Foundations Chapter 13

Reflective Practice: Person-Centered Care

1. All team members are considered caregivers. 2. Care is based on continuous healing relationships. 3.Care is customized and reflects patient needs, values, and choices. 4. Knowledge and information are freely shared between and among patients, care partners, health care providers, and caregivers. 5. Care is provided in a healing environment of comfort, peace, and support. 6. Families and friends of the patient are considered an essential part of the care team. 7. Patient safety is a visible priority. 8. Transparency is the rule in the care of the patient. 9. All caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient. 10. The patient is the source of control for his or her care.

The idea of person-centered care emerged about

30 years ago as a return to the holistic roots of health care. Promoters of this model of care included the Picker Institute, the Planetree membership network, and the 2001 Institute of Medicine's seminal report Crossing the Quality Chasm. With the introduction of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience of care survey, there now exists a standardized tool to evaluate the way care is provided from the patient's perspective.

The person

Each person is unique and has his or her own set of beliefs, values, memories, hopes, and history. People are holistic beings with emotional, physical, social, and spiritual dimensions and needs that all meld together to create the whole individual person. The fact that a person has a disease is only one aspect of the whole in the same way as having red hair is only one aspect of the whole person. Therefore, each person's health journey and personal care are individual. Clinical care is an interaction between the carer and the cared for. Each of the people within this relationship is unique, so the respect and valuing of the person applies to both. Relationships based on this principle can become therapeutic.

Who believed in a holistic approach to nursing?

Florence Nightingale

Knowledge Based

For example, if the situation calls for reasoning about the manifestation of a clinical problem, the nurse will need to understand the disease or condition, its epidemiology, the mechanisms of its pathophysiology, its physical and psychological manifestations, signs and symptoms, and the probabilities of its progression or outcome.

Nursing Interventions Classification (NIC)

Identify, label, validate, and classify actions nurses perform, including direct and indirect care interventions (interventions done directly with patients, e.g., teaching; those done indirectly, e.g., obtaining laboratory studies).

Nursing-Sensitive Outcomes Classification (NOC)

Identify, label, validate, and classify nursing-sensitive patient outcomes and indicators to evaluate the validity and usefulness of the classification, and define and test measurement procedures for the outcomes and indicators.

North American Nursing Diagnosis Association (NANDA) International

Increase the visibility of nursing's contribution to patient care by continuing to develop, refine, and classify phenomena of concern to nurses

Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT)

Integrate, link, and map terms from various disciplines such as medicine, nursing, and occupational therapy.

Evidence-Based Practice

K—Describe evidence-based practice to include components of research evidence, clinical expertise, and patient and family values. S—Base individualized care plan on patient values, clinical expertise, and evidence. A—Value the concept of evidence-based practice as integral to determining best clinical practice.

Teamwork and Collaboration

K—Describe scope of practice and roles of health care team members. S—Follow communication practices that minimize risk associated with handoff among providers and across transition in care. A—Acknowledge own potential to contribute to effective team functioning.

Safety

K—Examine human factors and other basic safety design principles as well as commonly used unsafe practices (e.g., workarounds, dangerous abbreviations). S—Demonstrate effective use of strategies to reduce risk of harm to self or others. A—Value the contributions of standardization and reliability to safety.

Informatics

K—Explain why information and technology skills are essential for safe patient care. S—Apply technology and information management tools to support safe processes of care. A—Value technologies supporting decision making, error prevention, and care coordination.

Patient-Centered Care

K—Integrate understanding of multiple dimensions of person-centered care: patient, family, and community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. S—Elicit patient values, preferences, and expressed needs as part of the clinical interview, implementation of care plan, and evaluation of care. A—Value seeing health care situations "through patients' eyes."

Quality Improvement

K—Recognition that nursing and other health professions students are parts of systems of care and care processes that affect outcomes for patients and families. S—The Delphi ratings did not identify a beginning skill in quality improvement but rather recommended introduction and emphasis in intermediate or advanced experiences. A—Appreciate continuous quality improvement as essential in the daily work of all health care professionals.

Assessing purpose

Make a judgment about the patient's health status, ability to manage his or her own health care, and need for nursing. Plan individualized holistic care that draws on patient strengths and is responsive to changes in the patient's conditions.

Three types of reflection

Reflection in action happens in the here and now of the activity and is also known as "thinking on your feet." Reflection on action occurs after the fact and involves thinking through a situation that has occurred in the past. It is used as a means of evaluating the experience and deciding what could have been done differently. Reflection for action is the desired outcome of the first two types of reflection: it helps the person to think about how future actions might change as a result of the reflection.

REFLECTIVE PRACTICE LEADING TO PERSONAL LEARNING

Reflective practice occurs when the carer has a profound awareness of self; awareness of one's own biases, prejudgments, prejudices, and assumptions; and understands how these may affect the therapeutic relationship. This awareness is developed through the process of reflection, thinking back on what has occurred for the purpose of learning in order to improve.

Purpose of Thinking

The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. This helps to discipline your thinking by directing your thoughts toward the goal. The purpose of critical thinking might be to make a judgment about a particular patient or situation or to make a decision about how best to intervene.

The Nurse's Action in Response to Individual Clinical Need

The healing action that occurs in response to individual need completes the cycle of thoughtful practice when it is considered, personalized, appropriate, valued, and effective.

Person-Centered Nursing Process

The nursing process describes the way in which care is organized through a series of actions undertaken in response to the individual needs of the patient. The components of the nursing process are assessing, diagnosing, planning, implementing, and evaluating.

DEVELOPING THE METHOD OF CRITICAL THINKING

To develop the critical thinking skills essential to quality nursing practice, nurses find it helpful when posed with a challenge to work methodically through a set of five types of considerations: the purpose of thinking, adequacy of knowledge, potential problems, helpful resources, and critique of judgment/decision.

In 1967, Yura and Walsh published the first comprehensive book on nursing process, in which they described four steps in the nursing process: assessment, planning, intervention, and evaluation.

True

The Joint Commission requires that care be documented according to the nursing process, and the National League for Nursing has recommended that educational programs incorporate the nursing process as their intellectual process.

True

Critique of Judgment/Decision

Ultimately, you must identify alternative judgments or decisions, weigh the merits of each, and reach a conclusion. It helps to try to predict the consequences of your major options before concluding your reasoning. You will also want to evaluate the alternative you selected as your decision begins to influence your actions. After using this method to work through an intellectually challenging situation, critique your use of the method in light of the standards for critical thinking: clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for the purpose), and fair.

Two milestone monographs in nursing science are

Unifying Nursing Languages: The Harmonization of NANDA, NIC, and NOC (Dochterman & Jones, 2003) and Clinical Information Systems: A Framework for Reaching the Vision (Androwich et al., 2002).

INTUITIVE PROBLEM SOLVING

is thus a direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible. A recovery room nurse who realizes that a postoperative patient is deteriorating before there are measurable signs to suggest trouble is using intuitive problem solving, as is an oncology nurse who somehow senses the right moment to teach, offer encouragement, affirm, or simply listen.

Gebbie and Lavin (1974)

later made nursing diagnosis a separate step in the process. These and other studies led to the development of the five-step nursing process commonly used today: assessment, diagnosis, outcome identification and planning, implementation, and evaluation.

The overall goal of the QSEN (Quality and Safety Education for Nurses) project is to

meet the challenge of preparing future nurses who will have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems within which they work.

Thoughtful nurses base care decisions on

sound clinical reasoning and judgments that they evaluate and review through reflective practice, so that they continually learn from practice for the benefit of future patients

Characteristics of the nursing process

systematic, dynamic, interpersonal, outcome oriented, and universally applicable.

Watson's (2008)

theory of transpersonal caring begins with the conviction that humans are to be valued, cared for, respected, nurtured, understood, and assisted. She believes that caring can be demonstrated and practiced, and that nurses should create caring environments in which patients are accepted as they are and are invited to grow and realize their full potential. She reminds nurses that this model is transformative in that the nurse-patient relationship influences both the nurse and the patient for better or for worse.

When the relationship between the carer and the person who is being cared for is focused on promoting or restoring the health and well-being of the person being cared for in the relationship, it becomes a

therapeutic relationship

The steps of the nursing process were legitimized in 1973,

when the ANA Congress for Nursing Practice developed standards of practice to guide nursing performance. The following definition serves as the foundation for the scope and standards of nursing practice: "Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations"

Benner and Wrubel (1989)

wrote that caring is a basic way of being in the world, and that caring is central to human expertise, curing, and healing. "Nursing is viewed as a caring practice whose science is guided by the moral art and ethics of care and responsibility.... Nurses provide care for people in the midst of health, pain, loss, fear, disfigurement, death, grieving, challenge, growth, birth, and transition on an intimate front-line basis. Expert nurses call this the privileged place of nursing"

BENNER: THE HELPING ROLE OF THE NURSE

• Creating a climate for establishing a commitment to healing • Providing comfort measures and preserving personhood in the face of pain and extreme breakdown • Presencing • Maximizing the patient's participation and control in the patient's recovery • Interpreting kinds of pain and selecting appropriate strategies for pain management and control • Providing comfort and communication through touch • Providing emotional and informational support to patients and families • Guiding patients through emotional and developmental changes

WATSON'S CARATIVE FACTORS

• Humanistic altruistic system of values • Instillation of faith/hope • Sensitivity to self and others • Helping/trusting human care relationship • Expressing positive and negative feelings • Creating problem-solving caring process • Transpersonal teaching/learning • Supportive, protective, and/or corrective mental, physical, societal, and spiritual environment • Human needs assistance • Existential-phenomenologic-spiritual forces

SWANSON'S CARING PROCESS

• Knowing: avoiding assumptions, centering on the one cared for, assessing thoroughly, seeking cues, engaging the self of both • Being with: being there, conveying ability, sharing feelings, not burdening • Doing for: comforting, anticipating, performing competently/skillfully, protecting, preserving dignity • Enabling: informing/explaining, supporting/allowing, focusing, generating alternatives/thinking it through, validating/giving feedback • Maintaining belief: believing in/holding in esteem, maintaining a hope-filled attitude, offering realistic optimism, "going the distance"

Errors in decision making

Bias Placing excess emphasis on the first data received Avoiding information contrary to one's opinion Selecting alternatives to maintain status quo Being predisposed to a single solution Stating the problem in a way to support one's choices Making decisions to support past choices Failure to consider the total situation Using inaccurate data Not clearly identifying the problem Failing to prioritize or rank the problems in order of importance Using unrealistic goals Impatience Failing to identify multiple solutions Incorrectly implementing the decision Failing to use appropriate resources

Dynamic

Although the nursing process is presented as an orderly progression of steps, in reality, there is great interaction and overlapping among the five steps. No single step in the nursing process is a one-time phenomenon; each step flows into the next step. In some nursing situations, all five stages occur almost simultaneously.

Interpersonal

Always at the heart of nursing is the human being. Read one student's account of this truth in the accompanying Through the Eyes of a Student feature (on page 321). The nursing process ensures that nurses are person centered rather than task centered (Fig. 13-6 on page 320). Rather than simply approaching a patient to take vital signs, the nurse might ask, "How are you today, Mr. Byrd? Are we helping you to achieve your goals? What are the most important things you'd like me to do?" The nurse might also consider any new data that indicate a need to modify the patient's care plan.

Potential Problems

As you become skilled in critical thinking, you will learn to "flag" and remedy pitfalls to sound reasoning. Common problems include working with untested or faulty assumptions, accepting an unproven claim or line of argument, allowing bias to color your thinking, and reasoning illogically, such as making a generalization on the basis of a single experience or case or allowing emotion to rule reason. The more familiar you are with these common blocks to critical thinking, the easier it is to detect them in your own thinking.

Implementing purpose

Assist patients to achieve desired outcomes—promote wellness, prevent disease and illness, restore health, and facilitate coping with altered functioning.

Adequacy of Knowledge

At the outset of critical thinking, you need to judge whether the knowledge you have is accurate, complete, factual, timely, and relevant. If you reason with false information or a lack of important data, it is impossible to draw a sound conclusion. You also want to be sure that you understand all the details relevant to the issue. What is at stake? How much time do you have to make a decision? How much room is there for error?

Home Health Care Classification (HHCC)

Provide a structure for documenting and classifying home health and ambulatory care. Consists of two interrelated taxonomies: HHCC of Nursing Diagnoses and HHCC of Nursing Interventions.

International Classification for Nursing Practice (ICNP)

Capture nursing's contributions to health and provide a framework into which existing vocabularies and classifications can be cross-mapped, enabling comparison of nursing data from various countries throughout the world.

International Association of Human Caring (IAHC) believe

Caring is the human mode of being. Caring is the essence of nursing and the moral imperative that guides nursing praxis (education, practice, and research). Caring is both spiritual and human consciousness that connects and transforms everything in the universe. Caring in nursing is action and competencies that aim toward the good and welfare of others. Caring in nursing is a special way of being, knowing, and doing with the goal of protection, enhancement, and preservation of human dignity. Care is culturally diverse and universal, and provides the broadest and most important means to study and explain nursing knowledge and nursing care practices (www.humancaring.org).

Clinical Reasoning, Judgment, and Decision Making

Clinical reasoning is the process for analyzing a situation, making a judgment, deciding on possible alternative reasons, and choosing an action to be taken. It is built on a foundation of knowledge, experience, and the personal attributes of the person doing the reasoning. Critical thinking is fundamental in the process of clinical reasoning. Care can become ritualistic and depersonalized when nurses fail in clinical reasoning.

Evaluating purpose

Continue, modify, or terminate nursing care.

Diagnosing purpose

Develop a prioritized list of nursing diagnoses/problems/issues.

Outcome identification and planning purpose

Develop an individualized plan of nursing care. Identify patient strengths that can be tapped to facilitate achievement of desired outcomes.

Systematic

Each nursing activity is part of an ordered sequence of activities. Moreover, each activity depends on the accuracy of the activity that precedes it and influences the actions that follow it. Without a complete and accurate database, the nurse cannot identify patient strengths and problems. Lacking knowledge of these, the nurse and patient cannot develop a care plan based on realistic and valued patient goals. Unless the goals and outcomes are well written, nursing actions and evaluation lack focus and might be ineffective. The nursing process directs each step of nursing care in a sequential, ordered manner.

Personal attributes

Open-mindedness A profound sense of the value of the person Self-awareness and knowledge of your own beliefs and values A sense of personal responsibility for your actions Motivation to do what you do to the best of your ability because you care about the well-being of those entrusted to your care Leadership skills. Bravery to question the "system."

The professional nurse

Professional nursing requires cultivated personal attributes, mastery of the science of nursing, and reflective clinical experience in which nurses develop the blended competencies and QSEN competencies that promote thoughtful and effective person-centered practice.

Developing Technical Competencies

When a procedure demands manual dexterity or a complex series of steps, practice the necessary skill until you feel confident in your ability before attempting to perform it with a patient. Simulation exercises are a great help in developing both your competence and confidence. Take time to familiarize yourself with new equipment before using it in a clinical procedure. Understand how it works and what supplies are needed to ensure optimal functioning. If possible, anticipate problems and know how to remedy them. Identify nurses who are technical experts and ask them to share their secrets. Many experienced clinicians have developed quality, time-saving techniques they are willing to share. Never be ashamed to ask for help when feeling unsure of how to perform a procedure or manage equipment. Don't overlook the patient or family caregiver as a source of helpful hints for care they routinely provide. Never forget that the patient's well-being—and sometimes the patient's life—depend on your technical competence.

Helpful Resources

Wise professionals are quick to recognize their limits and seek help to remedy their deficiencies. Experienced clinicians know that learning is continuous and expect their practice to involve challenges that demand new knowledge. Critical thinkers know what help they need to assist their reasoning and what resources to tap. Key resources include experienced clinicians, texts and journals, institutional policies and procedures, and professional groups and writings.

The nursing process is

a systematic method that directs the nurse, with the patient's participation, to accomplish the following: (1) assess the patient to determine the need for nursing care, (2) determine nursing diagnoses for actual and potential health problems, (3) identify expected outcomes and plan care, (4) implement the care, and (5) evaluate the results.

Travelbee (1971)

an early nurse theorist, developed the Human-to-Human Relationship Model, which defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering and, if necessary, to find meaning in these experiences.

blended competencies

because, in most instances, nursing actions require all four competencies. A nurse who sets out to suction a patient, for example, must understand the evidence that supports this action, be skilled in handling the required equipment, use the encounter to promote the patient's sense of well-being, and practice in an ethically and legally defensible manner. Few nurses excel naturally in all four of these competencies, and even experienced nurses continue working on becoming more proficient in the knowledge, attitudes, and skills that lead to excellence

Finally, Swanson (1991)

identified five caring processes and defined caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility"

Focused Critical Thinking Guides

illustrates the use of these five considerations to facilitate critical thinking about a care dilemma experienced by a nursing student. The merits of thinking critically about which of the options is most likely to meet that patient's needs are easily seen. Because nurses are accountable for the well-being of their patients, sloppy reasoning is both dangerous and inexcusable—even for someone new to nursing and clinical practice. Other Focused Critical Thinking Guides are found throughout the book.

Creative thinking

involves imagination, intuition, and spontaneity, factors that underpin the art of nursing. Creative thinking is brought into play when you ask "why" or "what if" questions, and is most useful when conventional solutions have not resolved a situation. Creative nurse thinkers are able to "think outside the box" and imagine possible consequences, generate original approaches, and identify alternative perspectives.

Trial-and-error problem solving

involves testing any number of solutions until one is found that works for that particular problem. This method is not efficient for the nurse and can be dangerous to the patient; it is therefore not recommended as a guide for nursing practice. For example, although you might enjoy experimenting with different types of ethnic food as you discover and develop personal food preferences, you would not want to use the trial-and-error method of determining food preferences for a dehydrated and malnourished patient.

Reflective practice

is a purposeful activity that leads to action, improvement of practice, and better patient outcomes. It is about looking at an event, understanding it, and learning from it. Learning from reflection is not automatic; it requires a deeper understanding of how and why reflection contributes to the competence of the effective nurse. Schön (1983) has identified three types of reflection.

Scientific problem solving

is a systematic, seven-step problem-solving process that involves: (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation, resulting in a conclusion or revision of the hypothesis. This method is used most commonly in a controlled laboratory setting but is closely related to the more general problem-solving processes commonly used by health care professionals as they work with patients

Thoughtful practice

is nursing practice that is considerate and compassionate. A thoughtful nurse always keeps the person at the center of caregiving in order to promote the humanity, dignity, and well-being of the patient. Thoughtful nurses value their own integrity and development, reflecting on each day's practice to better understand and learn from each day's challenges. They seek to establish powerful partnerships with patients and to deliver care through processes that are holistic and tailored to meet the individual needs of patients.