I teach in the last semester (Med-Surg) of an ADN program. I have complete faith in the faculty in earlier semesters. I know they are teaching the nursing process, and they are as frustrated as am I. I know it's very well covered in the texts we use. But the "seniors" can't reason their way out of a wet paper bag. How bad is it? Let me count the ways.
I ask my students to give me a focused assessment on their patient's principle problem. Here's how it typically goes....
" She is a 49 year old female who has a 18 g. IV in her left AC and has had vicodin 7.5 three times today, her leg is elevated and she is eating well. She uses the bedpan. She's very eager to go home because she doesn't like the food. Her blood sugars were all below 150 so she didn't get insulin today and her husband has been in the room all day."
There you go.
The real story is that the woman is a diabetic who had an rapidly evolving outrageous infection that went from a small lesion to involve almost the entire leg - ankle to thigh, came to ER where they did an ultrasound... on the wrong leg... and found a big DVT, in addition to the extensive cellulitis on the other. So the lady is on a weight-based heparin protocol and some significant IV antibiotics.
After listing a lot of random facts, including some vital signs, a student might tell me that the patient's problem is hypertension. Questioned about it, the student will say the patient's problem is hypertension because his blood pressure is elevated. Rather like saying, "my dog is a quadraped because he has four feet." Clearly, they don't use/understand nursing diagnosis and fall back on medical diagnoses but I KNOW they know better. Sometimes they make a show of using NANDA, but only in as much as they can run their fingers down a list and find something that sounds applicable to their patient. Usually they get it pretty close to the organ system involved.
Their goals are usually things like... "I will get him up three times today and walk him in the hall." The plan/nursing action for meeting the goal is "I will get him up three times today and walk him in the hall." Again... tautologies.
Obviously, then, since they can't identify related and relevant data, can't articulate (in any syntax) the patient's problems, and don't know what appropriate goals might be, the rest of their plan-of-care is silly and superficial.
This is the 4th cohort I've taught, and it hasn't been this bad before. However, (sad to say) it's also not a fluke, because I'm seeing the same thing in lower classmen coming my way. Trying to do this heavy lifting in their final semester of nursing school is not the answer. How do you bring your students along in their understanding and application of the nursing process. I know that is a huge question, but any ideas would be appreciated.
I would be so grateful to hear from any of you.
Nov 19, '11
Quick addendum: "The Nursing Process" is a lot like Jesus, in a way. Everyone knows who Jesus is and claims devotion to him. But put a Catholic, Presbyterian, and Baptist in a room and the disputations will never end. Same way with two or three nursing educators and the nursing process. I have been trying to actually use benign words like "critical thinking" or "clinical reasoning" and "problem statement" as opposed to "nursing diagnosis."
My question is really pretty broad. I'd take logical thought about patient care in any form I can find it. I am just not finding it in my students.
Nov 20, '11
I teach skills in an RN program as well as clinical. I'm continuously referring to the nursing process in my demonstrations of skills. I ask the students to give me examples of nursing diagnoses that would be appropriate for the particular skill I'm teaching. I then talk about the assessments necessary to that skills and then, of course, the interventions that are related. In clinical, I challenge my students to identify for me the main nursing focus of their day, i.e., safety because a patient was confused and trying to get out of bed. Then they have to share with their peers in post-conference discussion, all the things they did to keep their patient safe (their goal) during their shift. I generally see good care plans
from my students in clinical. Hope this helps.
Dec 3, '11
For medsurg teaching on specific diseases we start with overview, assessment, management, then potential nursing diagnosis with examples of related to and evidenced by followed by outcomes and nursing interventions. We wrap it up with evaluation ....the plan of care is considered effective if.......
Report is ISBARR format completed on every pt in clinical. For care plans
the students must prepare in same format we teach. They are required to include the related to and as evidenced by specific to their pt.....takes them awhile to get it but when teaching is presented in this format it helps.
Dec 6, '11
A major issue is that we try to teach nursing process as an entirely separate entity, when in reality it is integrated into our daily care routines. Students should not think "First I go to clinical and do tasks, then I go home and write a care plan," yet you'll find most subscribe to that mentality. Why? In part, because the working world expects psychomotor skills. Students think being a nurse means starting a difficult IV or dropping an NG. In my experience, we must model this process. I don't try to teach the nursing process just in class. I teach it by modeling in clinical. I think out loud. We focus on a different part of the process each day at clinicals. For example, if today's focus is assessment, we form assessment groups and assess as many patients as possible. I ask students things like :
What assessments are key to perform for a patient with "x"?
How do our findings reflect pathophysiology?
Why do these findings differ between patient "x" and "y"?
What assessment findings would indicate a therapeutic response to treatment?
What assessment findings would indicate deterioration, and what would be your priority actions?
Think out loud with them, from day one until graduation.
Some still will not make the connection to an extent that they can safely practice. These students should not be passing.
Dec 13, '11
I remember when i was in school what helped me was a presentation by a fellow student (who was a teacher starting a new career) on how the nursing process is the nursing term for critical thinking. It made so much sense afterward and was very helpfull to most of the class. After that presentation I used the steps in critical thinking knowing how closely related it was to nursing process except for the NANDA terminologies. How we were taught NANDA was that we were asked to place oursves in the position of patients and ask what we would require if say we just came out of surgery. We would create a list and then convert that into potential problems which would be in the risk category and actual would stay an actual problem. When it came to writing notes we were shown the SBAR method for writing nursing notes. It helped us out alot, even those that needed more instruction
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