The NCLEX-RN examination and nursing practice require the nurse to apply the fundamental prin­ciples of clinical decision making and critical thinking to nursing practice. The NCLEX-RN examination "test plan also makes the assumption that the nurse integrates concepts from the following bodies of knowledge:

  • Social sciences (psychology and sociology);
  • Biological sciences (anatomy, physiology, biology and microbiology); and
  • Physical sciences (chemistry and physics)"

The four integrated processes that are tested throughout the NCLEX-RN examination and fundamental to the practice of registered nursing are The Nursing Process, Caring, Communication and Documentation, and Teaching and Learning.

The Nursing Process is defined as the "scientific, clinical reasoning approach to client care that includes assessment, analysis, planning, implementation and evaluation".

Caring is defined as the "interaction of the nurse and client in an atmosphere of mutual respect and trust. In this col­laborative environment, the nurse provides encouragement, hope, support and compassion to help achieve desired outcomes."

Communication and Documentation is defined as the verbal and nonverbal interactions between the nurse and the client, the client's significant others and other members of the health care team. Events and activities associated with client care are recorded and documented in written and/or electronic records that demonstrate adher­ence to the standards of practice and accountability in the provision of care. This documentation is a form of written communication."

Teaching/Learning is defined as the "facilitation of the acquisition of knowledge, skills and attitudes promoting a change in behavior."

The Nursing Process

Although many aspects of nursing, and the knowledge needed, for both registered nurses and licensed practical or vocational nurses are similar, there are also some major differences.

The Clinical Problem Solving Process and the Nursing Process is one of these major differences.

RN's use the Clinical Problem Solving Process to guide their thinking and problem solving and registered nurses use the Nursing Process to guide their thinking, professional judgment, critical thinking and their problem solving when it comes to patient care.

The Clinical Problem Solving Process that is used by the licensed/practical or vocational nurse is a scientific process that includes data collection, planning, implementation and evaluation. On the other hand, the Nursing Process that is used by the professional registered nurse is a scientific, dynamic and cyclical process that includes assessment, data analysis, planning, implementation and evaluation.

The Nursing Process is defined as the "scientific, clinical reasoning approach to client care that includes assessment, analysis, planning, implementation and evaluation", according to the National Council of State Boards of Nursing.

Although the National Council of State Boards of Nursing defines the components of the Nursing Process as assessment, analysis, planning, implementation and evaluation, the data analysis phase of the Nursing Process additionally includes the generation of a nursing diagnosis as based on the analysis of the data that were collected during the assessment phase of the Nursing Process are:

  1. Assessment
  2. Data Collection
  3. Data Organization and Analysis
  4. Nursing Diagnosis
  5. Planning
  6. Implementation
  7. Evaluation

The nursing process is a goal directed, systematic, ongoing cyclical, dynamic, goal directed problem solving approach to nursing care.

This process has a series of interrelated and interconnected phases that move cyclically, smoothly and coherently toward meeting the needs of our clients and/or their significant others. Each phase of this process is affected by and impacted with all of the other phases of the Nursing Process.

For example, the data that is collected during the assessment phase of the Nursing Process is used for the nursing diagnosis and the planning of client care. When data collected during the assessment phase of the Nursing Process is not current, accurate and/or complete, the nursing diagnosis and the plan of care will not be appropriate because it is impacted with and affected by faulty and incomplete data.

Assessment Phase of the Nursing Process

The Nursing Process begins with the assessment phase of the Nursing Process and this assessment phase must begin during the first client contact and continue throughout the entire course of care. The first client contact data collection and assessment is often referred to as the "Initial Assessment" and the data collection and assessments that are done after the "Initial Assessment" are often referred to as "Ongoing Assessments" or "Re-Assessments".

A newly admitted patient to a medical center will have an initial assessment as soon as they are admitted and this same patient will have re-assessments and ongoing assessments throughout the course of their hospitalization because their condition will change. For example, a client who is admitted to a medical center with chest pain will have a number of diagnostic tests and then even have cardiac surgery. Re-assessments, therefore, are done when the client's condition changes as the result of cardiac treatments, cardiac diagnostic tests, and the surgical procedure that they have during the course of their hospitalization after admission.

Data Collection Phase of the Nursing Process

During the assessment phase of the Nursing Process data that is related to the client, family members and significant others, are collected during the assessment phase of the nursing process and, then, this data is also organized and documented.

The client who is being assessed by the registered nurse can be an individual, family, the community or another group. As you should recall, the definition of a "client" or "patient" is defined as an individual, a family, or a group and a "group" is more than one client or patient. Groups can be defined as populations of people, age groups of people and other groups of people.

The data that are collected during the assessment phase of the Nursing Process can be described and classified in a number of different ways. This assessment data can be described and classified as:

  • Current or retrospective, historical data
  • Subjective and objective data
  • Primary and secondary data
  • Qualitative and quantitative data
  • Physical, psychological, social, cultural and spiritual data

Current data is described as that data that reflects the current physical, psychological, social, cultural or spiritual condition or status of the client. In contrast, retrospective, historical data reflects the client's past physical, psychological, social, cultural or spiritual condition or status. An example of current data that is collected during the assessment phase of the Nursing Process is the client's current vital signs and the status of their peripheral pulses, for example. An example of retrospective, historical data that is collected during the assessment phase of the Nursing Process is the client's past surgeries and illnesses.

Historical data like that contained in an old medical record gives healthcare providers some information about and insight into the patient's past medical problems. Current data gives us up to date data and information about the patient's current medical status.

Subjective and objective data are defined as that data that is not empirical, and objective data is defined as data that is empirical. Empirical data is defined as that data that can be perceived with our senses and data that is not empirical cannot be confirmed with the senses.

Subjective data includes things that the client, patient or family member says. For example, the client may state, "I have chest pain" or "I am tired all the time" or a family member may state, "My mother has become tearful and depressed after the loss of my father". Many subjective data statements consist of the client's chief complaint and their symptoms.

Subjective data is recorded and documented in the exact and precise words of the person that has made the statement and these words are put into quotation marks.

Objective data, on the other hand, is data that is collected with the senses of the person collecting the objective data. For example, observing and measuring wound drainage, laboratory diagnostic test results, the smelling a fruity breath odor, feeling peripheral pulses and sensing bodily coolness with your finger tips and your tactile senses are examples of objective data that you see, hear, smell and feel.

Subjective data is also recorded and documented in the client's medical record in a factual and objective manner.

There are some occasions when data that is collected during the assessment phase of the Nursing Process is both subjective and objective. For example, a client may state that, "I have soreness on my lower back", which is subjective data, at the same time that the registered nurse assesses the client's back and notices an area of pressure and blanching, which is objective data because the nurse actually sees it.

Primary and secondary data are also collected during the data collection portion of the assessment.

Primary data is data that is collected from the patient themselves; and secondary data that is collected from things other than the patient.

The patient's vital signs, the patent's complaints of pain and the patient's level of balance are examples of primary data. Examples of secondary data include things like laboratory results, the results of x rays and information that is told to the nurse by others like family members.

Qualitative data is defined as data that is NOT numerical and quantitative data is defined as data that is numerical.

Examples of quantitative data are vital signs, diagnostic laboratory test values and the quantity of sputum or wound drainage; and examples of qualitative data include the interpretation of X rays and other radiographic diagnostic tests, a description of a wound in terms of wound drainage color and a narrative patient's past medical history.

Physical or biological data is current and historical data, primary and secondary data, subjective and objective, qualitative and quantitative data that relates to the client's physical and biological status. This data includes data and information about things that are normal and things that are not normal. It also includes data relating to risk factors that can impact on the client's level of health, wellness and illnesses.

Psychological data includes current and historical data, primary and secondary data, subjective and objective, qualitative and quantitative data that relates to the client's psychological, mental and emotional status. This data includes data and information about things that are normal and things that are not normal. It also includes data relating to risk factors that can impact on the client's level of health, wellness and illnesses in terms of their mental and psychological condition.

Social data is data is defined as current and historical data, primary and secondary data, subjective and objective, qualitative and quantitative data that relates to the client's social status. This data includes data and information about things that are normal and things that are not normal relating to the client's social support systems and economic factors, for example. It also includes social data relating to risk factors that can impact on the client's level of health, wellness and illnesses.

Cultural data is data that is defined as current and historical data, primary and secondary data, subjective and objective, qualitative and quantitative data that relates to the client's culture and cultural status. This data includes data and information about the client's cultural beliefs, practices and values that are passed on to the client through the generations of people who share this culture.

Lastly, spiritual data is data that is defined as current and historical data, primary and secondary data, subjective and objective, qualitative and quantitative data that relates to the client's spiritual and/or religious status. This data includes data and information about the client's religious and spiritual beliefs, practices and values that are held by the client.

The registered nurse assesses individuals, groups like families and the local as well as global community to determine their healthcare needs.

Assessment data is collected, in collaboration with the licensed practical nurse and all of the other members of the healthcare team. This data is then organized, validated with the client and others, and finally documented by the registered nurse and other members of the interdisciplinary team.

Some of the data that is particular to the role and responsibility of the registered nurse, when compared and contrasted to the licensed practical nurse, includes a complete and thorough head to toe physical assessment and a complete and thorough history which includes the current and past medical history. The licensed practical nurse can collect some data with the guidance and under the direction of the registered nurse, however, the assessment and data collection processes are the ultimate responsibilities of the registered nurse and not the licensed practical nurse.

Again, data is collected in reference to the physical or biological, psychological or emotional, social, spiritual and cultural characteristics and needs for the whole or holistic client in their environment.

Data Organization and Analysis Phase of the Nursing Process

Data organization and analysis are also the role and responsibility of the registered nurse rather than the licensed practical nurse. Data analysis entails the organization and analysis of data that requires the critical thinking skills and the professional judgment skills that the registered nurse, rather than the licensed practice nurse, is academically prepared to do.

Data is organized by the nurse in a number of possible ways. For example, the nurse can organize the collected assessment data into bodily systems, according to priorities, according to current health care problems and according to past health data that can indicate some risk factors for the client.

The purpose of analyzing the collected and organized assessment data is to identify existing patterns and trends in the data, to compare data to established norms, standards and normal parameters using the knowledge, skills, abilities, inductive and deductive reasoning of the registered nurse which is often done in close collaboration with other members of the healthcare team. After this analysis, the analyzed data is used for conclusions and decision making in terms of the client and their healthcare needs and problems.

For example, if the current patient data indicates that the client is vomiting, has diarrhea, poor fluid intake, scant urinary output, dry mucous membranes, orthostatic hypotension and confusion, the registered nurse would use their professional judgement, critical thinking and reasoning skills to conclude that the patient is likely affected with dehydration. Because this data indicates the presence of dehydration, decisions and planning of care will be based on this analyzed data.

Nursing Diagnosis Phase of the Nursing Process

This diagnosing phase of the nursing process involves the nurse's application of critical thinking to determine the client's health related risk factors, health related concerns and problem, and their strengths and weaknesses in terms of the client's complete biological, psychological, social, cultural and spiritual data.

The generation of nursing diagnoses, after assessment and data analysis, is also the sole responsibility of the registered nurse according to the states' scope of practice for the registered nurse.

Nursing diagnoses are different from medical diagnoses. Nursing diagnoses identify actual and potential healthcare problems and their defining characteristics, rather than a medical diagnosis.

There are several types of nursing diagnoses, including actual diagnoses, risk diagnoses, wellness diagnoses, possible nursing diagnoses, and syndrome nursing diagnoses.

An example of an actual nursing diagnosis is "Ineffective urinary elimination as related to...". An example of a risk nursing diagnosis is "At risk for impaired oxygenation as related to...". An example of a wellness nursing diagnosis is "Readiness for enhanced client education relating to the pathophysiology of diabetes mellitus." Likewise, an example of a possible nursing diagnosis is "Possible anticipatory grief related to..."; and lastly an example of a syndrome nursing diagnosis is "Risk for disuse syndrome related to..."

Nursing diagnoses have several components. The most complete and useful nursing diagnoses consist of a problem or diagnostic statement, a qualifier, the etiology of the healthcare need or concern and the defining characteristics of the healthcare need or concern.

For example, in the nursing diagnosis "Impaired spiritual comfort related to a terminal disease as evidenced by spiritual anxiety and distress", the problem or diagnostic statement is "spiritual comfort, the qualifier is "impaired", the etiology is the presence of a "terminal disease" and the defining characteristic is "as evidenced by spiritual anxiety and distress".

Other than "impaired", other commonly used qualifiers that can and are used in nursing diagnoses are:

  • Deficient
  • Chronic
  • Decreased
  • Increased
  • Altered
  • Ineffective
  • Disturbed
  • Imbalanced and
  • Compromised

Depending on your organization's policies and procedures, nursing diagnoses may be required to have at least two components which are the problem and the etiology of the problem; but ideally, nursing diagnoses should have all the elements of a complete and most beneficial nursing diagnosis, that is, the problem or diagnostic statement, a qualifier, the etiology of the healthcare need or concern and the defining characteristics of the healthcare need or concern as stated in the nursing diagnosis "Impaired spiritual comfort related to a terminal disease as evidenced by spiritual anxiety and distress."

Planning Phase of the Nursing Process

Planning is based on and follows the previously collected assessment data, the previous organization of the collected data, the careful and unbiased analysis of data, and the nursing diagnosis. Again, this planning should be in collaboration with the client, significant other(s), the registered nurse and other members of the interdisciplinary healthcare team.

The goal and the purpose of the planning phase of the Nursing Process are to insure that the client's and significant other's care is appropriate. All planning must be:

  • Specific and appropriate to the identified needs of the client which can include an individual client, a family, family members, a group and a community or population
  • Amenable to evaluation so that the effectiveness of the plan of care can be established
  • Consistent the client's preferences, age specific and related needs, and cultural, ethnical, religious preferences, needs and wishes
  • Updated and modified according to any new data and changes in the client's physical, psychological, social, religious/spiritual and cultural status and needs

This client care planning should be:

  • Complete
  • Current
  • Accurate
  • Unbiased
  • Done in a timely manner
  • An interdisciplinary process
  • Collaboratively agreed to and participated in by the client and significant others.

A complete planning process consists of employing valid and analyzed assessment data to:

  • Develop expected outcomes, or patient goals
  • Establish priorities of care
  • Decide upon implementation strategies, aspects of care and treatments that are consistent with and congruent with the client's needs, and other considerations such as evidence based practice

The planning can be categorized as initial planning, ongoing planning and discharge planning.

Initial planning, like the initial assessment of the client and their needs, is done upon admission to a hospital or entry into another care setting such as an outpatient facility. This planning should be completed as soon as possible after the first client contact.

Ongoing planning is planning that is done on a continuous and ongoing manner in order to insure that the plan of care accurately reflects the current client condition and their changing priorities of care.

Discharge planning, similar to initial planning, should also begin at the time of the nurse's first client contact. It cannot be delayed because lengths of stay are too short to wait to do discharge planning after the day of admission or the first client contact. Discharge planning typically reflects the ongoing care of the client along the continuum of care. For example, a discharge plan may include home health care or physical therapy in the client's home.

Setting and Establishing Client Priorities

As previously mentioned, the purpose of planning is to establish priorities of care, to determine what the patient's expected outcomes of care should be and to determine the interventions that should be given to the patient to achieve these expected outcomes as based on the patient's needs and the data that was collected during the assessment, the analyzing and nursing diagnosis phases of the Nursing Process.

Priorities of care are established using a number of methods and frameworks including the ABCs, Maslow's Hierarchy of Needs, and the ABCs combined with the MAAUAR method of priority setting.

The ABCs method of priority setting identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities in that sequential order.

Maslow's Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others, and the self-actualization needs in that order of priority from the highest priority to the lowest priority.

Lastly, the ABCs / MAAUAR method of priority setting places the ABCs, again, as the highest and greatest priorities which is then followed with the 2nd and 3rd priority level needs of the MAAUAR method of priority setting.

The 2nd priority needs according to the MAAUAR method of priority setting after the ABCs include M-A-A-U-A-R which stands for:

  • Mental status changes and alterations
  • Acute pain
  • Acute urinary elimination concerns
  • Unaddressed and untreated problems that require immediate priority attention
  • Abnormal laboratory and other diagnostic data that are outside of normal limits and
  • Risks including those relating to a healthcare problem like safety, skin breakdown, infection and other medical conditions

The 3rd level priorities include all concerns and problems that are NOT covered under the 2nd level priority needs and the ABCs. For example, increased levels of self care abilities and skills and enhanced knowledge of a medical condition are considered 2nd level priority needs.

Expected outcomes of care are based on the data collected, data analysis, nursing diagnoses, and priorities of care.

  • S = Specific
  • M = Measurable
  • A = Achievable
  • R = Realistic
  • T = Timeframe defined
  • T = Trackable and measurable
  • A = Agreed to by the client and significant other(s)

A complete and appropriate expected outcome of patient goals must have:

  • A subject in the sentence. For example, the client, spouse, family member, group of people receiving the nursing care or the population of people who are receiving the nursing care MUST be the subject of the expected outcome statement. Client goals are client centered and not nurse centered. The nurse is NOT the subject of the expected outcome statement. All client goals must be in terms of the client and not the nurse or another healthcare provider.
  • A verb that describes what the client will do, or say, or demonstrate in another manner.
  • Conditions. Conditions specify the when, how, what, where and other specific performance criteria that clearly state what is expected in terms of the client's demonstration of the goal directed behavior or characteristic. For example, the conditions may state that the client will relate and/or discuss the components of the diabetic diet or they client may able to ambulate at least 3 times per day with a walker and the assistance of another.

An example of how to generate an appropriate expected outcome is to include "The client will…" or the "The wife will…" and then follow this statement with what exactly you can expect the patient or spouse to do. For example, "The client will ambulate at least 20 feet three times a day with a walker" is a good expected outcome. It is client centered ("The client will"), specific in terms of exactly what you expect the client to do, measurable in terms of feet and frequency, in a time frame, trackable, and presumably realistic and agreed to by the client.

Another example of a good, useful, complete expected outcome could be, "The patient will select appropriate attire each morning according to their planned activities and the environmental temperature." This expected outcome is in terms of the patient; it states "The patient will…" It is specific; it states "select appropriate attire" and "according to the planned activities and the environmental temperature"). It is within a time frame; it states "every morning." And, it is also observable and measurable and able to be tracked each day over time.

Implementation Phase of the Nursing Process

Interventions are planned according to the assessment data, the analysis of the data, the nursing diagnoses, the priorities of care, and the expected outcomes of that care. Providing interventions to clients require that the registered nurse possesses and employs:

  • Critical thinking skills
  • Professional clinical judgment
  • Problem solving skills
  • Priority setting skills
  • High quality and effective interpersonal skills
  • High quality and competent psychomotor and technical skills

Nurses, including licensed practical nurses, perform independent and dependent nursing interventions. Independent nursing interventions are those things that nurses can provide to the patient without a doctor's order and dependent nursing interventions are those things that nurses can provide to the patient only with a doctor's order.

A dependent nursing intervention is the administration of medication which can only be done with a complete doctor's order; and independent nursing interventions include things like turning the patient, positioning the patient, and assisting with the patient's activities of daily living which can be done without a doctor's order.

Registered nurses render, and delegate, patient care and they document it during the implementation phase of the Nursing Process.

Care is given and implemented according to the plan of care, the particular healthcare facility's policies and procedures, the nurse's job description, their level of competency, and the scope of practice for the different members of the nursing team.

For example, some healthcare facilities allow licensed practical nurses to start and manage intravenous fluids, and others do not. Some registered nurses in a particular healthcare facility are permitted to change central venous line dressings, and others are not permitted to do so according to a particular healthcare facility's policies and procedures

Lastly, registered nurses must follow the scope of practice for their state. When a registered nurse does things that are not included in their legal state's scope of practice, they are practicing nursing outside of their scope of practice which can be punished with the suspension or revocation of the nurse's license to practice nursing.

Registered nurses must deliver high quality, competent care to patients that is consistent with their healthcare facility's policies and procedures, their job description, their level of competency, and the scope of practice for the licensed practical nurse.

Evaluation Phase of the Nursing Process

The process of evaluation is done by collecting data related to the expected outcome, analyzing this data, comparing this analyzed data to the data collected prior to the current time and making a decision about whether or not the goals were completely, partially or not met at all.

Although the licensed practical nurse can collect evaluation data, it is the registered nurse who is accountable for the analysis of this data and the formal evaluation process as well as any modifications to the plan of care if these changes are indicated by this evaluation of the goal achievement or the lack thereof.

For example, the registered nurse monitors the patient's level of pain in about one hour after administering an ordered pain medication and then they will compare the patient's current level of pain the reported level of pain before the medication was administered. Did the patient's level of pain decrease, increase or remain the same?

Now, let's do a couple of sample questions for the nursing process and the roles of the registered nurse:

Your patient tells you that they are "very itchy". What kind of data is this?

  1. Historical data
  2. Subjective data
  3. Secondary data
  4. Objective data

The correct answer is B -subjective data

When a patient tells you that they are "very itchy", they are providing you with subjective data that cannot, like objective data, be observed and measured.

When a patient tells you that they are "very itchy", they are providing you with subjective data that cannot, like objective data, be observed and measured.

Historical data is old data and not current like this patient's statement. Lastly, secondary data comes from a source, like a spouse or a part of the medical record, rather than from the patient themselves.

Now let's try another question:

Which phase of the Nursing Process requires the consideration of the scope of practice for the registered nurse?

  1. Data collection
  2. Planning
  3. Implementation
  4. Evaluation

The correct answer is C - the implementation phase

The state scope of practice for the registered nurse is considered during the implementation phase of the Nursing Process. The scope of practice outlines what the registered nurse can and cannot do in terms of their implementation of patient care and the scope of practice for the licensed practical nurse specifies what the licensed practical nurse can and cannot do in terms of their implementation of patient care.

Data collection, participation in the planning process and evaluating the patient's responses to care are not associated with the nurse's legal scope of practice.

The state scope of practice for the registered nurse is considered during the implementation phase of the Nursing Process. The scope of practice outlines what the registered nurse can and cannot do in terms of their implementation of patient care and the scope of practice for the licensed practical nurse specifies what the licensed practical nurse can and cannot do in terms of their implementation of patient care.

Data collection, participation in the planning process and evaluating the patient's responses to care are not associated with the nurse's legal scope of practice.

Now, let's try this one:

Which phase of the Nursing Process is NOT within the scope of practice for the licensed practical nurse?

  1. The data collection phase
  2. The data analysis phase
  3. The implementation phase
  4. The evaluation phase

The correct answer is B - the data analysis phase

The data analysis phase of the Nursing Process is not within the scope of practice for the licensed practical nurse. Data analysis is exclusively within the scope of practice for registered nurses. Data analysis requires the critical thinking and professional judgment skills that the registered nurse only is prepared to do.

Data collection, implementation and evaluation are within the scopes of practice for both the licensed practical nurse and the registered nurse, however, as previously discussed, there are some differences.

Now, let's do another question:

Which of the following is a complete and appropriate nursing diagnosis for a patient who was admitted with a high fever of unknown origin?

  1. The client will be free of complications such as dehydration.
  2. The nurse will monitor the patient's vital signs q 4 h.
  3. At risk for impaired fluid balance related to dehydration
  4. At risk for impaired fluid balance related to the febrile state

The correct answer is D - "At risk for impaired fluid balance related to the febrile state"

"At risk for impaired fluid balance related to the febrile state" is a complete and appropriate nursing diagnosis for a patient who is affected with a fever of unknown origin. This at risk nursing diagnosis consists a qualifier which is "impaired", a problem which is "fluid balance", and the etiology which is a "fever of unknown origin".

"The client will be free of complications such as dehydration" is an expected patient outcome and not a nursing diagnosis. "The nurse will monitor the patient's vital signs q4 h" is also a nursing intervention and "At risk for impaired fluid balance related to dehydration" is not appropriate for this patient because the etiology is the fever and not dehydration.

Caring

Caring is defined as the "Caring is defined as the "interaction of the nurse and client in an atmosphere of mutual respect and trust. In this col­laborative environment, the nurse provides encouragement, hope, support and compassion to help achieve desired outcomes".

Caring and compassion are universal elements of all aspects of nursing care in all settings for individuals, significant others, families, populations and communities.

Concepts of Caring and Related Concepts

Some of the concepts relating to caring and their definitions will now be discussed.

  • Caring is "An intentional action that conveys physical and emotional security and genuine connectedness with another person or group of people" (Berman and Synder, 2012)
  • Compassion is defined as one's feelings that you want to decrease and alleviate another's pain and suffering when you become aware of it.
  • Empathy is "The ability to discriminate what the other person's world is like and to communicate to the other this understanding in a way that shows that the helper understands the client's feelings and the behavior and experience underlying these feelings" (Berman and Synder, 2012)
  • Sympathy is defined as feelings of compassion that that prompt action but, unlike empathy, sympathy does not include having the same shared feelings.
  • Altruism is the thoughtful and selfless actions that are taken when a person is motivated with compassion and the need to decrease and alleviate another's pain and suffering.

Theory of Human Caring

Jean Watson, who developed the Human Caring Theory, states that caring is the essence of nursing. According to Jean Watson, the ten nursing interventions that show and demonstrate genuine caring are:

  1. Initiating, developing and maintaining an environment and relationship with the client that is supportive of the client and the protective or corrective elements that are needed for the client's mental, physical, societal, and spiritual needs
  2. Facilitating the integration of existential, phenomenological and spiritual forces and influences into client care
  3. Initiating, developing and maintaining a helping and trusting relationship with the client and significant others
  4. The facilitation of transpersonal teaching and learning in the nurse-client relationship of caring
  5. Facilitating and promoting the expressions of positive and negative feelings
  6. Using effective problem-solving for decision-making
  7. Facilitating and assisting the client with the gratification of the clients' biophysical and psychosocial human needs
  8. Forming, developing and maintaining a humanistic altruistic value system when providing client care
  9. Instilling faith and hope into the client
  10. Recognizing and cultivating a sensitivity to one self and others

Now, here are some questions relating to care, an Integrated Process that will be integrated into the NCLEX-RN examination.

Which emotion entails sharing the same feelings as another?

  1. Sympathy
  2. Empathy
  3. Caring
  4. Compassion

The correct answer is B - Empathy

Empathy entails sharing the same feelings as another. Sympathy is a feeling of compassion that prompts action but sympathy does not include having the same shared feelings. Caring is "An intentional action that conveys physical and emotional security and genuine connectedness with another person or group of people" (Berman and Synder, 2012). Compassion is defined as one's feelings that you want to decrease and alleviate another's pain and suffering when you become aware of it.

Now, here is another practice question:

Whose theory describes caring?

  1. Jean Watson
  2. Dorothea Orem
  3. Madeline Leininger
  4. Martha Rogers

The correct answer is A - Jean Watson

Jean Watson developed the Human Caring Theory. Dorothea Orem developed the Self Care Theory; Madeline Leininger developed the Transcultural Nursing Theory and Martha Rogers developed the theory of Unitary Man.

Communication and Documentation

Communication and documentation are defined as the verbal and nonverbal interactions between the nurse and the client, the client's significant others and other members of the health care team.

Events and activities associated with client care are recorded and documented in written and/or electronic records that demonstrate adher­ence to the standards of practice and accountability in the provision of care. This documentation is a form of written communication.

The primary purpose of communication and documentation is to convey a message from one person to another person or a group of people.

Communication

Communication is an interactive process that transmits some message, meaning, information, emotions, and/or beliefs to another person or a group of people. It establishes and maintains connectedness between and among human beings.

Communication can be written, verbal, nonverbal body language and in a graphic or pictorial way. An example of verbal communication is talking with a patient about the treatment that you will be giving them; an example of written communication is the documentation of medications administered so that others, including other nurses, know that any ordered medications have indeed been given according to the doctor's order; an example of nonverbal body language is tapping one's foot in the presence of a patient which conveys a message that the nurse is impatient; and graphic and pictorial communication is the primary purpose of art and art work. Art and music are universal ways of communicating a message or feeling without the use of words or writing. Nurses often use pictures and diagrams to communicate a message to a patient, particularly when they are non-English speaking and/or they are not able to verbally send and receive messages.

Components of Communication

Regardless of the type of communication, all communication consists of several essential components.

These components are the:

  • Sender of the message
  • The message itself
  • The receiver of the message and
  • The response or feedback that occurs.

The sender transmits and conveys the message to others; the receiver is the person who gets the message from the sender; the message is the information or emotion that is being conveyed or sent to another; and the feedback is the response of the receiver to the message.

For example, when the sender of the message gently touches the shoulder of a patient to convey caring and compassion, the receiver of the message, which is the patient, decodes this message as a feeling of caring and compassion after which the patient acknowledges these feelings verbally or nonverbally and then sends this message of acknowledgment back to the other person.

Notice that, in this example, the receiver of the message becomes the sender of the message when they respond back to the person who was the original sender of the message. This feedback allows the nurse to acknowledge that the message was received and to respond to the message.

Factors That Impact On and Affect Communication

Many factors impact on and affect communication. Some of these factors are beneficial to this dynamic, interactive process and others are barriers to effective communication. At all times, nurses must overcome barriers to communication when they exist. Communication with the patient and/or significant other is essential to nursing and the provision of patient care.

Factors that impact on communication include:

  • Level of development and age
  • Level of consciousness
  • Emotional state and level of stress
  • Language spoken
  • The nature of the relationships between and among people involved in the communication process
  • Individual values, beliefs and perceptions
  • Culture
  • Past experiences
  • The environment itself

The level of development and age impact on communication. For example, nurses communicate with neonates and infants with touch and a soft, soothing voice. Levels of consciousness and levels of awareness enhance the communication process when it is normal, but it hampers communication when the patient has a decreased level of consciousness and awareness.

High levels of stress and the presence of other stressors, such as pain, can be a barrier to effective communication.

Language and language skills, including vocabulary and reading skills, can also impede communication. Accommodations, like the use of a professional translator, may be necessary for some patients when they do not communicate in English.

The nature of the relationships between and among people involved in the communication process affects the communication process in many ways. For example, figures that are perceived as in a position of power and influence, like nurses and doctors, may impact on the openness of the patient who does not view themselves as an equal in the nurse-patient relationship.

Not only does culture impact on a person's values, beliefs, opinions and perspectives, culture also influences the person's use of terms and terminology as well as their perceptions of nonverbal messages. For example, some cultures view eye contact, touch and proxemics, which is the distance between people, differently than others who are outside of the culture. Some view touch as invasive and not caring, some view eye contact as a sign of honesty and others may view it as aggressive and hostile. Still more have different tolerances for various distances between them and the person they are communicating with. We will discuss these personal spaces and proxemics later.

Past experiences impact on the way many people communicate with others. For example, when a patient has been shunned in the past for expressing their true feelings of depression, for example, the person will be reluctant to discussing these feelings in the future.

Lastly, the physical environment and the tenor of the environment also impact on communication. For example, a calm, open, trusting environment at a comfortable temperature is conducive to communication and conversations; and an environment that is environmentally uncomfortable, not trusting and filled with judgments is not conducive to effective communication.

Verbal Communication

Verbal communication consists of words and sounds. When compared and contrasted to nonverbal communication, verbal communication is far more consciously controlled and often less ambiguous than nonverbal communication.

People simultaneously communicate with both verbal and nonverbal communication. At times, the messages conveyed with the verbal communication are consistent with the messages conveyed by nonverbal communication; however, this is often not the case. At times, the verbal and nonverbal messages do not match. For example, when a nurse stands at a patient's doorway with their arms crossed and their foot tapping on the floor while asking the patient why they seem to be upset, the verbal message conveys and communicates caring and compassion but the nonverbal foot tapping and crossed arms conveys and sends a message that the nurse is impatient, in a hurry and really not wanting the patient to tell the nurse why they are upset.

The tone of the voice, the speed or pace of the communication, the brevity, simplicity, the use of pauses, and the clarity of the message affect the communication and the communication process among and between people. For example, effective communication with a hostile patient should be done with a soft, calming voice that may deescalate the patient's level of hostility, and communicating with brief and clear messages often facilitates nurses' effective communication with confused and lethargic patients.

Pauses during a conversation, when not lengthy in duration, are helpful because it gives the sender and receiver of the verbal message time to think about the message and its meaning; however, lengthy pauses can be very uncomfortable at times.

Sounds are a form of verbal communication. When compared and contrasted to words, sounds are often more difficult to interpret. For example, a grunt may indicate a number of things including the presence of pain, restlessness and exasperation. For this reason, nurses should communicate with the patient to clarify the meaning of their sounds.

In summary, verbal communication must be modified according to the needs of the patient and their level of understanding within an open, honest and nonjudgmental and professional environment.

Nonverbal Communication

As previously mentioned, nonverbal communication is very often out of the conscious control of the sender of these nonverbal messages. Some refer to nonverbal facial cues as a "poker face."

Nonverbal communication like other forms of communication also transmits feelings and emotions but, unlike verbal communication, it does not communicate these feelings and emotions with words. Nonverbal communication is also not as clear and unambiguous as verbal communication is. It has to be interpreted by the receiver of the nonverbal communication message.

Nonverbal communication conveys a message with bodily movements, facial expressions, gestures, touch, the use of space and distance, eye movements and eye contact, bodily posture, and one's personal appearance.

For example, eye movements and eye contact can convey a number of emotions. Eye contact can convey honesty, caring and interest during communication and the lack of eye contact can convey that the person is dishonest, nervous and even with a low level of self-esteem. Also, communication at eye level with the patient conveys the message that the nurse and the patient are equals in the nurse-patient relationship.

Facial expressions convey a wide variety of emotions including sorrow, joy, boredom and pain; a lack of facial expression, referred to as a flat affect, communicates a lack of interest and/or the presence of a psychological problem.

Proxemics and Territoriality

Proxemics is the use of personal spaces during the communication process. Although individuals and some cultures may differ in terms of their use and tolerance of different personal spaces, most Americans have these spatial distances:

  • The Intimate Zone: This zone ranges from direct bodily contact and touching to a distance of about 1 1/2 feet away from the body's surface.
  • The Personal Zone: This zone begins at 1 1/2 feet away from the body's surface and it continues to about 4 feet away from the body.
  • The Social Zone: The social zone extends from about 4 feet away from the body to 12 feet from the person.
  • The Public Zone: The public zone is defined as 12 or more feet from the person.

The intimate zone is typically reserved for intimate partners; however, the intimate zone is often invaded by nurses and other healthcare providers as they care for patients. For example, the intimate zone is invaded when a nurse gives a caring touch to a patient, when a urinary catheter is inserted, when perineal care and bathing are provided and when the patient is turned and positioned in bed.

Many patients become overwhelmed and uncomfortable when their intimate zone and/or their personal zone are invaded, therefore, nurses and other members of the healthcare team must always explain procedures to the patient before rendering care and they must also provide the patient with as much personal privacy as possible during the provision of care.

Territoriality is the connection of possessions and things with a person. Feelings of territoriality and the need to protect one's territory is part of human nature. People protect their territories in their home and in healthcare facilities. For example, a patient may feel that their room in the hospital is their territory and they may feel they need to protect it. Nurses, therefore, must knock on the door and get permission to enter from the patient and they should also ask the patent for permission before moving and rearranging things in the bedside area.

Therapeutic Relationship and Therapeutic Communication

The therapeutic nurse-patient relationship begins with the establishment of trust after which this relationship matures to an effective one that employs proper therapeutic communication techniques.

Some of these therapeutic communication techniques are:

  • Attentive, Active Listening: Although many do not immediately recognize the fact that listening is an essential part of communication, it is. Attentive listening is far more than hearing; attentive listening involves active listening and it is not a passive activity.
  • Silence: Like listening, many do not realize that silence is a useful part of communication. Silence allows the sender and the receiver of the conveyed message to think about the received message and to contemplate the best response or feedback to the other person relating to the message. When silence is prolonged, however, it may make some feel uncomfortable and/or that there is no interest in the conversation by the other.
  • Reflection: This form of therapeutic communication mirrors, or reflects, the patient's feelings, not words, back to the patient's so that these feelings can be further explored and expressed by the patient. For example, when the nurse states, "You seem very stressed today", the patient will be likely to tell the nurse why they are upset.
  • Focusing: This therapeutic communication technique allows the patient to remain focused on the subject at hand rather than becoming distracted and disorganized in terms of the conversation. For example, the nurse may say, "Mr. Jones, we will talk about the diabetic diet in a little while, but now let's discuss you blood glucose results over the last month".
  • Paraphrasing and Restating: Restating and paraphrasing allows the nurse to acknowledge that they have a good understanding of what the patient has said and meant in their sent message. An example of paraphrasing and restating is, "I heard you state that you are going to agree to the surgery for next week."
  • Clarification of Received Messages: Received messages are always clarified and validated with patients to insure that the nurse has received and interpreted the complete and correct message without any errors or false assumptions.Nurses can clarify patient messages by asking the client a question like, "Am I correct that you told me that you plan on having the surgery done next week?"
  • Providing Leads to the Patient: Providing the patient with a lead facilitates the patient's open expression of feelings, concerns and messages. Providing a lead like, "Tell me a little bit more about your concerns relating to your surgery next week" will promote and facilitate the patient's communication with the nurse.
  • Summarizing: Summarizing is highly useful to sum up the main points of the nurse-client interactive discussion and also to further validate that messages sent and received were interpreted correctly. For example, the nurse may state, "During this conversation, we talked about your blood glucose readings and specific ways, including dietary choices, that you can lower your blood glucose levels."

Ineffective Communication

Some of the things that can impede effective, therapeutic communication include making judgments, stereotyping and assuming that all people in one group or another has the same opinions, beliefs or practices, changing the subject or topic of conversation, challenging, probing, and being defensive during communication.

Overcoming Barriers to Effective Communication

Nurses are responsible for effective communication with patients. In order to fulfill this responsibility, nurses must immediately identify any barriers to communication and then overcome these barriers with effective strategies.

For example, the nurse will use simple terms and make discussions brief when the patient is in pain or confused; the nurse will modify their terminology and vocabulary when they are communicating with a young child for example; and the nurse will also use therapeutic touch when a patient is upset or sorrowful.

Documentation

Like verbal and nonverbal communication, written documentation is used to transmit and convey messages. In fact, the primary purpose of documentation is communication. Other purposes of documentation include meeting the legal mandates relating to Medicare's Conditions of Participation, using documentation for reimbursement from third party payers like health insurance companies, and also to meet the regulatory requirements of the states and to fulfill the recommendations and standards put forth by other regulatory bodies such as the state departments of health and Joint Commission on the Accreditation of Healthcare Organizations.

Medical Records and Documentation

Documentation must be complete, timely, accurate, objective and factual.

Some forms of documentation in the healthcare environment are the clients' medical records, care plans, employee schedules and time cards, policies and procedures, minutes of meetings, interoffice letters and messages, and e mails.

All medical records and all parts of it are legal documents. This legal nature of documentation applies to hard copy and electronic versions of the medical record.

In order to be effective, documentation must be complete, timely, accurate and professional. It must reflect all patient care, data and information; it must be done in a timely manner and according to the policies and procedures of the healthcare facility and other legal or regulatory requirements; it must be without errors and it also must be professional, legible, clear, understandable, and without any ambiguity.

Complete, timely, accurate and professional documentation prevents errors of commission and omission, it avoids unnecessary delays in treatment and care, and it facilitates the highest possible quality of care for the patient.

Most documentation errors are errors of omission. The nurse, or another healthcare provider, neglects to, forgets to, and/or simply fails to document something that should have been documented.

Errors of commission can also occur. For example, the certified nursing assistant or nurse who records incorrect vital signs in the patient's medical record has made an error of commission relating to documentation. All documentation errors have the potential to lead to serious and severe patient effects including death.

Approved and Acceptable Abbreviations and Terminology

A multitude of abbreviations can be differently interpreted among healthcare providers, therefore, the Joint Commission on the Accreditation of Healthcare Organizations and common sense mandates that only accepted and approved abbreviations and terminology are used for documentation. The use of these risky abbreviations jeopardizes client safety and the quality of care that they are given. For example, the abbreviation "MS" is NOT an approved abbreviation because "MS" can be interpreted as multiple sclerosis, morphine sulfate and magnesium sulfate.

All healthcare facilities are required to have a formalized list of unacceptable abbreviations that cannot be used because they are problematic and can lead to errors and confusion.

Some of the abbreviations that are no longer used include:

  • MS
  • MSO 4
  • MGSO 4
  • U for unit
  • IU for international unit
  • for once daily
  • qod, for every other day
  • A trailing zero like 9.20 milligrams
  • The lack of leading zero like .9
  • H. S.

Legal Aspects of Documentation and Documents

Some of the legal aspects of documentation include the legal prohibitions against altering a record, obliterating entries in the medical record, and falsifying documentation.

Medical documents are protected as confidential records; and sharing or accessing patient information is prohibited except when this sharing and accessing is necessary to provide care to the patient.

Types of Medical Records and Documentation

All types of medical records and documentation systems have advantages and disadvantages. Healthcare facilities select the types of medical records and documentation systems that they use.

The most commonly employed types of medical records are:

  • Source Oriented Medical Record
  • Focused Charting
  • Charting by Exception
  • Problem Oriented Medical Record
  • PIE Method
  • Case Management & Critical Pathways

The Source Oriented Medical Record

The source oriented medical record is the oldest kind of medical record documentation. The source oriented medical record is typically kept in a binder or a metal flip chart with dividers that are labeled with the contents of each section. For example, nursing, laboratory, physical therapy and medical doctors each have a separate section in the source oriented medical record for their own documentation.

This discipline specific chart typically includes flow sheets, vital sign graphic charts, progress notes and other forms of documentation such as the medication record, doctors' order sheets, the medical history and physical, the nursing admission assessment, and a standardized patient teaching form or record.

Some of the advantages of the source oriented medical record include the fact that it highly familiar to healthcare providers, it is relatively simple to use, and the progress notes are typically free flow narrative notes that do not require a special format like other systems, such as the problem oriented medical record.

Some of the disadvantages of the source oriented medical record include the fact that they are not multidisciplinary in nature and the fact that the patient information is scattered all over the medical record.

Focused Charting

Focused charting is less commonly encountered than other documentation systems. Focused charting makes patient related issues, like the patient's problems, the patient's strengths, the patient's nursing diagnosis and changes in the patient's condition, the focus of the medical record.

The progress note for focus charting is done on a three columned form that includes the date and time of the entry, the focus or patient related issue and the progress note that is done in the DAR format. DAR stands for Data, Action and Response as shown below.

Data is assessment data, action is what was done to solve the patient problem or concern, and the response reflects the evaluation of the patient after an intervention in terms of their negative or possible responses to the intervention.

Date

Focus

DAR Progress Note

11/27/2015

Acute pain secondary to abdominal surgery

D: The patient reports a pain level of 8 out of 10

A: The patient was given the ordered morphine sulfate 2 mg

R: The patient reports their level of pain at 4 out of 10 a half hour after the prn medication

An advantage of focus charting includes the fact that it is relatively simple to use but its disadvantages are similar to those of the source oriented medical record, that is, focus charting is not multidisciplinary in nature and the patient information is scattered all over the medical record.

Charting by Exception

Charting by exception is based on the principle that only abnormal and significant things have to be recorded and documented. This method is rarely used because it has some serious disadvantages.

The charting by exception method employs flow sheets of all types, references to established standards of nursing care, and a narrative nursing progress note which only includes significant and/or abnormal data and information.

An advantage of this method is that it significantly decreases the length of the progress notes because only abnormal and significant data and information are documented.

The perils and pitfalls of charting by exception, however, can potentially jeopardize patients because, with this system, it is assumed that ALL exceptions have been charted and documented when, in reality, many nurses and other healthcare providers simply forget to chart and document as they should. When documentation is not done, a person can assume that, for example, the patient's vital signs were normal when in fact they are not.

Problem Oriented Medical Record

The problem oriented medical record is very distinct from the source oriented medical record and other documentation systems.

The problem oriented medical record is multidisciplinary and, instead of patient information being spread throughout the medical record for each discipline like nursing and physical therapy, the patient information and data are organized and clustered according to the patient's problems in one part of the client's medical record.

All members of the healthcare team, including the doctors, nurses, and others, collaboratively develop, maintain and compile a complete list of patient problems. Each of the disciplines in the multidisciplinary team then provide and document the care and services that they provide in reference to one or more of these documented patient problems. The established and ongoing problem list for the client is typically found in the front of the client's medical record for easy access and updating as the client's condition changes.

This method of documentation consists of a patient data base, a formalized list of problems that is typically placed in the front of the patient's medical record for rapid reference, a plan of care and uniquely done patient progress notes that are also multidisciplinary.

The data base section includes assessment data like the medical history and physical, the nursing assessment and other information.

The problem list, as based on the patient's current assessments and condition, includes bio-psycho-social, cultural, spiritual and educational needs. Medical doctors typically write problems using the patient's medical diagnosis such as "COPD" and nurses typically record patient problems using a nursing diagnosis such as "At risk for impaired skin integrity related to immobility".

The plan of care is also generated by all the disciplines in the healthcare team and it, too, is directly aligned with the established problem list. As with all other documentation systems, ongoing assessments, modifications of the problem list and changes in the plan of care are done in an ongoing manner according to the changing status and needs of the patient.

The progress notes for the problem oriented medical record are also multidisciplinary and, instead of free flowing narrative progress note, these progress notes are highly structured, goal directed, and organized according to the patient problems. For example, if a patient problem is a cerebrovascular accident, the progress notes are labeled with the specific problem number and label.

The format of the progress notes is one of the following as decided upon by the particular healthcare agency. It can be:

  • SOAP
  • SOAPIE or
  • SOAPIER

A SOAP progress note for Problem # 1: At risk for impaired skin integrity related to immobility may appear like this:

  • S - Subjective data: The patient states that they "are turning themselves in bed"
  • O - Objective data: The patient's skin is dry an intact
  • A - Assessment: Intact skin
  • P - Planning: Encourage out of bed activity and continue to monitor the condition of the skin

The SOAPIE progress note for Problem # 2: COPD can be composed like this:

  • S - Subjective data: "I am breathing better after my treatment"
  • O - Objective data: Decreased pallor and cyanosis
  • A - Assessment: Improved arterial blood gases
  • P - Planning: Continue the plan of care
  • I - Interventions: Monitor the client and administer respiratory medications and treatments as ordered
  • E - Evaluation: Respiratory medications and treatments are effective

The SOAPIER progress note for Problem # 2: COPD can be composed like this:

  • S - Subjective data: "I am breathing better after my treatment"
  • O - Objective data: Decreased pallor and cyanosis
  • A - Assessment: Improved arterial blood gases
  • P - Planning: Continue the plan of care
  • I - Interventions: Monitor the client and administer respiratory medications and treatments
  • E - Evaluation: Respiratory medications and treatments are effective
  • R - Revisions: Encourage increased activity

The advantages of the problem oriented medical record are that it promotes multidisciplinary collaboration among the various disciplines; it is organized in a method that facilitates ready access to the patient's current problems and it allows members of the healthcare team to track and review the patient's progress over time according to their documented healthcare problems and concerns.

The disadvantages of the problem oriented medical record include the facts that this method is unfamiliar to nurses and other healthcare team members and it is more difficult than other methods in terms of the structured format of the progress notes.

Problem, Intervention and Evaluation (PIE) Progress Notes

The PIE method for documenting progress notes can be used in the problem oriented medical record or with any other style of medical record.

An example of PIE using a problem like postoperative pain is below:

  • P: Problem: Pain related to abdominal surgery
  • I: Interventions: Monitor the patient's level of pain and administer analgesics for pain as ordered prn
  • E: Evaluation: Pain level has decreased from 8 to 4 after analgesic medication

Assessment, Problem, Intervention and Evaluation (APIE) Progress Notes

APIE is an expansion of the PIE method but it adds assessment data.

  • A: Assessment: The patient reports an 8 level of pain and the patient is guarding the incisional site.
  • P: Problem: Pain related to abdominal surgery
  • I: Interventions: Monitor the patient's level of pain and administer analgesics for pain as ordered prn
  • E: Evaluation: Pain level has decreased from 8 to 4 after analgesic medication

Case Management and Critical Pathways

Case management and the use of critical pathways is perhaps the newest of the documentation systems.

Case management and critical pathways are based on the premise that most patients with a specific medical diagnosis, healthcare problem, illness, and/or nursing diagnosis are more similar in terms of their anticipated treatments than they are different.

Briefly stated, critical pathways are pre planned plans of care that are generated with the efforts of the entire multidisciplinary team, as appropriate according to the patients' diagnoses, and include interventions, time frames and expected outcomes.

The time frames vary according to the patient's level of acuity. For example, patients in the special intensive care unit have more frequent monitoring and care than a resident in a long term care facility and a stable patient in a medical/surgical unit after surgery without any complications. The time frames for the client in the emergency and special care intensive care areas may be as brief as every 15 minutes; the time frames for the client in a long term care facility may be as long as every month; and the time frames for the stable patient in a medical/surgical unit after surgery without any complications may be every 4 hours or every shift, for example.

A variance occurs and is documented whenever the patient's established critical pathway is not followed. Variances can include patent related, provider related and system related variances. For example, if a critical pathway is not followed because the current patient's condition does not permit a particular intervention, which is a client or patient related variance, or a provider fails to draw a preplanned laboratory test, which is a provider related variance, or the system fails in terms of processing and/or reporting the results of a radiological study, which is a system related variance, a variance has occurred. All variances are documented using this critical pathway method of documentation and care planning.

Not only are variances and their documentation significant, crucial and critical to the quality of patient care, they are useful and beneficial in terms of providing data that can be used in process improvement and performance improvement studies. For example, the analysis of variances over time may suggest patterns and trends that should be addressed in terms of increasing the timeliness, appropriateness and completeness of care or client assessments.

A sample critical pathway is shown below:

Post Op Day 1Day 2 Post OpDay 3 Post Op
Pain ManagementExpected outcome(s):

The patient will verbalize a pain level of 5 or less using a numerical pain management scale from 1 to 10.

Variance:

(If this expected outcome is NOT achieved, the variance is documented here)

Date and Time

Signature and Title

Expected outcome(s):

The patient will verbalize a pain level of 3 or less using a numerical pain management scale from 1 to 10.

Variance:

(If this expected outcome is NOT achieved, the variance is documented here)

Date and Time

Signature and Title

Expected outcome(s):

The patient will verbalize a pain level of 2 or less using a numerical pain management scale from 1 to 10.

Variance:

(If this expected outcome is NOT achieved, the variance is documented here)

Date and Time

Signature and Title

At Risk for Respiratory CompromiseExpected outcome:

The breath sounds are clear bilaterally

The patient will use the incentive spirometer and meet at least 80% of their established goal.

The patient will cough and deep breathe while splinting at least every 2 hours.

Variance:

Date and Time

Signature and Title

Expected outcome:

The breath sounds remain clear bilaterally

The patient will use the incentive spirometer and meet at least 90% of their established goal.

The patient will cough and deep breathe while splinting at least every 2 hours.

Variance:

Date and Time

Signature and Title

Expected outcome:

The breath sounds are clear bilaterally

The patient will use the incentive spirometer and meet 100% of their established goal.

The patient will cough and deep breathe while splinting at least every 2 hours.

Variance:

Date and Time

Signature and Title

Guidelines for Documentation

In addition to the legal aspects of documentation that were previously mentioned, other guidelines for documentation include the use of permanent ink, the use of only accepted terms and abbreviations, legible writing, accurate spelling, proper grammar, accurate dating and time of the entry, the signature and title of the person who documented the entry, and a professional tone.

If an error in documentation occurs, a thin line that does NOT obliterate the entry is drawn through the erroneous entry, the notation "Error" is written above the entry and the nurse signs this notation with their name and title.

Under no circumstances should any pre charting or charting and documenting for others be done.

Now, here are some sample questions for the Communication and Documentation section:

Which communication technique is the vaguest of all?

  1. Touch
  2. Silence
  3. A groan
  4. A smile

The correct answer is C - a groan

Sounds like a groan are the vaguest of all of the above communication techniques. It can have many meanings. Touch has one meaning; it conveys caring. Silence can indicate thought or it can simply be a pause in the conversation. Lastly, a smile is a universal sign of happiness or fondness.

Now, let's do another one.

Place the letters of a problem oriented medical record progress note in correct sequential order:

R
O
S
P
A
I
E

SOAPIER is the correct sequential order for the problem oriented medical record.

Teaching and Learning Processes

Teaching and Learning is defined as the "facilitation of the acquisition of knowledge, skills and attitudes promoting a change in behavior."

Basic Terms and Terminology Relating to Teaching and Learning

Some of the basic terms and terminology relating to the teaching and learning process that you should know will now be discussed.

  • The assessment of learning needs is the collection and analysis of data and information that reveals that the patient has an actual or potential learning need. Registered nurses analyze this data and information; licensed practical nurses can contribute to the collection of this data and information, but they do not analyze the data.
  • A learning need, simply stated, is defined as the gap or a discrepancy between what the patient should know or be able to do and what they actually do know and are able to do. For example, a learning need nursing diagnosis for a newly diagnosed diabetic patient may be a "Knowledge deficit relating to the role of exercise in the management of diabetes" when the assessment of learning needs indicates that this gap in knowledge about the role exercise in terms of diabetes management.
  • Andragogy is adult learning and adult learning principles.
  • Pedagogy is childhood learning and childhood learning principles.
  • The domains of learning are the three types or domains of learning. The three domains of learning are the affective domain of learning, the cognitive domain of learning and the psychomotor domain of learning.
  • The affective domain of learning involves values, beliefs, feelings, interests and other social and emotional elements.
  • The psychomotor domain of learning entails "hands on skills" like using the correct procedure for the self administration of insulin and using the correct procedure for monitoring blood glucose levels.
  • The cognitive domain of learning is the knowledge and thinking domain. For example, a patient teaching plan for a newly diagnosed diabetic client will contain information about diet, exercise and their diabetic medications.
  • Teaching is a planned, dynamic, systematic process like the nursing process. Teaching consists of the assessment of learning needs, the generation of a learning need nursing diagnosis, the generation of educational patient goals or expected outcomes, the planning of educational activities, implementation and evaluation. It is an active process that imparts some knowledge, skill or ability to a person with a learning need.
  • Learning is the acquisition of new knowledge, skills or abilities. When learning occurs, a change in the patient's behavior and/or attitudes should occur.

Teaching Learning Process

The teaching/learning process is a planned, dynamic, systematic process like the nursing process that includes:

  • The assessment of the patient's learning needs
  • The organization of assessment data
  • The analysis of the educational related data
  • The generation of a nursing diagnosis based on the learning need
  • The planning of an appropriate educational activity
  • The implementation of the teaching/learning plan
  • The evaluation of the education in terms of the client and their increased knowledge and/or a change in behavior

Assessing Learning Needs and Other Factors

During the assessment and data collection phase of the teaching/learning process, nurses collect information about the patient's learning needs, their strengths and weaknesses in terms of learning, their learning styles and preferences, their level of motivation, and other factors including other patient characteristics and potential barriers that may negatively impact on the education and the effectiveness of the education.

Learning styles, other patient characteristics and barriers to education will be fully discussed later in this section.

Analyzing Learning Needs Data

After data is collected, the registered nurse organizes and analyzes this data in the same manner that the registered nurse analyzes data during the nursing process using the professional judgment and the critical thinking skills of the registered nurse.

Learning Need Nursing Diagnoses

The registered nurse then generates a learning need nursing diagnosis such as:

  • A "knowledge deficit relating to the performance of active range of motion exercises" which is within the psychomotor domain of learning and "At risk for a performance deficit relating to the self administration of insulin secondary to impaired fine motor skills" which is also within the psychomotor domain of learning
  • A "lack of knowledge about antihypertensive medications and their actions" which is within the cognitive domain of learning
  • A "lack of motivation relating to the performance of self care activities" which is within the affective domain of learning

Planning Educational Activities: Expected Outcomes and Selecting Teaching Methods

Registered nurses often collaborate with other members of the healthcare team to plan educational activities for individual patients, their significant others and groups of patients who share a common educational need. For example, the registered nursing may collaborate with a dietician to plan an educational activity for an individual client and their significant others in terms of the dietary management of high cholesterol or triglycerides, or the registered nursing may collaborate with a pharmacist or a physical therapist to plan a series of educational activities for a large or small group of newly diagnosed diabetic clients who have shared and common educational needs relating to diabetic medications and the role of exercise in terms of diabetes management, respectively.

During the planning stage, the nurse generates learning objectives or expected outcomes for the patient or the group of patients. Like the nursing process and its expected outcomes, or goals, educational related expected outcomes are also S-M-A-R-T-T-A.

Expected outcomes are also:

  • Specific
  • Measurable
  • Achievable
  • Realistic
  • Time framed
  • Trackable
  • Agreed to by the patient.

Learning objectives, or outcomes, are in terms of what the person will know, or do, after the planned education is given. They are also written according to the domain of learning that is being taught. For example, a psychomotor domain learning outcome could be, "The patient will change their dressing using medical aseptic technique" and a cognitive domain learning outcome could be, "The patient will list the foods that are not permitted with a soft diet."

The format of these documented expected outcomes relating to education is "The patient will…" followed by a measurable and observable verb that is consistent with the domain of learning. For example, some expected outcomes for the cognitive domain of learning are "The patient will describe, list, define, summarize and discuss…" Some expected outcomes for the psychomotor domain of learning are "The patient will perform and demonstrate the proper procedure for…" and "the patient will select heart healthy foods". Similarly, expected outcomes for the affective domain of learning could include "The patient will value …" and "The patient will demonstrate a belief that…"

Teaching strategies must be selected based on the domain of learning that is being taught. For example, lecture and discussion are appropriate strategies for the cognitive domain; demonstration, return demonstration and practice are appropriate strategies for the psychomotor domain of learning; and role playing as well as value clarification exercises are appropriate strategies and methodologies for the affective domain of learning.

Other strategies that can be used for the cognitive and psychomotor domains of learning are:

  • Online classes and information, reading material, videos, posters and pictures for the cognitive domain of learning.
  • A video showing the procedure, live demonstration, simulated practice and the use of a medical model for the psychomotor domain of learning.

The content and information that is planned for the educational activity should be sequenced from the known to the unknown, from the simple to the complex, and from the least threatening to the most threatening. Additionally, psychomotor skills should be taught going step by step through the procedure with the learner(s) beginning with step one and then proceeding to the last step of the skill or procedure.

Patient and family teaching activities are planned for adults using androgogy. Pedagogy is childhood learning; androgogy, is adult learning.

Unlike pedagogy, adult learning must have immediate usefulness in terms of solving problems; it involves active learner involvement and participation; and the curriculum and content are based on the learner's problems, needs and desires and not the state or federal government like pedagogy does.

Implementing the Teaching Plan

When time permits, psychomotor skills are best taught with short teaching sessions for each step of the procedure after which time the patient can practice what they have just learned before they are taught the next step.

Many clients have a short attention span and short term memory that may interfere with the learning process; therefore, the teaching sessions should be brief and modified, as based on the individual's need.

Evaluating the Outcomes of Education

The two kinds of evaluation that are used for education are formative evaluation and summative evaluation.

Formative evaluation is determining how effective the education is at the same time the educational activity is being conducted; and summative evaluation determines how effective the education was after the educational activity has ended.

Formative evaluation allows us to adjust or modify the teaching and/or to overcome any barriers to learning during the teaching session so the teaching can be made more effective when necessary. For example, when a patient does not appear to understand what you are teaching, you must adjust and modify the teaching with strategies such as using simpler language, using pictures, and clarifying the content as often as necessary during the teaching session to increase the level of understanding.

Summative evaluation allows us to determine if the education that was provided has met or exceeded or not at all met the patient's expected outcomes in terms of the knowledge, skills and/or abilities that was taught. Did the education close the gap between what should be known or done and what actually is known or done?

Evaluation methods also vary according to each of the domains of learning. Questioning and giving a test are ways that cognitive domain learning can be evaluated. Having the patient return demonstrate a "hands on" or psychomotor procedure or skill is the best way to evaluate psychomotor domain learning; and, the affective domain can be evaluated by observing the patient's changes in terms of their attitudes, beliefs or values, for example.

Learner Characteristics and Preferences

Learners, like all other human beings, are different in terms of the characteristics and preferences. Learners vary in terms of their cognitive abilities and their fine and gross motor skills which can impact on psychomotor skills acquisition; they also differ in terms of their learning styles and preferences, and they also vary in terms of other characteristics that can impact on the teaching and learning processes.

In terms of the learners' characteristic learning styles and preferences are the following:

  • Visual Learners: Visual learners learn best and have a preference when they are able to see things like an educational video, a live teacher demonstration, medical models, pictures and diagrams.
  • Verbal Learners: Verbal learners, on the other hand, learn best and have a preference when they are able to hear the teachers' spoken words. These spoken words can be delivered to the learner in a live presentation or with a taped presentation.
  • Tactile Learners: Tactile learners learn best and have a preference when they are able to learn by doing rather than seeing or hearing. They learn best with "hands on" experiences and the opportunity to manipulate, practice, and experiment with things.
  • Active Learners: These learners prefer to learn when they actively engaging with others, including the teacher, such as when they are discussing things with others and they are working on a small group project.
  • Reflective Learners: Unlike active learners, reflective learners tend to prefer working alone and thinking alone in solitude rather than interacting with others and working on small group projects.
  • Sequential Learners: These learners learn best when content is orderly, logical, and orderly and presented in a step by step manner. Sequential learners will then follow these logical and orderly steps to learn the content or skill and then to solve problems related to the content or skill that was taught.
  • Global Learners: Global learners, unlike sequential learners, do best when they themselves, rather than the teachers, are able to organize the content themselves during the learning process.
  • Sensing Learners: These learners prefer concrete and practical "real world" learning to solve a problem rather than abstraction and information that they cannot readily use.

Whenever possible, the nurse should use a variety of methods that meet most learner preferences when a group presentation is being given and they should employ the individual's learning preference strategies when one-to-one individual teaching activities are given.

Barriers Related to Learning

Some of the potential barriers to learning and possible ways to overcome these barriers will be discussed now:

English Language Barriers

Teaching and communicating with patients who do not have English as their primary language pose challenges in terms of teaching. The patient may not understand what is being taught.

Some of the things that you can do to overcome this barrier is to use pictures, to provide written information in the patient's native language, to get the help of a professional translator, to use simple terms and words without any medical jargon when the person is limited in terms of the English language, to speak slowly and clearly, and to clarify and restate whenever necessary.

A Low Level of Literacy

Individuals vary in terms of their levels of literacy and ability to read and understand material. For example, some patients can read and understand complex material with ease and others may have poor literacy skills that cause them to only understand material that is written at or below 6th grade reading level.

The nurse must determine the patient's literacy level and then provide them with material and information that they are able to read and fully understand.

Poor Health Literacy

Many people across our nation are, unfortunately, not health literate. Health literacy is the ability of the person to make knowledgeable and appropriate healthcare decisions that are based on the particular person's sufficient level of understanding of the particular healthcare concern or need that they are making a decision about.

Registered nurses must assess clients' level of health literacy and provide the understandable patient education that is necessary to insure that the client is making a knowledgeable decision about their care or treatments.

For example, nurses and other healthcare providers must use simple, understandable terms and terminology as well as alternative aids such as pictures or a medical model, to enhance learning. All medical jargon and complex explanations should be avoided.

The Lack of Motivation and Readiness for Learning

Patients have to be motivated and ready to learn before any learning can occur.

Nurses can motivate and encourage patients and significant others to learn by convincing them that the education will help them to solve their healthcare problems and concerns and also empower them in terms of making knowledgeable decisions relating to their health and health care.

The Presence of Stress and Pain

The presence of pain impedes learning. The nurse should consider using interventions, including pain medications, to reduce the pain prior to the teaching episode.

Mild stress is a motivator, but high levels of stress hamper effective learning. Again, the nurse should consider stress management strategies to reduce high levels of stress prior to the learning.

Age Specific Variables

The age and developmental level of patients also impacts on the teaching and learning processes.

Some examples of teaching modifications that are based on age and the learner's developmental level include simple concrete and brief explanations for the toddler, simple and brief explanations for the pre-school child, the encouragement of questions and more detailed explanations for the school age child, and adult like teaching for the adolescent.

Health Beliefs Including Spiritual, Cultural and Self Efficacy Beliefs

Patients who value health, health promotion and wellness will be most likely to be motivated to learn when compared and contrasted to other patients who do not value these same things.

Some of these beliefs can be spiritual, cultural and intrinsic in terms of their origin. For example, some believe that "medicine men" perform the role of a healthcare provider, rather than a medical doctor; others may have a cultural belief that immunizations are dangerous and not necessary; and still more may have an intrinsic belief that they are not able to do anything to solve their health related problem. It is all out of the control. These patients lack feelings of self efficacy and empowerment.

Nurses can overcome these barriers to learning by instilling new and different values and beliefs into the teaching session at the same time that any existing values and beliefs are incorporated into the teaching as much as possible.

Cognitive, Psychological and Emotional Challenges

Nurses have to accommodate for any actual or potential cognitive, sensory, psychological and emotional barriers to learning.

For example, cognitive limitations can be overcome with slow, brief, simple and understandable explanations. Psychological and emotional barriers can be decreased when the nurse-patient relationship is built on trust, respect, caring, and compassion.

Physical and Functional Limitations

Sensory barriers, like impaired vision and hearing, can be overcome with louder discussions with clients affected with a hearing loss, large print materials and Braille materials for the visually impaired, and the use of sensory assistive devices like glasses, magnifiers, and hearing aids.

Accommodations and modification must also be done when the learner has a functional limitation that can potentially hamper learning. For example, a patient with poor fine motor abilities and coordination may need an assistive device that accommodates for this.

Now it is time for you to be challenged with two sample questions relating to the teaching and learning processes:

"The ultimate purpose of teaching and learning is for the patient to...":

  1. Understand about their healthcare problem.
  2. Be knowledgeable.
  3. Be enlightened.
  4. Change behavior.

The correct answer is D- To change behavior

The ultimate purpose of teaching and learning is for the patient to change behaviors that can correct their healthcare problems and needs. Understanding, being knowledgably and enlightenment are needed for a change of behavior but it is a change in behavior is the ultimate goal of teaching and learning.

Now, here is another one:

What strategy would you use to teach a patient how to check their own blood pressure?

  1. Discussion
  2. Demonstration
  3. Reading material
  4. Affective learning

The correct answer is B- Demonstration

You would use demonstration to teach a patient how to check their own blood pressure because this is a psychomotor skill. Psychomotor skills are best taught with demonstration.