care providers.

While their duties don’t always include research, nurse educators must keep up with the health care industry’s needs and new patient care practices. This is so they can provide relevant education themselves and help their organizations design up-to-date curricula.

Make Nursing Research a Part of Your Journey

Conducting and implementing nurse research is a collaborative effort. It takes a team of informed leaders, skilled analysts, and creative educators to create effective, evidence-based policies. Those interested in pursuing nurse research should consider The University of Tulsa’s online MSN program , which can prepare you to fill any one of those roles and more.

All of TU’s MSN students take classes on research and evidence-based practices. However, the program’s specialty tracks allow students to take their studies in multiple research-oriented directions. For instance, if you’re interested in collecting and interpreting clinical data, you can choose the Informatics and Analysis track. If you have a passion for public health policy, the Public Health and Global Vision track includes classes on population health and epidemiology.

Delivered in a flexible online format, this program can be a great option for working nurses and nontraditional students alike. To find out more, read about TU’s admission policies and request more information today.

Recommended Readings

A Nurse Educator’s Role in the Future of Nursing

How Global Health Nursing Supports Population Health

What Can You Do With an MSN?

Gallup, “Record High in U.S. Put Off Medical Care Due to Cost in 2022”

International Journal of Nursing Practice, “Nursing Crisis: Challenges and Opportunities for Our Profession After COVID‐19”

Journal of Pain Symptom Management , “Risk Factors Associated With Chemotherapy-Induced Nausea in the Week Prior to the Next Cycle and Impact of Nausea on Quality of Life Outcomes”

Mayo Clinic, Nursing

National Institute of Nursing Research, Scientific Strategy: NINR’s Research Framework

National Institute of Nursing Research, The National Institute of Nursing Research 2022-2026 Strategic Plan

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Study on Flood Control Operation of Parallel Reservoir Groups Considering the Difference of Solution Order

• Published: 06 September 2024

Cite this article

• Qiong Wu 1 ,
• Zhiqiang Jiang   ORCID: orcid.org/0000-0002-7560-5755 1 ,
• Zongye Chang 1 &
• Suiling Wang 1  

In solving the joint optimal operation problem of reservoir groups, traditional optimization methods suffer from the defects of “dimension disaster”, premature convergence, and low efficiency. In this paper, an improved dynamic programming (DP) method is proposed, which reduces the dimension of the DP by using dynamic water level limits and a variable discrete mechanism. This approach improves computational efficiency while ensuring calculation accuracy. Taking the 5-reservoirs system in the Liuxi River Basin as the research object, and aiming at minimizing flood peak discharge at the control section in the lower reaches, an optimal operation model for joint flood control of the reservoir group is established. Based on the improved DP with dimensionality reduction, and considering the differences in scheduling order of the reservoirs, the model is solved. Through the comparison of the calculation results, it is found that the peak flow at the outlet section of the basin from positive sequence optimization is reduced by 24% compared with conventional operation. This fully exploits the role of peak shaving and shifting, which is conducive to the safety and stability of the downstream river. In addition, the flow peak obtained by the reverse sequence optimization at the outlet section is the smallest, being 12% lower than the positive sequence optimization and 0.7% lower than the mixed sequence optimization. This better achieves the purpose of joint peak cutting and peak staggering. The new algorithm can improve computational speed, and the model that offer higher safety and stability in scheduling has practical significance.

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Data and materials are available from the corresponding author upon reasonable request.

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This study was financially supported by the National Key R&D Program of China (2022YFC3002703); Natural Science Foundation of China (52179016, 52039004, and 52209020); Natural Science Foundation of Hubei Province (2023AFB722).

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W.Q.: methodology, formal analysis, writing – original draft; J.Z.Q.: conceptualization, funding acquisition, supervision; C.Z.Y: data curation, investigation. W.S.L: writing – review & editing, visualization.

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Wu, Q., Jiang, Z., Chang, Z. et al. Study on Flood Control Operation of Parallel Reservoir Groups Considering the Difference of Solution Order. Water Resour Manage (2024). https://doi.org/10.1007/s11269-024-03960-3

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Chapter 4 Nursing Process

4.1. nursing process introduction, learning objectives.

• Use the nursing process to provide patient care
• Identify nursing diagnoses from evidence-based sources
• Describe the development of a care plan
• Prioritize patient care
• Describe documentation for each step of the nursing process
• Differentiate between the role of the PN and RN

Have you ever wondered how a nurse can receive a quick handoff report from another nurse and immediately begin providing care for a patient they previously knew nothing about? How do they know what to do? How do they prioritize and make a plan?

Nurses do this activity every shift. They know how to find pertinent information and use the nursing process as a critical thinking model to guide patient care. The nursing process becomes a road map for the actions and interventions that nurses implement to optimize their patients’ well-being and health. This chapter will explain how to use the  nursing process  as standards of professional nursing practice to provide safe, patient-centered care.

4.2. BASIC CONCEPTS

Before learning how to use the nursing process, it is important to understand some basic concepts related to critical thinking and nursing practice. Let’s take a deeper look at how nurses think.

Critical Thinking and Clinical Reasoning

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning.  Critical thinking  is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” [ 1 ] Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research.

“Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

• Independence of thought: Thinking on your own
• Fair-mindedness:  Treating every viewpoint in an unbiased, unprejudiced way
• Insight into egocentricity and sociocentricity:  Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
• Intellectual humility:  Recognizing your intellectual limitations and abilities
• Nonjudgmental:  Using professional ethical standards and not basing your judgments on your own personal or moral standards
• Integrity:  Being honest and demonstrating strong moral principles
• Perseverance:  Persisting in doing something despite it being difficult
• Confidence:  Believing in yourself to complete a task or activity
• Interest in exploring thoughts and feelings:  Wanting to explore different ways of knowing
• Curiosity:  Asking “why” and wanting to know more

Clinical reasoning  is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.” [ 2 ]  To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. [ 3 ]

Inductive and Deductive Reasoning and Clinical Judgment

Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process.

Inductive reasoning  involves noticing cues, making generalizations, and creating hypotheses.  Cues  are data that fall outside of expected findings that give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A  generalization  is a judgment formed from a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes more clear. Based on generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. A  hypothesis  is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored.

No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. A nurse is similar to the detective looking for cues in Figure 4.1 . [ 4 ]  Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to take action quickly, especially in emergency situations. They can see how certain objects or events form a pattern (i.e., generalization) that indicates a common problem (i.e., hypothesis).

Inductive Reasoning Includes Looking for Cues

Example:  A nurse assesses a patient and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Deductive reasoning  is another type of critical thinking that is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Example:  Based on research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. (See Figure 4.2 ). [ 5 ]  The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking because the intervention is applied to all patients regardless if they have difficulty sleeping or not.

Deductive Reasoning Example: Implementing Interventions for a Quiet Zone Policy

Clinical judgment  is the result of critical thinking and clinical reasoning using inductive and deductive reasoning. Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.”  [ 6 ]  The NCSBN administers the national licensure exam (NCLEX) that measures nursing clinical judgment and decision-making ability of prospective entry-level nurses to assure safe and competent nursing care by licensed nurses.

Evidence-based practice (EBP)  is defined by the American Nurses Association (ANA) as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.” [ 7 ]

Nursing Process

The nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently. [ 8 ]  The mnemonic  ADOPIE  is an easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process:  A ssessment,  D iagnosis,  O utcomes Identification,  P lanning,  I mplementation, and  E valuation.

The nursing process is a continuous, cyclic process that is constantly adapting to the patient’s current health status. See Figure 4.3 [ 9 ]  for an illustration of the nursing process.

The Nursing Process

Review Scenario A in the following box for an example of a nurse using the nursing process while providing patient care.

Patient Scenario A: Using the Nursing Process [ 10 ]

A hospitalized patient has a prescription to receive Lasix 80mg IV every morning for a medical diagnosis of heart failure. During the morning assessment, the nurse notes that the patient has a blood pressure of 98/60, heart rate of 100, respirations of 18, and a temperature of 98.7F. The nurse reviews the medical record for the patient’s vital signs baseline and observes the blood pressure trend is around 110/70 and the heart rate in the 80s. The nurse recognizes these cues form a pattern related to fluid imbalance and hypothesizes that the patient may be dehydrated. The nurse gathers additional information and notes the patient’s weight has decreased 4 pounds since yesterday. The nurse talks with the patient and validates the hypothesis when the patient reports that their mouth feels like cotton and they feel light-headed. By using critical thinking and clinical judgment, the nurse diagnoses the patient with the nursing diagnosis Fluid Volume Deficit and establishes outcomes for reestablishing fluid balance. The nurse withholds the administration of IV Lasix and contacts the health care provider to discuss the patient’s current fluid status. After contacting the provider, the nurse initiates additional nursing interventions to promote oral intake and closely monitor hydration status. By the end of the shift, the nurse evaluates the patient status and determines that fluid balance has been restored.

In Scenario A, the nurse is using clinical judgment and not just “following orders” to administer the Lasix as scheduled. The nurse assesses the patient, recognizes cues, creates a generalization and hypothesis regarding the fluid status, plans and implements nursing interventions, and evaluates the outcome. Additionally, the nurse promotes patient safety by contacting the provider before administering a medication that could cause harm to the patient at this time.

The ANA’s Standards of Professional Nursing Practice associated with each component of the nursing process are described below.

The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” [ 11 ]  A registered nurse uses a systematic method to collect and analyze patient data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, a nurse’s assessment of a hospitalized patient in pain includes the patient’s response to pain, such as the inability to get out of bed, refusal to eat, withdrawal from family members, or anger directed at hospital staff. [ 12 ]

The “Assessment” component of the nursing process is further described in the “ Assessment ” section of this chapter.

The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.” [ 13 ]  A nursing diagnosis is the nurse’s clinical judgment about the  client's  response to actual or potential health conditions or needs. Nursing diagnoses are the bases for the nurse’s care plan and are different than medical diagnoses. [ 14 ]

The “Diagnosis” component of the nursing process is further described in the “ Diagnosis ” section of this chapter.

Outcomes Identification

The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” [ 15 ]  The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses.

The “Outcomes Identification” component of the nursing process is further described in the “ Outcomes Identification ” section of this chapter.

The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” [ 16 ]  Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each patient’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the patient’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care. [ 17 ]

The “Planning” component of the nursing process is further described in the “ Planning ” section of this chapter.

NURSING CARE PLANS

Creating nursing care plans is a part of the “Planning” step of the nursing process. A  nursing care plan  is a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific patient using the nursing process. Registered nurses (RNs) create nursing care plans so that the care provided to the patient across shifts is consistent among health care personnel. Some interventions can be delegated to Licensed Practical Nurses (LPNs) or trained Unlicensed Assistive Personnel (UAPs) with the RN’s supervision. Developing nursing care plans and implementing appropriate delegation are further discussed under the “ Planning ” and “ Implementing ” sections of this chapter.

Implementation

The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.” [ 18 ]  Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the patient. Interventions are also documented in the patient’s electronic medical record as they are completed. [ 19 ]

The “Implementation” Standard of Professional Practice also includes the subcategories “Coordination of Care” and “Health Teaching and Health Promotion” to promote health and a safe environment. [ 20 ]

The “Implementation” component of the nursing process is further described in the “ Implementation ” section of this chapter.

The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [ 21 ]  During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed. [ 22 ]

The “Evaluation” component of the nursing process is further described in the “ Evaluation ” section of this chapter.

Benefits of Using the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other members of the health care team. The benefits of using the nursing process include the following:

• Promotes quality patient care
• Decreases omissions and duplications
• Provides a guide for all staff involved to provide consistent and responsive care
• Encourages collaborative management of a patient’s health care problems
• Improves patient safety
• Improves patient satisfaction
• Identifies a patient’s goals and strategies to attain them
• Increases the likelihood of achieving positive patient outcomes
• Saves time, energy, and frustration by creating a care plan or path to follow

By using these components of the nursing process as a critical thinking model, nurses plan interventions customized to the patient’s needs, plan outcomes and interventions, and determine whether those actions are effective in meeting the patient’s needs. In the remaining sections of this chapter, we will take an in-depth look at each of these components of the nursing process. Using the nursing process and implementing evidence-based practices are referred to as the “science of nursing.” Let’s review concepts related to the “art of nursing” while providing holistic care in a caring manner using the nursing process.

Holistic Nursing Care

The American Nurses Association (ANA) recently updated the definition of  nursing  as, “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.” [ 23 ]

The ANA further describes nursing is a learned profession built on a core body of knowledge that integrates both the art and science of nursing. The  art of nursing  is defined as, “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.” [ 24 ]

Nurses care for individuals holistically, including their emotional, spiritual, psychosocial, cultural, and physical needs. They consider problems, issues, and needs that the person experiences as a part of a family and a community as they use the nursing process. Review a scenario illustrating holistic nursing care provided to a patient and their family in the following box.

Holistic Nursing Care Scenario

A single mother brings her child to the emergency room for ear pain and a fever. The physician diagnoses the child with an ear infection and prescribes an antibiotic. The mother is advised to make a follow-up appointment with their primary provider in two weeks. While providing discharge teaching, the nurse discovers that the family is unable to afford the expensive antibiotic prescribed and cannot find a primary care provider in their community they can reach by a bus route. The nurse asks a social worker to speak with the mother about affordable health insurance options and available providers in her community and follows up with the prescribing physician to obtain a prescription for a less expensive generic antibiotic. In this manner, the nurse provides holistic care and advocates for improved health for the child and their family.

Review how to provide culturally responsive care and reduce health disparities in the “ Diverse Patients ” chapter.

Caring and the nursing process.

The American Nurses Association (ANA) states, “The act of caring is foundational to the practice of nursing.” [ 25 ]  Successful use of the nursing process requires the development of a care relationship with the patient. A  care relationship  is a mutual relationship that requires the development of trust between both parties. This trust is often referred to as the development of  rapport  and underlies the art of nursing. While establishing a caring relationship, the whole person is assessed, including the individual’s beliefs, values, and attitudes, while also acknowledging the vulnerability and dignity of the patient and family. Assessing and caring for the whole person takes into account the physical, mental, emotional, and spiritual aspects of being a human being. [ 26 ] Caring interventions can be demonstrated in simple gestures such as active listening, making eye contact, touching, and verbal reassurances while also respecting and being sensitive to the care recipient’s cultural beliefs and meanings associated with caring behaviors. [ 27 ]  See Figure 4.4 [ 28 ]  for an image of a nurse using touch as a therapeutic communication technique to communicate caring.

Touch as a Therapeutic Communication Technique

Review how to communicate with patients using therapeutic communication techniques like active listening in the “ Communication ” chapter.

Dr. Jean Watson is a nurse theorist who has published many works on the art and science of caring in the nursing profession. Her theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and the public. Dr. Watson’s caring philosophy encourages nurses to be authentically present with their patients while creating a healing environment. [ 29 ]

Read more about Dr. Watson’s theory of caring at the  Watson Caring Science Institute .

Now that we have discussed basic concepts related to the nursing process, let’s look more deeply at each component of the nursing process in the following sections.

4.3. ASSESSMENT

Assessment  is the first step of the nursing process (and the first  Standard of Practice  set by the American Nurses Association). This standard is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” This includes collecting “pertinent data related to the health and quality of life in a systematic, ongoing manner, with compassion and respect for the wholeness, inherent dignity, worth, and unique attributes of every person, including but not limited to, demographics, environmental and occupational exposures, social determinants of health, health disparities, physical, functional, psychosocial, emotional, cognitive, spiritual/transpersonal, sexual, sociocultural, age-related, environmental, and lifestyle/economic assessments.” [ 1 ]

Nurses assess patients to gather clues, make generalizations, and diagnose human responses to health conditions and life processes. Patient data is considered either subjective or objective, and it can be collected from multiple sources.

Subjective Assessment Data

Subjective data  is information obtained from the patient and/or family members and offers important cues from their perspectives. When documenting subjective data stated by a patient, it should be in quotation marks and start with verbiage such as,  The patient reports.  It is vital for the nurse to establish rapport with a patient to obtain accurate, valuable subjective data regarding the mental, emotional, and spiritual aspects of their condition.

There are two types of subjective information, primary and secondary.  Primary data  is information provided directly by the patient. Patients are the best source of information about their bodies and feelings, and the nurse who actively listens to a patient will often learn valuable information while also promoting a sense of well-being. Information collected from a family member, chart, or other sources is known as  secondary data . Family members can provide important information, especially for individuals with memory impairments, infants, children, or when patients are unable to speak for themselves.

See Figure 4.5 [ 2 ]  for an illustration of a nurse obtaining subjective data and establishing rapport after obtaining permission from the patient to sit on the bed.

Example.  An example of documented subjective data obtained from a patient assessment is,  “The patient reports, ‘My pain is a level 2 on a 1-10 scale.’”

Objective Assessment Data

Objective data  is anything that you can observe through your sense of hearing, sight, smell, and touch while assessing the patient. Objective data is reproducible, meaning another person can easily obtain the same data. Examples of objective data are vital signs, physical examination findings, and laboratory results. See Figure 4.6 [ 3 ]  for an image of a nurse performing a physical examination.

Physical Examination

Example.  An example of documented objective data is,  “The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.”

Sources of Assessment Data

There are three sources of assessment data: interview, physical examination, and review of laboratory or diagnostic test results.

Interviewing

Interviewing includes asking the patient questions, listening, and observing verbal and nonverbal communication. Reviewing the chart prior to interviewing the patient may eliminate redundancy in the interview process and allows the nurse to hone in on the most significant areas of concern or need for clarification. However, if information in the chart does not make sense or is incomplete, the nurse should use the interview process to verify data with the patient.

After performing patient identification, the best way to initiate a caring relationship is to introduce yourself to the patient and explain your role. Share the purpose of your interview and the approximate time it will take. When beginning an interview, it may be helpful to start with questions related to the patient’s  medical diagnoses  to gather information about how they have affected the patient’s functioning, relationships, and lifestyle. Listen carefully and ask for clarification when something isn’t clear to you. Patients may not volunteer important information because they don’t realize it is important for their care. By using critical thinking and active listening, you may discover valuable cues that are important to provide safe, quality nursing care. Sometimes nursing students can feel uncomfortable having difficult conversations or asking personal questions due to generational or other cultural differences. Don’t shy away from asking about information that is important to know for safe patient care. Most patients will be grateful that you cared enough to ask and listen.

Be alert and attentive to how the patient answers questions, as well as when they do not answer a question. Nonverbal communication and body language can be cues to important information that requires further investigation. A keen sense of observation is important. To avoid making inappropriate  inferences , the nurse should validate any cues. For example, a nurse may make an inference that a patient is depressed when the patient avoids making eye contact during an interview. However, upon further questioning, the nurse may discover that the patient’s cultural background believes direct eye contact to be disrespectful and this is why they are avoiding eye contact. To read more information about communicating with patients, review the “ Communication ” chapter of this book.

A  physical examination  is a systematic data collection method of the body that uses the techniques of inspection, auscultation, palpation, and percussion. Inspection is the observation of a patient’s anatomical structures. Auscultation is listening to sounds, such as heart, lung, and bowel sounds, created by organs using a stethoscope. Palpation is the use of touch to evaluate organs for size, location, or tenderness. Percussion is an advanced physical examination technique typically performed by providers where body parts are tapped with fingers to determine their size and if fluid is present. Detailed physical examination procedures of various body systems can be found in the Open RN  Nursing Skills  textbook with a head-to-toe checklist in  Appendix C . Physical examination also includes the collection and analysis of vital signs.

Registered Nurses (RNs)  complete the initial physical examination and analyze the findings as part of the nursing process. Collection of follow-up physical examination data can be delegated to  Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs) , or measurements such as vital signs and weight may be delegated to trained  Unlicensed Assistive Personnel (UAP)  when appropriate to do so. However, the RN remains responsible for supervising these tasks, analyzing the findings, and ensuring they are documented .

A physical examination can be performed as a comprehensive, head-to-toe assessment or as a focused assessment related to a particular condition or problem. Assessment data is documented in the patient’s  Electronic Medical Record (EMR) , an electronic version of the patient’s medical chart.

Reviewing Laboratory and Diagnostic Test Results

Reviewing laboratory and diagnostic test results provides relevant and useful information related to the needs of the patient. Understanding how normal and abnormal results affect patient care is important when implementing the nursing care plan and administering provider prescriptions. If results cause concern, it is the nurse’s responsibility to notify the provider and verify the appropriateness of prescriptions based on the patient’s current status before implementing them.

Types of Assessments

Several types of nursing assessment are used in clinical practice:

• Primary Survey:  Used during every patient encounter to briefly evaluate level of consciousness, airway, breathing, and circulation and implement emergency care if needed.
• Admission Assessment:  A comprehensive assessment completed when a patient is admitted to a facility that involves assessing a large amount of information using an organized approach.
• Ongoing Assessment:  In acute care agencies such as hospitals, a head-to-toe assessment is completed and documented at least once every shift. Any changes in patient condition are reported to the health care provider.
• Focused Assessment:  Focused assessments are used to reevaluate the status of a previously diagnosed problem.
• Time-lapsed Reassessment:  Time-lapsed reassessments are used in long-term care facilities when three or more months have elapsed since the previous assessment to evaluate progress on previously identified outcomes. [ 4 ]

Putting It Together

Review Scenario C in the following box to apply concepts of assessment to a patient scenario.

Scenario C [5]

Ms. J. is a 74-year-old woman who is admitted directly to the medical unit after visiting her physician because of shortness of breath, increased swelling in her ankles and calves, and fatigue. Her medical history includes hypertension (30 years), coronary artery disease (18 years), heart failure (2 years), and type 2 diabetes (14 years). She takes 81 mg of aspirin every day, metoprolol 50 mg twice a day, furosemide 40 mg every day, and metformin 2,000 mg every day.

Ms. J.’s vital sign values on admission were as follows:

• Blood Pressure: 162/96 mm Hg
• Heart Rate: 88 beats/min
• Oxygen Saturation: 91% on room air
• Respiratory Rate: 28 breaths/minute
• Temperature: 97.8 degrees F orally

Her weight is up 10 pounds since the last office visit three weeks prior. The patient states, “I am so short of breath” and “My ankles are so swollen I have to wear my house slippers.” Ms. J. also shares, “I am so tired and weak that I can’t get out of the house to shop for groceries,” and “Sometimes I’m afraid to get out of bed because I get so dizzy.” She confides, “I would like to learn more about my health so I can take better care of myself.”

The physical assessment findings of Ms. J. are bilateral basilar crackles in the lungs and bilateral 2+ pitting edema of the ankles and feet. Laboratory results indicate a decreased serum potassium level of 3.4 mEq/L.

As the nurse completes the physical assessment, the patient’s daughter enters the room. She confides, “We are so worried about mom living at home by herself when she is so tired all the time!”

Critical Thinking Questions

Identify subjective data.

Identify objective data.

Provide an example of secondary data.

Answers are located in the Answer Key at the end of the book.

4.4. DIAGNOSIS

Diagnosis  is the second step of the nursing process (and the second Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.” The RN “prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the health care consumer across the health–illness continuum and the care continuum.” Diagnoses, problems, strengths, and issues are documented in a manner that facilitates the development of expected outcomes and a collaborative plan. [ 1 ]

Analyzing Assessment Data

After collection of assessment data, the registered nurse analyzes the data to form generalizations and create hypotheses for nursing diagnoses. Steps for analyzing assessment data include performing data analysis, clustering of information, identifying hypotheses for potential nursing diagnosis, performing additional in-depth assessment as needed, and establishing nursing diagnosis statements. The nursing diagnoses are then prioritized and drive the nursing care plan. [ 2 ]

Performing Data Analysis

After nurses collect assessment data from a patient, they use their nursing knowledge to analyze that data to determine if it is “expected” or “unexpected” or “normal” or “abnormal” for that patient according to their age, development, and baseline status. From there, nurses determine what data are “clinically relevant” as they prioritize their nursing care. [ 3 ]

Example.  In Scenario C in the “Assessment” section of this chapter, the nurse analyzes the vital signs data and determines the blood pressure, heart rate, and respiratory rate are elevated, and the oxygen saturation is decreased for this patient. These findings are considered “relevant cues.”

Clustering Information/Seeing Patterns/Making Hypotheses

After analyzing the data and determining relevant cues, the nurse  clusters  data into patterns. Assessment frameworks such as Gordon’s  Functional Health Patterns  assist nurses in clustering information according to evidence-based patterns of human responses. See the box below for an outline of Gordon’s Functional Health Patterns. [ 4 ]  Concepts related to many of these patterns will be discussed in chapters later in this book.

Example.  Refer to Scenario C of the “Assessment” section of this chapter. The nurse clusters the following relevant cues: elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, shortness of breath, a medical history of heart failure, and currently prescribed a diuretic medication. These cues are clustered into a generalization/pattern of fluid balance, which can be classified under Gordon’s Nutritional-Metabolic Functional Health Pattern. The nurse makes a hypothesis that the patient has excess fluid volume present.

Gordon’s Functional Health Patterns [ 5 ]

Health Perception-Health Management:  A patient’s perception of their health and well-being and how it is managed

Nutritional-Metabolic:  Food and fluid consumption relative to metabolic need

Elimination:  Excretory function, including bowel, bladder, and skin

Activity-Exercise:  Exercise and daily activities

Sleep-Rest:  Sleep, rest, and daily activities

Cognitive-Perceptual:  Perception and cognition

Self-perception and Self-concept:  Self-concept and perception of self-worth, self-competency, body image, and mood state

Role-Relationship:  Role engagements and relationships

Sexuality-Reproductive:  Reproduction and satisfaction or dissatisfaction with sexuality

Coping-Stress Tolerance:  Coping and effectiveness in terms of stress tolerance

Value-Belief:  Values, beliefs (including spiritual beliefs), and goals that guide choices and decisions

Identifying Nursing Diagnoses

After the nurse has analyzed and clustered the data from the patient assessment, the next step is to begin to answer the question, “What are my patient’s human responses (i.e., nursing diagnoses)?” A  nursing diagnosis  is defined as, “A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.” [ 6 ]  Nursing diagnoses are customized to each patient and drive the development of the nursing care plan. The nurse should refer to a care planning resource and review the definitions and defining characteristics of the hypothesized nursing diagnoses to determine if additional in-depth assessment is needed before selecting the most accurate nursing diagnosis.

Nursing diagnoses are developed by nurses, for use by nurses. For example, NANDA International (NANDA-I) is a global professional nursing organization that develops nursing terminology that names actual or potential human responses to health problems and life processes based on research findings. [ 7 ]  Currently, there are over 220 NANDA-I nursing diagnoses developed by nurses around the world. This list is continuously updated, with new nursing diagnoses added and old nursing diagnoses retired that no longer have supporting evidence. A list of commonly used NANDA-I diagnoses are listed in  Appendix A . For a full list of NANDA-I nursing diagnoses, refer to a current nursing care plan reference.

NANDA-I nursing diagnoses are grouped into 13 domains that assist the nurse in selecting diagnoses based on the patterns of clustered data. These domains are similar to Gordon’s Functional Health Patterns and include health promotion, nutrition, elimination and exchange, activity/rest, perception/cognition, self-perception, role relationship, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development.

Knowledge regarding specific NANDA-I nursing diagnoses is not assessed on the NCLEX. However, analyzing cues and creating hypotheses are part of the measurement model used to assess a candidate’s clinical judgment. Read more about the NCLEX and Next Generation NCLEX in the “ Scope of Practice ” chapter.

Nursing diagnoses vs. medical diagnoses.

You may be asking yourself, “How are nursing diagnoses different from medical diagnoses?” Medical diagnoses focus on diseases or other medical problems that have been identified by the physician, physician’s assistant, or advanced nurse practitioner. Nursing diagnoses focus on the  human response  to health conditions and life processes and are made independently by RNs. Patients with the same medical diagnosis will often  respond  differently to that diagnosis and thus have different nursing diagnoses. For example, two patients have the same medical diagnosis of heart failure. However, one patient may be interested in learning more information about the condition and the medications used to treat it, whereas another patient may be experiencing anxiety when thinking about the effects this medical diagnosis will have on their family. The nurse must consider these different responses when creating the nursing care plan. Nursing diagnoses consider the patient’s and family’s needs, attitudes, strengths, challenges, and resources as a customized nursing care plan is created to provide holistic and individualized care for each patient.

Example.  A medical diagnosis identified for Ms. J. in Scenario C in the “Assessment” section is heart failure. This cannot be used as a nursing diagnosis, but it can be considered as an “associated condition” when creating hypotheses for nursing diagnoses. Associated conditions are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents that are not independently modifiable by the nurse, but support accuracy in nursing diagnosis. The nursing diagnosis in Scenario C will be related to the patient’s response to heart failure.

Additional Definitions Used in NANDA-I Nursing Diagnoses

The following definitions of patient, age, and time are used in association with NANDA-I nursing diagnoses:

The NANDA-I definition of a “patient” includes:

• Individual:  a single human being distinct from others (i.e., a person).
• Caregiver:  a family member or helper who regularly looks after a child or a sick, elderly, or disabled person.
• Family:  two or more people having continuous or sustained relationships, perceiving reciprocal obligations, sensing common meaning, and sharing certain obligations toward others; related by blood and/or choice.
• Group:  a number of people with shared characteristics generally referred to as an ethnic group.
• Community:  a group of people living in the same locale under the same governance. Examples include neighborhoods and cities. [ 8 ]

The age of the person who is the subject of the diagnosis is defined by the following terms: [ 9 ]

• Fetus:  an unborn human more than eight weeks after conception, until birth.
• Neonate:  a person less than 28 days of age.
• Infant:  a person greater than 28 days and less than 1 year of age.
• Child:  a person aged 1 to 9 years
• Adolescent:  a person aged 10 to 19 years
• Adult:  a person older than 19 years of age unless national law defines a person as being an adult at an earlier age.
• Older adult:  a person greater than 65 years of age.

The duration of the diagnosis is defined by the following terms: [ 10 ]

• Acute:  lasting less than 3 months.
• Chronic:  lasting greater than 3 months.
• Intermittent:  stopping or starting again at intervals
• Continuous:  uninterrupted, going on without stop.

New Terms Used in 2018-2020 NANDA-I Diagnoses

The 2018-2020 edition of  Nursing Diagnoses  includes two new terms to assist in creating nursing diagnoses: at-risk populations and associated conditions. [ 11 ]

At-Risk Populations  are groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences.

Associated Conditions  are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis [ 12 ]

Types of Nursing Diagnoses

There are four types of NANDA-I nursing diagnoses: [ 13 ]

• Problem-Focused
• Health Promotion – Wellness

A  problem-focused nursing diagnosis  is a “clinical judgment concerning an undesirable human response to health condition/life processes that exist in an individual, family, group, or community.” [ 14 ]  To make an accurate problem-focused diagnosis, related factors and defining characteristics must be present.  Related factors  (also called etiology) are causes that contribute to the diagnosis.  Defining characteristics  are cues, signs, and symptoms that cluster into patterns. [ 15 ]

A  health promotion-wellness nursing diagnosis  is “a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential.” These responses are expressed by the patient’s readiness to enhance specific health behaviors. [ 16 ] A health promotion-wellness diagnosis is used when the patient is willing to improve a lack of knowledge, coping, or other identified need.

A  risk nursing diagnosis  is “a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes.” [ 17 ]  A risk nursing diagnosis must be supported by risk factors that contribute to the increased vulnerability. A risk nursing diagnosis is different from the problem-focused diagnosis in that the problem has not yet actually occurred. Problem diagnoses should not be automatically viewed as more important than risk diagnoses because sometimes a risk diagnosis can have the highest priority for a patient. [ 18 ]

A  syndrome diagnosis  is a “clinical judgment concerning a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.” [ 19 ]

Establishing Nursing Diagnosis Statements

When using NANDA-I nursing diagnoses, NANDA-I recommends the structure of a nursing diagnosis should be a statement that includes the  nursing diagnosis  and  related factors  as exhibited by  defining characteristics . The accuracy of the nursing diagnosis is validated when a nurse is able to clearly link the defining characteristics, related factors, and/or risk factors found during the patient’s assessment. [ 20 ]

To create a nursing diagnosis statement, the registered nurse completes the following steps. After analyzing the patient’s subjective and objective data and clustering the data into patterns, the nurse generates hypotheses for nursing diagnoses based on how the patterns meet defining characteristics of a nursing diagnosis.  Defining characteristics  is the terminology used for observable signs and symptoms related to a nursing diagnosis. [ 21 ]  Defining characteristics are included in care planning resources for each nursing diagnosis, along with a definition of that diagnosis, so the nurse can select the most accurate diagnosis. For example, objective and subjective data such as weight, height, and dietary intake can be clustered together as defining characteristics for the nursing diagnosis of nutritional status.

When creating a nursing diagnosis statement, the nurse also identifies the cause of the problem for that specific patient.  Related factors  is the terminology used for the underlying causes (etiology) of a patient’s problem or situation. Related factors should not be a medical diagnosis, but instead should be attributed to the underlying pathophysiology that the nurse can treat. When possible, the nursing interventions planned for each nursing diagnosis should attempt to modify or remove these related factors that are the underlying cause of the nursing diagnosis. [ 22 ]

Creating nursing diagnosis statements has traditionally been referred to as “using PES format.” The  PES  mnemonic no longer applies to the current terminology used by NANDA-I, but the components of a nursing diagnosis statement remain the same. A nursing diagnosis statement should contain the problem, related factors, and defining characteristics. These terms fit under the former PES format in this manner:

Problem (P)  – the patient  p roblem (i.e., the nursing diagnosis)

Etiology (E)  – related factors (i.e., the  e tiology/cause) of the nursing diagnosis; phrased as “related to” or “R/T”

Signs and Symptoms (S)  – defining characteristics manifested by the patient (i.e., the  s igns and  s ymptoms/subjective and objective data) that led to the identification of that nursing diagnosis for the patient; phrased with “as manifested by” or “as evidenced by.”

Examples of different types of nursing diagnoses are further explained below.

Problem-Focused Nursing Diagnosis

A problem-focused nursing diagnosis contains all three components of the  PES format :

Problem (P)  – statement of the patient response (nursing diagnosis)

Etiology (E)  – related factors contributing to the nursing diagnosis

Signs and Symptoms (S)  – defining characteristics manifested by that patient

SAMPLE PROBLEM-FOCUSED NURSING DIAGNOSIS STATEMENT

Refer to Scenario C of the “Assessment” section of this chapter. The cluster of data for Ms. J. (elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, and shortness of breath) are defining characteristics for the NANDA-I Nursing Diagnosis  Excess Fluid Volume . The NANDA-I definition of  Excess Fluid Volume  is “surplus intake and/or retention of fluid.” The related factor (etiology) of the problem is that the patient has excessive fluid intake. [ 23 ]

The components of a  problem-focused nursing diagnosis  statement for Ms. J. would be:

Fluid Volume Excess

Related to excessive fluid intake

As manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, increased weight of 10 pounds, and the patient reports, “ My ankles are so swollen .”

A correctly written problem-focused nursing diagnosis statement for Ms. J. would look like this:

Fluid Volume Excess related to excessive fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”

Health-Promotion Nursing Diagnosis

A health-promotion nursing diagnosis statement contains the problem (P) and the defining characteristics (S). The defining characteristics component of a health-promotion nursing diagnosis statement should begin with the phrase “expresses desire to enhance”: [ 24 ]

Signs and Symptoms (S)  – the patient’s expressed desire to enhance

SAMPLE HEALTH-PROMOTION NURSING DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. demonstrates a readiness to improve her health status when she told the nurse that she would like to “learn more about my health so I can take better care of myself.” This statement is a defining characteristic of the NANDA-I nursing diagnosis  Readiness for Enhanced Health Management , which is defined as “a pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae, which can be strengthened.” [ 25 ]

The components of a  health-promotion nursing diagnosis  for Ms. J. would be:

Problem (P):  Readiness for Enhanced Health Management

Symptoms (S):  Expressed desire to “learn more about my health so I can take better care of myself.”

A correctly written health-promotion nursing diagnosis statement for Ms. J. would look like this:

Enhanced Readiness for Health Promotion as manifested by expressed desire to “learn more about my health so I can take better care of myself.”

Risk Nursing Diagnosis

A risk nursing diagnosis should be supported by evidence of the patient’s risk factors for developing that problem. Different experts recommend different phrasing. NANDA-I 2018-2020 recommends using the phrase “as evidenced by” to refer to the risk factors for developing that problem. [ 26 ]

A risk diagnosis consists of the following:

As Evidenced By  – Risk factors for developing the problem

SAMPLE RISK DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. has an increased risk of falling due to vulnerability from the dizziness and weakness she is experiencing. The NANDA-I definition of  Risk for Falls  is “increased susceptibility to falling, which may cause physical harm and compromise health.” [ 27 ]

The components of a  risk diagnosis  statement for Ms. J. would be:

Problem (P)  – Risk for Falls

As Evidenced By  – Dizziness and decreased lower extremity strength

A correctly written risk nursing diagnosis statement for Ms. J. would look like this:

Risk for Falls as evidenced by dizziness and decreased lower extremity strength.

Syndrome Diagnosis

A syndrome is a cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions. To create a syndrome diagnosis, two or more nursing diagnoses must be used as defining characteristics (S) that create a syndrome. Related factors may be used if they add clarity to the definition, but are not required. [ 28 ]

A syndrome statement consists of these items:

Problem (P)  – the syndrome

Signs and Symptoms (S)  – the defining characteristics are two or more similar nursing diagnoses

SAMPLE SYNDROME DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Clustering the data for Ms. J. identifies several similar NANDA-I nursing diagnoses that can be categorized as a  syndrome . For example,  Activity Intolerance  is defined as “insufficient physiological or psychological energy to endure or complete required or desired daily activities.”  Social Isolation  is defined as “aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.” These diagnoses can be included under the the NANDA-I syndrome named  Risk for Frail Elderly Syndrome.  This syndrome is defined as a “dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domains of health (physical, functional, psychological, or social) and leads to increased susceptibility to adverse health effects, in particular disability.” [ 29 ]

The components of a  syndrome nursing diagnosis  for Ms. J. would be:

– Risk for Frail Elderly Syndrome

– The nursing diagnoses of  Activity Intolerance  and  Social Isolation

Additional related factor: Fear of falling

A correctly written syndrome diagnosis statement for Ms. J. would look like this:

Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling

Prioritization

After identifying nursing diagnoses, the next step is prioritization according to the specific needs of the patient. Nurses prioritize their actions while providing patient care multiple times every day.  Prioritization  is the process that identifies the most significant nursing problems, as well as the most important interventions, in the nursing care plan.

It is essential that life-threatening concerns and crises are identified immediately and addressed quickly. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds for life-threatening concerns. In critical situations, the steps of the nursing process are performed through rapid clinical judgment. Nurses must recognize cues signaling a change in patient condition, apply evidence-based practices in a crisis, and communicate effectively with interprofessional team members. Most patient situations fall somewhere between a crisis and routine care.

There are several concepts used to prioritize, including Maslow’s Hierarchy of Needs, the “ABCs” (Airway, Breathing and Circulation), and acute, uncompensated conditions. See the infographic in Figure 4.7 [30]  on  The How To of Prioritization .

The How To of Prioritization

Maslow’s Hierarchy of Needs  is used to categorize the most urgent patient needs. The bottom levels of the pyramid represent the top priority needs of physiological needs intertwined with safety. See Figure 4.8 [31]  for an image of Maslow’s Hierarchy of Needs. You may be asking yourself, “What about the ABCs – isn’t airway the most important?” The answer to that question is “it depends on the situation and the associated safety considerations.” Consider this scenario – you are driving home after a lovely picnic in the country and come across a fiery car crash. As you approach the car, you see that the passenger is not breathing. Using Maslow’s Hierarchy of Needs to prioritize your actions, you remove the passenger from the car first due to safety even though he is not breathing. After ensuring safety and calling for help, you follow the steps to perform cardiopulmonary resuscitation (CPR) to establish circulation, airway, and breathing until help arrives.

Maslow’s Hierarchy of Needs

In addition to using Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation, the nurse also considers if the patient’s condition is an acute or chronic problem. Acute, uncompensated conditions generally require priority interventions over chronic conditions. Additionally, actual problems generally receive priority over potential problems, but risk problems sometimes receive priority depending on the patient vulnerability and risk factors.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Four types of nursing diagnoses were identified for Ms. J.:  Fluid Volume Excess, Enhanced Readiness for Health Promotion, Risk for Falls , and  Risk for Frail Elderly Syndrome . The top priority diagnosis is  Fluid Volume Excess  because it affects the physiological needs of breathing, homeostasis, and excretion. However, the  Risk for Falls  diagnosis comes in a close second because of safety implications and potential injury that could occur if the patient fell.

American Nurses Association. (2021).  Nursing: Scope and standards of practice  (4th ed.). American Nurses Association.  ↵

Herdman, T. H., & Kamitsuru, S. (Eds.). (2018).  Nursing diagnoses: Definitions and classification, 2018-2020 . Thieme Publishers New York.  ↵

Herdman, T. H., & Kamitsuru, S. (Eds.). (2018).  Nursing diagnoses: Definitions and classification, 2018-2020.  Thieme Publishers New York.  ↵

Gordon, M. (2008).  Assess notes: Nursing assessment and diagnostic reasoning.  F.A. Davis Company.  ↵

NANDA International. (n.d.).  Glossary of terms .  https://nanda ​.org/nanda-i-resources ​/glossary-of-terms /  ↵

NANDA International. (n.d.).  Glossary of terms .  https://nanda ​.org/nanda-i-resources ​/glossary-of-terms/   ↵

NANDA International. (n.d.).  Glossary of terms.   https://nanda ​.org/nanda-i-resources ​/glossary-of-terms/   ↵

“The How To of Prioritization” by Valerie Palarski for  Chippewa Valley Technical College  is licensed under  CC BY 4.0   ↵

“ Maslow's hierarchy of needs.svg ” by  J. Finkelstein  is licensed under  CC BY-SA 3.0   ↵

4.5. OUTCOME IDENTIFICATION

Outcome Identification  is the third step of the nursing process (and the third Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” The RN collaborates with the health care consumer, interprofessional team, and others to identify expected outcomes integrating the health care consumer’s culture, values, and ethical considerations. Expected outcomes are documented as measurable goals with a time frame for attainment. [ 1 ]

An  outcome  is a “measurable behavior demonstrated by the patient responsive to nursing interventions.” [ 2 ]  Outcomes should be identified before nursing interventions are planned. After nursing interventions are implemented, the nurse will evaluate if the outcomes were met in the time frame indicated for that patient.

Outcome identification includes setting short- and long-term goals and then creating specific expected outcome statements for each nursing diagnosis.

Short-Term and Long-Term Goals

Nursing care should always be individualized and patient-centered. No two people are the same, and neither should nursing care plans be the same for two people. Goals and outcomes should be tailored specifically to each patient’s needs, values, and cultural beliefs. Patients and family members should be included in the goal-setting process when feasible. Involving patients and family members promotes awareness of identified needs, ensures realistic goals, and motivates their participation in the treatment plan to achieve the mutually agreed upon goals and live life to the fullest with their current condition.

The nursing care plan is a road map used to guide patient care so that all health care providers are moving toward the same patient goals.  Goals  are broad statements of purpose that describe the overall aim of care. Goals can be short- or long-term. The time frame for short- and long-term goals is dependent on the setting in which the care is provided. For example, in a critical care area, a short-term goal might be set to be achieved within an 8-hour nursing shift, and a long-term goal might be in 24 hours. In contrast, in an outpatient setting, a short-term goal might be set to be achieved within one month and a long-term goal might be within six months.

A nursing goal is the overall direction in which the patient must progress to improve the problem/nursing diagnosis and is often the opposite of the problem.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. had a priority nursing diagnosis of  Fluid Volume Excess.  A broad goal would be, “ Ms. J. will achieve a state of fluid balance. ”

Expected Outcomes

Goals are broad, general statements, but outcomes are specific and measurable.  Expected outcomes  are statements of measurable action for the patient within a specific time frame that are responsive to nursing interventions. Nurses may create expected outcomes independently or refer to classification systems for assistance. Just as NANDA-I creates and revises standardized nursing diagnoses, a similar classification and standardization process exists for expected nursing outcomes. The Nursing Outcomes Classification (NOC) is a list of over 330 nursing outcomes designed to coordinate with established NANDA-I diagnoses. [ 3 ]

Patient-Centered

Outcome statements are always patient-centered. They should be developed in collaboration with the patient and individualized to meet a patient’s unique needs, values, and cultural beliefs. They should start with the phrase “The patient will…” Outcome statements should be directed at resolving the defining characteristics for that nursing diagnosis. Additionally, the outcome must be something the patient is willing to cooperate in achieving.

Outcome statements should contain five components easily remembered using the “SMART” mnemonic: [ 4 ]

• M easurable
• A ttainable/Action oriented
• R elevant/Realistic

See Figure 4.9 [ 5 ]  for an image of the SMART components of outcome statements. Each of these components is further described in the following subsections.

SMART Components of Outcome Statements

Outcome statements should state precisely what is to be accomplished. See the following examples:

• Not specific:  “The patient will increase the amount of exercise.”
• Specific:  “The patient will participate in a bicycling exercise session daily for 30 minutes.”

Additionally, only one action should be included in each expected outcome. See the following examples:

• “The patient will walk 50 feet three times a day with standby assistance of one and will shower in the morning until discharge”  is actually two goals written as one. The outcome of ambulation should be separate from showering for precise evaluation. For instance, the patient could shower but not ambulate, which would make this outcome statement very difficult to effectively evaluate.
• Suggested revision is to create two outcomes statements so each can be measured: The patient will walk 50 feet three times a day with standby assistance of one until discharge. The patient will shower every morning until discharge.

Measurable outcomes have numeric parameters or other concrete methods of judging whether the outcome was met. It is important to use objective data to measure outcomes. If terms like “acceptable” or “normal” are used in an outcome statement, it is difficult to determine whether the outcome is attained. Refer to Figure 4.10 [ 6 ]  for examples of verbs that are measurable and not measurable in outcome statements.

Figure 4.10

Measurable Outcomes

See the following examples:

• Not measurable:  “The patient will drink adequate fluid amounts every shift.”
• Measurable:  “The patient will drink 24 ounces of fluids during every day shift (0600-1400).”

Action-Oriented and Attainable

Outcome statements should be written so that there is a clear action to be taken by the patient or significant others. This means that the outcome statement should include a verb. Refer to Figure 4.11 [ 7 ]  for examples of action verbs.

Figure 4.11

Action Verbs

• Not action-oriented:  “The patient will get increased physical activity.”
• Action-oriented:  “The patient will list three types of aerobic activity that he would enjoy completing every week.”

Realistic and Relevant

Realistic outcomes consider the patient’s physical and mental condition; their cultural and spiritual values, beliefs, and preferences; and their socioeconomic status in terms of their ability to attain these outcomes. Consideration should be also given to disease processes and the effects of conditions such as pain and decreased mobility on the patient’s ability to reach expected outcomes. Other barriers to outcome attainment may be related to health literacy or lack of available resources. Outcomes should always be reevaluated and revised for attainability as needed. If an outcome is not attained, it is commonly because the original time frame was too ambitious or the outcome was not realistic for the patient.

• Not realistic:  “The patient will jog one mile every day when starting the exercise program.”
• Realistic:  “The patient will walk ½ mile three times a week for two weeks.”

Time Limited

Outcome statements should include a time frame for evaluation. The time frame depends on the intervention and the patient’s current condition. Some outcomes may need to be evaluated every shift, whereas other outcomes may be evaluated daily, weekly, or monthly. During the evaluation phase of the nursing process, the outcomes will be assessed according to the time frame specified for evaluation. If it has not been met, the nursing care plan should be revised.

• Not time limited: “The patient will stop smoking cigarettes.”
• Time limited:  “The patient will complete the smoking cessation plan by December 12, 2021.”

In Scenario C in Box 4.3, Ms. J.’s priority nursing diagnosis statement was  Fluid Volume Excess related to excess fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”  An example of an expected outcome meeting SMART criteria for Ms. J. is,  “The patient will have clear bilateral lung sounds within the next 24 hours.”

4.6. PLANNING

Planning  is the fourth step of the nursing process (and the fourth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” The RN develops an individualized, holistic, evidence-based plan in partnership with the health care consumer, family, significant others, and interprofessional team. Elements of the plan are prioritized. The plan is modified according to the ongoing assessment of the health care consumer’s response and other indicators. The plan is documented using standardized language or terminology. [ 1 ]

After expected outcomes are identified, the nurse begins planning nursing interventions to implement.  Nursing interventions  are evidence-based actions that the nurse performs to achieve patient outcomes. Just as a provider makes medical diagnoses and writes prescriptions to improve the patient’s medical condition, a nurse formulates nursing diagnoses and plans nursing interventions to resolve patient problems. Nursing interventions should focus on eliminating or reducing the related factors (etiology) of the nursing diagnoses when possible. [ 2 ]  Nursing interventions, goals, and expected outcomes are written in the nursing care plan for continuity of care across shifts, nurses, and health professionals.

Planning Nursing Interventions

You might be asking yourself, “How do I know what evidence-based nursing interventions to include in the nursing care plan?” There are several sources that nurses and nursing students can use to select nursing interventions. Many agencies have care planning tools and references included in the electronic health record that are easily documented in the patient chart. Nurses can also refer to other care planning books our sources such as the Nursing Interventions Classification (NIC) system. Based on research and input from the nursing profession, NIC categorizes and describes nursing interventions that are constantly evaluated and updated. Interventions included in NIC are considered evidence-based nursing practices. The nurse is responsible for using clinical judgment to make decisions about which interventions are best suited to meet an individualized patient’s needs. [ 3 ]

Direct and Indirect Care

Nursing interventions are considered direct care or indirect care.  Direct care  refers to interventions that are carried out by having personal contact with patients. Examples of direct care interventions are wound care, repositioning, and ambulation.  Indirect care  interventions are performed when the nurse provides assistance in a setting other than with the patient. Examples of indirect care interventions are attending care conferences, documenting, and communicating about patient care with other providers.

Classification of Nursing Interventions

There are three types of nursing interventions: independent, dependent, and collaborative. (See Figure 4.12 [ 4 ]  for an image of a nurse collaborating with the health care team when planning interventions.)

Figure 4.12

Collaborative nursing interventions, independent nursing interventions.

Any intervention that the nurse can independently provide without obtaining a prescription is considered an  independent nursing intervention . An example of an independent nursing intervention is when the nurses monitor the patient’s 24-hour intake/output record for trends because of a risk for imbalanced fluid volume. Another example of independent nursing interventions is the therapeutic communication that a nurse uses to assist patients to cope with a new medical diagnosis.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of an evidence-based independent nursing intervention is,  “The nurse will reposition the patient with dependent edema frequently, as appropriate.” [ 5 ]  The nurse would individualize this evidence-based intervention to the patient and agency policy by stating,  “The nurse will reposition the patient every 2 hours.”

Dependent Nursing Interventions

Dependent nursing interventions  require a prescription before they can be performed. Prescriptions are orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider. [ 6 ]  A  primary health care provider  is a member of the health care team (usually a physician, advanced practice nurse, or physician’s assistant) who is licensed and authorized to formulate prescriptions on behalf of the client. For example, administering medication is a dependent nursing intervention. The nurse incorporates dependent interventions into the patient’s overall care plan by associating each intervention with the appropriate nursing diagnosis.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of a dependent nursing intervention is,  “The nurse will administer scheduled diuretics as prescribed.”

Collaborative nursing interventions  are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, respiratory therapists, physical therapists, and occupational therapists. These actions are developed in consultation with other health care professionals and incorporate their professional viewpoint. [ 7 ]

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of a collaborative nursing intervention is consulting with a respiratory therapist when the patient has deteriorating oxygen saturation levels. The respiratory therapist plans oxygen therapy and obtains a prescription from the provider. The nurse would document “ The nurse will manage oxygen therapy in collaboration with the respiratory therapist ” in the care plan.

Individualization of Interventions

It is vital for the planned interventions to be individualized to the patient to be successful. For example, adding prune juice to the breakfast meal of a patient with constipation will only work if the patient likes to drink the prune juice. If the patient does not like prune juice, then this intervention should not be included in the care plan. Collaboration with the patient, family members, significant others, and the interprofessional team is essential for selecting effective interventions. The number of interventions included in a nursing care plan is not a hard and fast rule, but enough quality, individualized interventions should be planned to meet the identified outcomes for that patient.

Creating Nursing Care Plans

Nursing care plans are created by registered nurses (RNs). Documentation of individualized nursing care plans are legally required in long-term care facilities by the Centers for Medicare and Medicaid Services (CMS) and in hospitals by The Joint Commission. CMS guidelines state, “Residents and their representative(s) must be afforded the opportunity to participate in their care planning process and to be included in decisions and changes in care, treatment, and/or interventions. This applies both to initial decisions about care and treatment, as well as the refusal of care or treatment. Facility staff must support and encourage participation in the care planning process. This may include ensuring that residents, families, or representatives understand the comprehensive care planning process, holding care planning meetings at the time of day when a resident is functioning best and patient representatives can be present, providing sufficient notice in advance of the meeting, scheduling these meetings to accommodate a resident’s representative (such as conducting the meeting in-person, via a conference call, or video conferencing), and planning enough time for information exchange and decision-making. A resident has the right to select or refuse specific treatment options before the care plan is instituted.” [ 8 ]  The Joint Commission conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care. [ 9 ]

Many facilities have established standardized nursing care plans with lists of possible interventions that can be customized for each specific patient. Other facilities require the nurse to develop each care plan independently. Whatever the format, nursing care plans should be individualized to meet the specific and unique needs of each patient. See Figure 4.13 [ 10 ]  for an image of a standardized care plan.

Figure 4.13

Standardized Care Plan

Nursing care plans created in nursing school can also be in various formats such as concept maps or tables. Some are fun and creative, while others are more formal.  Appendix B  contains a template that can be used for creating nursing care plans.

4.7. IMPLEMENTATION OF INTERVENTIONS

Implementation  is the fifth step of the nursing process (and the fifth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse implements the identified plan.” The RN may delegate planned interventions after considering the circumstance, person, task, communication, supervision, and evaluation, as well as the state Nurse Practice Act, federal regulation, and agency policy. [ 1 ]

Implementation of interventions requires the RN to use critical thinking and clinical judgment. After the initial plan of care is developed, continual reassessment of the patient is necessary to detect any changes in the patient’s condition requiring modification of the plan. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing safe care.

During the implementation phase of the nursing process, the nurse prioritizes planned interventions, assesses patient safety while implementing interventions, delegates interventions as appropriate, and documents interventions performed.

Prioritizing Implementation of Interventions

Prioritizing implementation of interventions follows a similar method as to prioritizing nursing diagnoses. Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation are used to establish top priority interventions. When possible, least invasive actions are usually preferred due to the risk of injury from invasive options. Read more about methods for prioritization under the “ Diagnosis ” subsection of this chapter.

The potential impact on future events, especially if a task is not completed at a certain time, is also included when prioritizing nursing interventions. For example, if a patient is scheduled to undergo a surgical procedure later in the day, the nurse prioritizes initiating a NPO (nothing by mouth) prescription prior to completing pre-op patient education about the procedure. The rationale for this decision is that if the patient ate food or drank water, the surgery time would be delayed. Knowing and understanding the patient’s purpose for care, current situation, and expected outcomes are necessary to accurately prioritize interventions.

Patient Safety

It is essential to consider patient safety when implementing interventions. At times, patients may experience a change in condition that makes a planned nursing intervention or provider prescription no longer safe to implement. For example, an established nursing care plan for a patient states,  “The nurse will ambulate the patient 100 feet three times daily.”  However, during assessment this morning, the patient reports feeling dizzy today, and their blood pressure is 90/60. Using critical thinking and clinical judgment, the nurse decides to not implement the planned intervention of ambulating the patient. This decision and supporting assessment findings should be documented in the patient’s chart and also communicated during the shift handoff report, along with appropriate notification of the provider of the patient’s change in condition.

Implementing interventions goes far beyond implementing provider prescriptions and completing tasks identified on the nursing care plan and must focus on patient safety. As front-line providers, nurses are in the position to stop errors before they reach the patient. [ 2 ]

In 2000 the Institute of Medicine (IOM) issued a groundbreaking report titled  To Err Is Human: Building a Safer Health System . The report stated that as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors.  To Err Is Human  broke the silence that previously surrounded the consequences of medical errors and set a national agenda for reducing medical errors and improving patient safety through the design of a safer health system. [ 3 ]  In 2007 the IOM published a follow-up report titled  Preventing Medication Errors  and reported that more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. This report emphasized actions that health care systems could take to improve medication safety. [ 4 ]

Read additional information about specific actions that nurses can take to prevent medication errors; go to the “Preventing Medication Errors” section of the “ Legal/Ethical”  chapter of the Open RN  Nursing Pharmacology  textbook.

In an article released by the Robert Wood Johnson Foundation, errors involving nurses that endanger patient safety cover broad territory. This territory spans “wrong site, wrong patient, wrong procedure” errors, medication mistakes, failures to follow procedures that prevent central line bloodstream and other infections, errors that allow unsupervised patients to fall, and more. Some errors can be traced to shifts that are too long that leave nurses fatigued, some result from flawed systems that do not allow for adequate safety checks, and others are caused by interruptions to nurses while they are trying to administer medications or provide other care. [ 5 ]

The Quality and Safety Education for Nurses (QSEN) project began in 2005 to assist in preparing future nurses to continuously improve the quality and safety of the health care systems in which they work. The vision of the QSEN project is to “inspire health care professionals to put quality and safety as core values to guide their work.” [ 6 ]  Nurses and nursing students are expected to participate in quality improvement (QI) initiatives by identifying gaps where change is needed and assisting in implementing initiatives to resolve these gaps.  Quality improvement  is defined as, “The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).” [ 7 ]

Delegation of Interventions

While implementing interventions, RNs may elect to delegate nursing tasks.  Delegation  is defined by the American Nurses Association as, “The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel or licensed practical nurses (LPNs) while retaining accountability for the outcome.” [ 8 ]  RNs are accountable for determining the appropriateness of the delegated task according to condition of the patient and the circumstance; the communication provided to an appropriately trained LPN or UAP; the level of supervision provided; and the evaluation and documentation of the task completed. The RN must also be aware of the state Nurse Practice Act, federal regulations, and agency policy before delegating. The RN cannot delegate responsibilities requiring clinical judgment. [ 9 ]  See the following box for information regarding legal requirements associated with delegation according to the Wisconsin Nurse Practice Act.

Delegation According to the Wisconsin Nurse Practice Act

During the supervision and direction of delegated acts a Registered Nurse shall do all of the following:

Delegate tasks commensurate with educational preparation and demonstrated abilities of the person supervised.

Provide direction and assistance to those supervised.

Observe and monitor the activities of those supervised.

Evaluate the effectiveness of acts performed under supervision. [ 10 ]

The standard of practice for Licensed Practical Nurses in Wisconsin states, “In the performance of acts in basic patient situations, the LPN. shall, under the general supervision of an RN or the direction of a provider:

Accept only patient care assignments which the LPN is competent to perform.

Provide basic nursing care. Basic nursing care is defined as care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.

Record nursing care given and report to the appropriate person changes in the condition of a patient.

Consult with a provider in cases where an LPN knows or should know a delegated act may harm a patient.

Perform the following other acts when applicable:

Assist with the collection of data.

Assist with the development and revision of a nursing care plan.

Reinforce the teaching provided by an RN provider and provide basic health care instruction.

Participate with other health team members in meeting basic patient needs.” [ 11 ]

Read additional details about the scope of practice of registered nurses (RNs) and licensed practical nurses (LPNs) in Wisconsin’s Nurse Practice Act in  Chapter N 6 Standards of Practice .

Read more about the American Nurses Association’s  Principles of Delegation.

Table 4.7 outlines general guidelines for delegating nursing tasks in the state of Wisconsin according to the role of the health care team member.

General Guidelines for Delegating Nursing Tasks

Documentation of Interventions

As interventions are performed, they must be documented in the patient’s record in a timely manner. As previously discussed in the “Ethical and Legal Issues” subsection of the “ Basic Concepts ” section, lack of documentation is considered a failure to communicate and a basis for legal action. A basic rule of thumb is if an intervention is not documented, it is considered not done in a court of law. It is also important to document administration of medication and other interventions in a timely manner to prevent errors that can occur due to delayed documentation time.

Coordination of Care and Health Teaching/Health Promotion

ANA’s Standard of Professional Practice for Implementation also includes the standards  5A   Coordination of Care  and  5B   Health Teaching and Health Promotion . [ 12 ]   Coordination of Care  includes competencies such as organizing the components of the plan, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and holistic care by the interprofessional team.  Health Teaching and Health Promotion  is defined as, “Employing strategies to teach and promote health and wellness.” [ 13 ]  Patient education is an important component of nursing care and should be included during every patient encounter. For example, patient education may include teaching about side effects while administering medications or teaching patients how to self-manage their conditions at home.

Refer to Scenario C in the “Assessment” section of this chapter. The nurse implemented the nursing care plan documented in Appendix C. Interventions related to breathing were prioritized. Administration of the diuretic medication was completed first, and lung sounds were monitored frequently for the remainder of the shift. Weighing the patient before breakfast was delegated to the CNA. The patient was educated about her medications and methods to use to reduce peripheral edema at home. All interventions were documented in the electronic medical record (EMR).

4.8. EVALUATION

Evaluation  is the sixth step of the nursing process (and the sixth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [ 1 ]  Both the patient status and the effectiveness of the nursing care must be continuously evaluated and the care plan modified as needed. [ 2 ]

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a patient’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a patient, discusses the care plan with others on the interprofessional team, or reviews updated laboratory or diagnostic test results. Nursing care plans should be updated as higher priority goals emerge. The results of the evaluation must be documented in the patient’s medical record.

Ideally, when the planned interventions are implemented, the patient will respond positively and the expected outcomes are achieved. However, when interventions do not assist in progressing the patient toward the expected outcomes, the nursing care plan must be revised to more effectively address the needs of the patient. These questions can be used as a guide when revising the nursing care plan:

• Did anything unanticipated occur?
• Has the patient’s condition changed?
• Were the expected outcomes and their time frames realistic?
• Are the nursing diagnoses accurate for this patient at this time?
• Are the planned interventions appropriately focused on supporting outcome attainment?
• What barriers were experienced as interventions were implemented?
• Does ongoing assessment data indicate the need to revise diagnoses, outcome criteria, planned interventions, or implementation strategies?
• Are different interventions required?

Refer to Scenario C in the “Assessment” section of this chapter and Appendix C . The nurse evaluates the patient’s progress toward achieving the expected outcomes.

For the nursing diagnosis  Fluid Volume Excess , the nurse evaluated the four expected outcomes to determine if they were met during the time frames indicated:

The patient will report decreased dyspnea within the next 8 hours.

The patient will have clear lung sounds within the next 24 hours.

The patient will have decreased edema within the next 24 hours.

The patient’s weight will return to baseline by discharge.

Evaluation of the patient condition on Day 1 included the following data: “ The patient reported decreased shortness of breath, and there were no longer crackles in the lower bases of the lungs. Weight decreased by 1 kg, but 2+ edema continued in ankles and calves .” Based on this data, the nurse evaluated the expected outcomes as “ Partially Met ” and revised the care plan with two new interventions:

Request prescription for TED hose from provider.

Elevate patient’s legs when sitting in chair.

For the second nursing diagnosis,  Risk for Falls , the nurse evaluated the outcome criteria as “ Met ” based on the evaluation, “ The patient verbalizes understanding and is appropriately calling for assistance when getting out of bed. No falls have occurred. ”

The nurse will continue to reassess the patient’s progress according to the care plan during hospitalization and make revisions to the care plan as needed. Evaluation of the care plan is documented in the patient’s medical record.

4.9. SUMMARY OF THE NURSING PROCESS

You have now learned how to perform each step of the nursing process according to the ANA Standards of Professional Nursing Practice. Critical thinking, clinical reasoning, and clinical judgment are used when assessing the patient, creating a nursing care plan, and implementing interventions. Frequent reassessment, with revisions to the care plan as needed, is important to help the patient achieve expected outcomes. Throughout the entire nursing process, the patient always remains the cornerstone of nursing care. Providing individualized, patient-centered care and evaluating whether that care has been successful in achieving patient outcomes are essential for providing safe, professional nursing practice.

Video Review of Creating a Sample Care Plan [ 1 ]

4.10. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

Instructions: Apply what you’ve learned in this chapter by creating a nursing care plan using the following scenario. Use the template in   Appendix B   as a guide.

The client, Mark S., is a 57-year-old male who was admitted to the hospital with “severe” abdominal pain that was unable to be managed in the Emergency Department. The physician has informed Mark that he will need to undergo some diagnostic tests. The tests are scheduled for the morning.

After receiving the news about his condition and the need for diagnostic tests, Mark begins to pace the floor. He continues to pace constantly. He keeps asking the nurse the same question (“How long will the tests take?”) about his tests over and over again. The patient also remarked, “I’m so uptight I will never be able to sleep tonight.” The nurse observes that the client avoids eye contact during their interactions and that he continually fidgets with the call light. His eyes keep darting around the room. He appears tense and has a strained expression on his face. He states, “My mouth is so dry.” The nurse observes his vital signs to be: T 98, P 104, R 30, BP 180/96. The nurse notes that his skin feels sweaty (diaphoretic) and cool to the touch.

Critical Thinking Activity:

Group (cluster) the subjective and objective data.

Create a problem-focused nursing diagnosis (hypothesis).

Develop a broad goal and then identify an expected outcome in “SMART” format.

Outline three interventions for the nursing diagnosis to meet the goal. Cite an evidence-based source.

Imagine that you implemented the interventions that you identified. Evaluate the degree to which the expected outcome was achieved: Met – Partially Met – Not Met.

• IV GLOSSARY

The act or process of pleading for, supporting, or recommending a cause or course of action. [ 1 ]

Unconditionally acceptance of the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care. [ 2 ]

Groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences. [ 3 ]

Medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis. [ 4 ]

Care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable. [ 5 ]

A relationship described as one in which the whole person is assessed while balancing the vulnerability and dignity of the patient and family. [ 6 ]

Individual, family, or group, which includes significant others and populations. [ 7 ]

The observed outcome of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care. [ 8 ]

A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.  [ 9 ]

Grouping data into similar domains or patterns.

Nursing interventions that require cooperation among health care professionals and unlicensed assistive personnel (UAP).

While implementing interventions during the nursing process, includes components such as organizing the components of the plan with input from the health care consumer, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and person-centered care by the interprofessional team. [ 10 ]

Reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow. [ 11 ]

Subjective or objective data that gives the nurse a hint or indication of a potential problem, process, or disorder.

“Top-down thinking” or moving from the general to the specific. Deductive reasoning relies on a general statement or hypothesis—sometimes called a premise or standard—that is held to be true. The premise is used to reach a specific, logical conclusion.

Observable cues/inferences that cluster as manifestations of a problem-focused, health-promotion diagnosis, or syndrome. This does not only imply those things that the nurse can see, but also things that are seen, heard (e.g., the patient/family tells us), touched, or smelled. [ 12 ]

The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel while retaining accountability for the outcome. [ 13 ]

Interventions that require a prescription from a physician, advanced practice nurse, or physician’s assistant.

Interventions that are carried out by having personal contact with a patient.

An electronic version of the patient’s medical record.

A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values. [ 14 ]

Statements of measurable action for the patient within a specific time frame and in response to nursing interventions. “SMART” outcome statements are specific, measurable, action-oriented, realistic, and include a time frame.

An evidence-based assessment framework for identifying patient problems and risks during the assessment phase of the nursing process.

A judgment formed from a set of facts, cues, and observations.

Broad statements of purpose that describe the aim of nursing care.

Employing strategies to teach and promote health and wellness. [ 15 ]

Any intervention that the nurse can provide without obtaining a prescription or consulting anyone else.

Interventions performed by the nurse in a setting other than directly with the patient. An example of indirect care is creating a nursing care plan.

A type of reasoning that involves forming generalizations based on specific incidents.

Interpretations or conclusions based on cues, personal experiences, preferences, or generalizations.

Nurses who have had specific training and passed a licensing exam. The training is generally less than that of a Registered Nurse. The scope of practice of an LPN/LVN is determined by the facility and the state’s Nurse Practice Act.

A disease or illness diagnosed by a physician or advanced health care provider such as a nurse practitioner or physician’s assistant. Medical diagnoses are a result of clustering signs and symptoms to determine what is medically affecting an individual.

Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity. [ 16 ]

Specific documentation of the planning and delivery of nursing care that is required by The Joint Commission.

A systematic approach to patient-centered care with steps including assessment, diagnosis, outcome identification, planning, implementation, and evaluation; otherwise known by the mnemonic “ADOPIE.”

Data that the nurse can see, touch, smell, or hear or is reproducible such as vital signs. Laboratory and diagnostic results are also considered objective data.

A measurable behavior demonstrated by the patient that is responsive to nursing interventions. [ 17 ]

The format of a nursing diagnosis statement that includes:

Problem (P) – statement of the patient problem (i.e., the nursing diagnosis)

Etiology (E) – related factors (etiology) contributing to the cause of the nursing diagnosis

Signs and Symptoms (S) – defining characteristics manifested by the patient of that nursing diagnosis

Orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider. [ 18 ]

Information collected from the patient.

Member of the health care team (usually a medical physician, nurse practitioner, etc.) licensed and authorized to formulate prescriptions on behalf of the client. [ 19 ]

The skillful process of deciding which actions to complete first, second, or third for optimal patient outcomes and to improve patient safety.

The “combined and unceasing efforts of everyone — health care professionals, patients and their families, researchers, payers, planners, and educators — to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).” [ 20 ]

Developing a relationship of mutual trust and understanding.

A nurse who has had a designated amount of education and training in nursing and is licensed by a state Board of Nursing.

The underlying cause (etiology) of a nursing diagnosis when creating a PES statement.

Patients have the right to determine what will be done with and to their own person.

Principles and procedures in the discovery of knowledge involving the recognition and formulation of a problem, the collection of data, and the formulation and testing of a hypothesis.

Information collected from sources other than the patient.

Data that the patient or family reports or data that the nurse makes as an inference, conclusion, or assumption, such as  “The patient appears anxious.”

Any unlicensed personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. [ 21 ]

Obtaining Subjective Data in a Care Relationship

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021. Chapter 4 Nursing Process.
• PDF version of this title (216M)

In this Page

• NURSING PROCESS INTRODUCTION
• BASIC CONCEPTS
• OUTCOME IDENTIFICATION
• IMPLEMENTATION OF INTERVENTIONS
• SUMMARY OF THE NURSING PROCESS
• LEARNING ACTIVITIES

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