what is analysis in nursing

The 5 Nursing Process Steps – (Learn Each Step in Detail)

One of the most important tools a nurse can use in practice is the nursing process. Although nursing schools teach first-year students about the nursing process, some nurses fail to grasp the impact its proper use can have on patient care. In this article, I will share information about the nursing process, its history, its purpose, its main characteristics, and the 5 steps involved in carrying out the nursing process. After reading this article, you will be able to answer the question, “what is the nursing process” and understand what is involved in each of the 5 steps of the nursing process. Additionally, throughout this article, after discussing a step of the nursing process, I will share an example of how the nurse would proceed with that step. For this article’s purposes, we will use information about the following patient: Mr. Collie, a fifty-four-year-old white male being admitted to the Medical-Surgical floor for acute congestive heart failure.

What is the Nursing Process in Simple Words?

When was the nursing process developed, who developed the nursing process, what is the purpose of the nursing process, what are the 7 main characteristics of the nursing process, 1. within the legal scope of practice, 2. based on sound knowledge, 4. client-centered, 5. goal-directed, 6. prioritized, 7. dynamic and cyclical, how many steps are there in the nursing process, what are the 5 steps of the nursing process, step #1: assessment phase.

The first phase of the nursing process is the assessment phase. In this phase, the nurse collects and organizes data related to the patient. Data includes information about the patient, family, caregivers, or the patient's community or environment as it is relevant to his health and well-being.

All phases of the nursing process are essential. The following are a few reasons why the assessment phase is important for nurses to provide care.

In the assessment phase of the nursing process steps, the nurse gathers all pertinent information that will be used to establish a care plan.
Every other step of the nursing process builds upon the previous. Without a thorough assessment, the other steps of nursing care may be negatively impacted, resulting in unfavorable outcomes.
When assessments are performed correctly, they help reduce risks to patient safety which could occur when symptoms or other factors are not considered.

The assessment phase of the nursing process involves gathering information about the patient which is used to guide planning care, setting goals for recovery, and evaluating patient progress. Nurses can obtain information about the patient by implementing the following objectives.

The patient is the nurse’s main source of information. Therefore, it is essential to establish rapport with them as soon as possible.

with the patient's family or caregivers when appropriate. Family members, friends, or other caregivers often offer insight into what is going on with the patient. It is important for nurses to listen to the patient’s support people and gather any information available.

When the patient feels comfortable, it makes it easier to get the necessary information that will be used to establish a plan of care. The patient interview is one of the main sources of information used to plan patient care.

Any information that is measurable or observable such as vital signs and test results is considered objective data.

Subjective data is information gathered from the patient.

Assessments are vital to the nursing process. The information gathered in the assessment phase impacts every component of patient care. Nurses must demonstrate excellent verbal and written communication skills, strong attention to detail, and possess an in-depth understanding of body systems. The most frequently used clinical skills for patient assessment are inspection, percussion, palpation, and auscultation.

The assessment phase is a critical component of the nursing process. Information gathered in this phase is used to establish a foundation upon which all patient care moving forward is established. Remember, it is normal for patients to feel nervous or fearful when they are sick and in an unfamiliar place, like a hospital. Therefore, the nurse needs to establish an environment conducive to patient comfort.

The assessment may include but is not limited to, the following aspects: environmental, physical, cultural, psychological, safety, and psychosocial assessments.

The following is a guideline of what should happen during the assessment phase.

During the assessment phase, the nurse collects objective and subjective data using proven methods to assess the patient. The most common methods for collecting data are the patient interview, physical examination, and observation.

The patient interview is a deliberate or intended communication or conversation with the patient. It is used to obtain information, identify problems that concern the patient and/or the nurse, evaluate changes, provide support, and educate the patient and family/caregivers.

The nurse will also conduct a head-to-toe nursing assessment addressing each body system and noting any abnormalities, complaints, or concerns. Observation requires the nurse to use all their senses (sight, touch, smell, hearing) to learn about the patient.

After collecting data, the nurse must organize and validate data and document about the patient's health status. Validation is the process of verifying data to be sure it is factual and accurate. Nurses must be careful to not come to conclusions without adequate data to support their conclusion.

It is also necessary to understand the difference between inferences and cues. Cues are signals the patient uses to alert the nurse about a concern or question or objective data the nurse can observe or measure. Inferences are the nurse's conclusion or interpretation based on cues.

For example, the patient may complain about a painful incision two days post-operatively, and the nurse may observe the incision site is red and feels hot. These are cues. The nurse then makes an inference that the operative incision is infected.

After data from the assessment is collected, organized, and validated, it must be recorded. One thing I always tell nursing students and cannot stress enough to any nurse is, "If you didn't document it, you didn't do it." While that may seem harsh, from a legal standpoint, if a nurse is asked to verify care or treatment and there is no supporting documentation, there is no way to prove the care occurred.

Thorough documentation is one of the best ways for everyone involved in patient care to be aware of changes in the patient's status, and it helps promote effective collaboration within the interdisciplinary team.

While all the nursing process steps are essential, without a thorough assessment, the other steps of the nursing process are not as easy to follow through. Nurses must recognize barriers that could impede the assessment phase and find ways to overcome them. The following are five common challenges you may face during the assessment phase and some suggestions on how to overcome them.

Limited Time There are days when nurses feel as though there aren’t enough hours to accomplish all the work that needs to be done. When you are short-staffed or have several patients waiting for a nursing assessment before you can initiate care, it can feel a bit overwhelming.

Even on the busiest of days, it is important for nurses to perform thorough nursing assessments for all patients assigned to them. That means it is necessary to learn to manage time efficiently. The first step in overcoming limited time is to be familiar with the format or forms your employer uses to record assessments.

For example, the Health Information Technology for Economic and Clinical Health Act of 2009 advanced the adoption and use of electronic health records. Nearly one hundred percent of hospitals use some type of EHR. Electronic health records have helped improve workflow by eliminating time spent pulling physical charts or documenting in paper charts.

Interruptions It is not uncommon for interruptions to occur when nurses are performing assessments. While some interruptions may be necessary, all are not. Interruptions during patient assessments can delay care and could result in errors or omissions.

The best way to overcome the challenge of interruptions during the assessment step of the nursing process is to provide for privacy before you begin the assessment.

Whether you are working in triage, assessing a patient newly admitted to your floor, or in a busy emergency room, it is possible to reduce interruption. Pull the privacy curtain closed if you are in an area with more than one patient or several staff close by. Some facilities use "Do Not Disturb" or "Room in Use" signs to provide privacy for nurses and patients.

Inexperience Every nurse knows the importance of a good nursing assessment. Newly graduated nurses are less experienced than other nurses and may feel uneasy about performing a nursing assessment alone. Additionally, if your facility changes its documentation format or implements a new program for charting, and you've not yet used the program, your inexperience could pose a challenge when doing an assessment.

The only way to overcome inexperience is to become experienced. Nursing assessments are typically classified as either a Complete Health Assessment or a Problem-Focused Assessment. Know which type of assessment you need to perform.

Gather basic equipment: gloves, thermometer, blood pressure cuff, stethoscope, penlight, and watch. Establish a sense of trust and respect between the patient and yourself.

No matter which type of assessment you perform, it should be systematic, making sure you cover each body system. If you assess each body system and make notes about what is normal/abnormal, you decrease the chances of omissions in documentation. Remember, take your time, trust your instincts, and if you need help, ask for it.

Patient Anxiety Patient anxiety can create a significant challenge for nurses during a patient assessment. Anxiety can hinder communication making it difficult to gather all the necessary data. If anxiety is bad enough, it can cause changes in vital signs, which could be misinterpreted as something more than an anxious reaction.

Before beginning an assessment, take the time to make your patient comfortable. While you may not have time for a long conversation or "get to know you" session, you can ease your patient's anxiety by being calm and friendly.

Some questions may make patients feel uncomfortable, especially teenagers. Allow them time to answer your questions without feeling rushed. Verify their understanding by asking if they can explain what you've discussed in their own words.

Remember, everyone gets nervous or anxious at times, and when we are sick, it can be worse. It's nothing personal against you or your skills. Make everything about the patient.

Patients Not Being Forthcoming About Symptoms Whether it is fear of the unknown, embarrassment, or another reason, there are times when patients may be apprehensive about sharing personal information.

Lack of information or omission of details that the patient may think is irrelevant may negatively impact the process of care planning. Therefore, while it is easy to understand a patient's apprehension, it is crucial for nurses to gather as much information as possible when performing a nursing assessment.

It can be easy to feel frustrated if a patient is not forthcoming about symptoms during an assessment. Keep in mind, being sick and needing medical care can be frightening.

The best way to get patients to talk to you is to be accepting of them, no matter what. Be sure to tell your patient you are there for them and will work with them to help them get better. When you say things like you will "work with them," it lets your patient know you are going to do your part, but you expect them to do theirs as well.

If you feel like your patient is withholding information, instead of making an accusation, try to rephrase the question. Make your questions clear so the patient knows what information you need.

The format for recording nursing assessment data may vary from one facility to another. However, the information gathered for the assessment is relatively similar. The following are examples of content the nurse should include in the initial nursing assessment phase of the nursing process.

04/19/22 13.30
J. Mock, LPN
54 yrs. 2 mos. M 6’2” 268lbs 4oz
Dr. Michael Coulvan
03/04/1968

CHF, acute
Temp 98.8, Resp. 20, Pulse 76, BP 136/80

NKDA, no food allergies

Jerold R. Collie
123 Blakely Lane, Clayton, MO. 1234
(318) 555-1234

Alert & Oriented x3; PERRLA, Unaided hearing; Bilateral hand grips equal; Bilateral foot push equal; no evidence of tremors; denies tingling, burning, loss of consciousness, hallucinations, disorientation, visual disturbances, or hx/o brain injury or stroke.

Pulses present, regular, and strong: x2 upper extremities (Radial); present X2 lower extremities (Pedal); heart rate regular, strong; capillary refill <3 second upper and lower extremities

Respirations even, labored; Dyspnea on exertion; Lungs: Bilateral rales in lung bases; Cough: Nonproductive; Oxygen: 2L per NC

Reports 10 lb weight gain in last two weeks. Continent of bowel; Last BM 4/19/22; Laxatives: No, Enemas: No; Hx of Constipation: No

Continent of bladder; Uses urinal prn; urinal emptied of approximately 200 cc clear, amber urine

Skin is pink, warm, and dry; Mucous membranes pink and moist

Reports pain and stiffness in joints of hands mostly in the a.m.; denies history of gout, arthritis, bursitis, or fractures; Negative paralysis; Negative contractures, No congenital anomalies; No prosthetic devices; Able to carry out most ADLs with minimal assist but may require periods of rest r/t dyspnea with exertion; Uses walker for ambulation.

Headache Constant, throbbing 5

Full weight-bearing; Ambulatory with 1 person assist; Client uses walker occasionally; No supportive devices

Client is alert, friendly, and answers questions readily; Comprehension: rapid.

Divorced; Client lives alone in his own home; Has two adult children who live nearby and visit frequently; Client reports he has several close friends who call or visit often.

History of hypertension; Denies any other medical issues prior to this admission.

Client reports previous substance abuse, methamphetamine was his drug of choice. Client states he has been substance and alcohol-free for three years.

Paternal hx/o CHF, HTN, and Lung Ca. Maternal hx/o DM, and HTN.

*In addition to the information the nurse will gather during her assessment, the assessment phase of the nursing process includes gathering objective data such as copies of laboratory or diagnostic testing. If the facility uses electronic health records, as most do, this information will probably already be uploaded to the patient’s electronic chart. It is, however, the nurse’s responsibility to gather and verify all data is available.

The assessment phase of the nursing process lays the foundation upon which all other nursing process steps build. The information gathered during the nursing assessment tells the nurse about the patient’s history, current complaints, medications, and any other pertinent information that may impact care planning. Without a thorough, proper patient assessment, it is impossible to develop a patient-specific care plan.

Nurses collect data during the assessment phase by communicating with the patient, spouse, and caregivers, reading patient records, nursing observation, and collecting measurable data such as vital signs.

Subjective data is any information the nurse collects through communication. A few examples of subjective data include the reason for the patient’s visit to the doctor, patient or family medical history, medications the patient is taking, and any symptoms such as chills, aches, or pain.

Objective data is any measurable information obtained from sources other than the patient. For example, the patient’s height, weight, vital signs, and laboratory or diagnostic test results are objective data collected during a patient assessment.

Nurses collect verbal data by talking to patients, their family members (when appropriate), and other members of the healthcare team. Subjective matter is usually often the result of verbal communication during the patient interview.

Nonverbal data is collected during the assessment phase of the nursing process by observing the patient's body language, reading patient charts, or medical test results. For example, the patient may not offer a verbal report of pain, but the nurse may observe him clutching or guarding his side, which could indicate pain.

The nurse can use the nonverbal data to form assessment questions as a way of following up with what she has observed or read.

The primary source of data collection during the nursing assessment is the patient. Other sources include family, friends, caregivers, and other members of the healthcare team. Data are also collected from laboratory or diagnostic reports, the patient’s medical records, and the nurse’s observations.

Tertiary data are data gathered from sources such as the patient's chart, lab, or x-ray reports. Nurses may also use tertiary sources such as diagnostic manuals or textbooks to verify or compare information.

Nurses can use a few methods to verify the accuracy of data collected during the assessment phase of the nursing process.

A few ways to verify data is to clarify information with the patient by asking additional questions, compare objective and subjective data to see if there are any discrepancies, recheck data by repeating the assessment, and verifying data with another nurse or healthcare team member.

One example of verifying data is to perform repeat vital sign check. For instance, if Mr. Jones has a blood pressure reading of 220/100 but has no history of hypertension, the nurse should retake his blood pressure to validate its accuracy. If the nurse feels it is necessary, they may use different equipment or ask someone else to perform the vital sign check to check for accuracy.

The primary methods nurses use to collect data are observation, patient interviews, and head-to-toe assessments.

Nurses use various tools and equipment to help gather data about patients. A few examples of tools and equipment nurses use include a stethoscope, blood pressure cuff, thermometer, pulse oximeter, and scales. You may need a glucometer and lancets to check blood sugar, as well.

Step #2: Diagnosis Phase

Diagnosis is the second phase of the nursing process. It is also designated by the American Nurses Association as the second Standard of Practice. The standard is defined by the ANA stating, "The registered nurse’s analysis of assessment data to determine actual or potential diagnoses, problems, and issues.” The nursing diagnosis reflects the nurse’s clinical judgment about a patient’s response to potential or actual health issues or needs.

Before a plan of care can be established, nurses must determine which nursing diagnosis/diagnoses apply to their patients. The following are a few reasons why the diagnosis phase of the nursing process is important.

The diagnosis phase of the nursing process helps nurses view the patient from a holistic perspective.
Using a nursing diagnosis can lead to higher quality nursing care and improved patient safety, as care is based upon the needs outlined in the diagnosis.
The diagnosis phase helps increase the nurse’s awareness and can strengthen their professional role.

In the diagnosis phase, the nurse follows a set of objectives that end with developing the nursing diagnosis/diagnoses used to establish patient care. These are the main objectives of the diagnosis phase:

The nurse must identify what problem the patient is experiencing related to the medical diagnosis.

Any situation or problem that could result because of the patient’s medical diagnosis is a risk factor for a nursing diagnosis and must be addressed.

All data gathered during the assessment phase of the nursing process must be compiled, validated, and analyzed to support an appropriate nursing diagnosis.

Nursing theories involve an organized framework of concepts and purposes that guide nursing practices. A nurse’s theory is their unique perspective about the patient’s status and measures needed to improve the patient’s outcome.

After identifying problems and risk factors, analyzing data, and developing a nursing theory, the nurse can then establish a nursing diagnosis or diagnoses which is used to establish a nursing care plan.

Nurses will utilize several skills in the diagnosis phase of the nursing process steps. Critical thinking, problem-solving, and communication skills are necessary to work in this phase. Nurses must also demonstrate the ability to prioritize patient needs.

The diagnosis phase of the nursing process involves three main steps: data analysis, identification of the patient’s health problems, risks, and strengths, and formation of diagnostic statements.

Data Analysis involves the nurse clustering cues, comparing patient data against standards, and identifying inconsistencies or gaps in the data.

After data analysis, the nurse will work with the client to identify actual, risk, and possible diagnoses. In this step, the nurse will determine if an identified problem classifies as a nursing diagnosis, medical diagnosis, or collaborative diagnosis/problem. It is important to involve the patient in this step whenever possible, to identify the client's resources, coping abilities, and strengths.

The last step of the diagnosis phase involves creating a nursing diagnosis. The nursing diagnosis may have up to three components: a NANDA-I approved , a which defines the cause of the diagnosis, and an as that uses patient-specific data to justify the diagnosis and diagnostic statement.

The nursing diagnosis is different from a medical diagnosis. It requires careful consideration of the patient’s individual problems, situation, and needs to develop appropriate nursing diagnoses. Here are a few examples of challenges that may occur during the diagnosis phase of the nursing process and some suggestions on how to overcome them.

Creating a Nursing Diagnosis Is Often a Complex Process Although there are resources and guidelines to help nurses develop nursing diagnoses, the process can be complex. Before nurses can create a nursing diagnosis, they must interview and assess the patient and review data, which can be time-consuming.

While you may not overcome the complexities of creating nursing diagnoses, it is possible to make the process easier.

For example, be sure to review all objective data, including baseline vitals, laboratory or diagnostic test results, and subjective data. Make sure the patient's medical history is accurate and find answers to any questions not yet answered. The more information you have to work with, the easier it becomes to develop diagnoses based on that data.

Nurses May Interpret Data Differently Some data are taken at face value, such as laboratory or diagnostic test results or vital signs, which are measurable. Subjective data is data reported by the patient. It is information given to the nurse by the patient based on the patient’s perception of what he is feeling. Despite efforts to appreciate the patient’s perception, nurses sometimes interpret data differently. When this happens, it can create a challenge when developing nursing diagnoses for the nursing care plan.

It is essential for nurses to have a clear understanding of which data is objective or subjective. Once the differences in data are realized, nurses must be careful to not rely upon only one piece of data or their own perception of data to create a nursing diagnosis. Instead, establishing nursing diagnoses should be a collaborative effort among the nursing care team. Nurses assigned to a patient’s care should discuss their perception of data and make informed decisions based on all data.

Insufficient Data to Support a Nursing Diagnosis Nurses must review all available data, including but not limited to subjective and objective findings, lab and diagnostic test results, and narrative notes from the patient interview before a nursing diagnosis can be made. If the nurse does not obtain enough data during the assessment, it will be difficult to establish appropriate nursing diagnoses.

The best way to overcome the challenge of insufficient data is to perform a thorough assessment, patient and/or family interview, and make sure all results from any tests are readily available for review.

If you have reached the diagnosis phase of the nursing process and find you do not have enough data, go back to the sources of information and gather data. You may find that you need to reassess the patient or ask additional questions.

Lack of Communication Between Nursing Staff Although patients are assigned a primary nurse, nursing is a team effort that requires collaboration. When there is a lack of communication between nursing team members, information may be inadvertently omitted from notes or reports. This failure in communication makes getting a complete view of the patient's status difficult, resulting in challenges in developing appropriate nursing diagnoses.

Nurses must be alert and responsive to patients and one another. End of shift report is an excellent way for nurses to communicate changes in a patient's status. Nurses should make notes of anything pertinent before handing off care to the next shift nurse and clearly communicate concerns about the patient's progress or lack thereof.

When the lack of communication is resolved, nurses can compare information to use when establishing nursing diagnoses, ensuring the patient gets the best care possible.

Deciding the Type of Nursing Diagnose to Use There are four main types of nursing diagnoses: Problem-focused, Risk, Health Promotion, and Syndrome.

When nurses get to the diagnosis phase of the nursing process, they must determine which type or types of diagnoses are relevant to their patients. While experienced nurses may find it easier to decide which type of diagnosis to use, new or less experienced nurses may find it challenging.

Additionally, some healthcare facilities prefer nurses to use a specific type of diagnosis, which can be frustrating, especially if the nurse feels a different type of nursing diagnosis is more appropriate.

Overcoming the challenge of choosing the right type of nursing diagnosis requires understanding when each type is most appropriate. If the nurse has sufficient data from the assessment phase, they can then identify potential diagnoses and determine which type of diagnosis to use.

The following are the four types of nursing diagnoses and examples of each.

focus on a specific problem the patient is experiencing. This type of diagnosis has three components: a nursing diagnosis, related factors or diagnosis statement, and defining characteristics or the as evidenced by statement.

For example, the patient with chronic obstructive pulmonary disease (COPD) could have a problem-focused nursing diagnosis of "Ineffective Breathing Pattern related to decreased lung expansion as evidenced by dyspnea and ineffective cough."

identify potential problems or risks the patient may experience because of his medical diagnosis. A risk nursing diagnosis typically has two components, the diagnosis, and risk factors. The patient with COPD may have a risk diagnosis of "Risk for Ineffective Airway Clearance related to decreased lung capacity."

(a.k.a. Wellness Nursing Diagnosis) is based on the nurse's clinical judgment about the patient's desire and motivation to increase his well-being. These diagnoses focus on the client's transition from one level of wellness to a higher level of wellness.

Health promotion nursing diagnoses are usually one-part statements or include only a diagnostic statement. The COPD patient's Health Promotion Nursing Diagnosis may state "Readiness for Enhanced Wellness."

are clinical judgments related to a cluster of risk nursing diagnoses predicted to occur because of a particular event or situation. The syndrome nursing diagnosis is also written as a one-part statement. For example, the COPD patient may have a syndrome diagnosis of “Ineffective Airway Clearance, Impaired Gas Exchange, Ineffective Breathing Pattern.”

After reviewing the data collected in the assessment phase of the nursing process, the nurse determines which type of diagnosis is appropriate and moves to the planning phase. In the case of Mr. Collie, the nurse chooses a problem-focused nursing diagnosis and a risk nursing diagnosis.

• Decreased Cardiac Output r/t impaired contractility and increased preload and afterload AEB irregular heartrate of 118, fatigue, and dyspnea on exertion (Problem-focused)
• Risk for Impaired Skin Integrity r/t edema, decreased tissue perfusion, and decreased activity. (Risk)

Although they share similarities, nursing and medical diagnoses are different. The nursing diagnosis is used by a nurse to identify a patient’s actual or potential risk(s), wellness, or responses to a health problem, condition, or state. A medical diagnosis is used by physicians to determine or identify a specific condition, disease, or pathologic state.

NANDA-I stands for North American Nursing Diagnosis Association International. NANDA-I is a professional organization that researches, develops, disseminates, and refines nursing diagnosis terminology. The organization was formed as NANDA in 1982, it was renamed NANDA-I in 2002 because of its increased worldwide membership.

Each nursing diagnosis is made up of four main components: problem and its definition, etiology, risk factors, and defining characteristics.

The primary purpose of establishing a nursing diagnosis is to communicate the healthcare needs of the patient among members of the healthcare team and within the delivery system. The nursing diagnosis allows nurses to facilitate individualized care for the patient and family and strengthens the profession.

The nursing diagnosis serves as the basis for selecting nursing interventions, which have a significant impact on patient outcomes. If an accurate nursing diagnosis is not chosen, the plan of care and subsequent nursing interventions may not address the patient’s issues appropriately resulting in negative patient outcomes.

Nursing diagnoses are ranked in order of importance. Immediate life-threatening problems or issues related to survival are given the highest priority.

Nursing diagnoses focus on the patient’s response to health conditions, and patients often respond differently. Therefore, it is not uncommon for patients with the same medical diagnosis to have different nursing diagnoses.

Step #3: Planning Phase

The planning phase of the nursing process is the stage where nursing care plans that outline goals and outcomes are created. The goals and outcomes formulated during this phase directly impact patient care and are based on evidence-based nursing practices.

The planning phase of the nursing process is essential in promoting high-quality patient care. It is considered the framework upon which scientific nursing practice is based. The following are three of the top reasons why the planning phase is so important.

Care planning provides direction for personalized patient care based on the client's unique needs.
The planning phase enhances communication between patients, nurses, and other members of the healthcare team.
Planning encourages continuity of care across the healthcare continuum and promotes positive patient outcomes.

The American Nurses Association's Standards of Clinical Nursing Practice identifies planning as one of the essential principles for promoting the delivery of competent nursing care. The planning phase of the nursing process has five main objectives, all of which focus on nursing interventions to promote positive patient outcomes. The following are the main objectives of the planning phase.

The nurse reviews the nursing diagnoses and prioritizes them according to physiological and psychological importance. This step helps the nurse organize the patient’s nursing diagnoses into a format that promotes effective planning.

This objective of the planning phase of the nursing process involves setting goals related to each diagnosis. Goal setting helps to provide guidelines for nursing interventions and establishes criteria by which the care plan's effectiveness is evaluated.

Remember the acronym SMART when developing goals. SMART goals are Specific, Measurable, Relevant, and Time-bound.

After goals are established, the nurse can identify expected outcomes based on each goal. Outcomes should be realistic, mutually desired by the patient and nurse, and attainable within a designated amount of time.

After goals are agreed upon and established, the nurse then implements decision-making skills to select nursing interventions that are relevant to the nursing diagnoses. Interventions are prioritized in order of planned implementation.

After priorities, goals, outcomes, and interventions are established, the nurse must document the care plan.

Documentation of the care plan includes nursing orders which communicate the interventions the nursing staff will implement for the client. Nursing orders must be well-written and should include the order date, which action will be performed, a detailed description, the time frame in which the intervention will be performed, and the nurse's signature.

Nurses utilize many of the same skills for each of the nursing process steps. In the planning phase, nurses must have strong communication skills, time management and organizational skills, and a willingness to work collaboratively with the patient and interdisciplinary team. Nurses must have strong critical thinking skills, as they must weigh the risks and consequences of each intervention.

The planning phase of the nursing process is when nurses formulate goals and outcomes that impact patient care. This step involves prioritizing patient needs, identifying expected outcomes, establishing nursing interventions, and identifying patient-centered goals.

In the planning phase, nurses identify goals and outcomes for patient care based on evidence-based practice guidelines. Once objectives of planning are met, the nurse creates a written plan of care, or care plan.

The care plan is a written guide organizing data about the patient's care into a formal statement of strategies or interventions the nurse will enact to help the patient achieve optimal outcomes.

It is normal to face challenges, no matter which phase of patient care you are involved with. The planning phase can feel a bit tricky because nurses need to be careful to develop plans considering the individuality of the patient. The following are a few examples of challenges you could phase when you begin planning patient care.

Not Knowing How to Format the Care Plan There are different formats for creating a care plan. If nurses do not know the format their facility uses, it can be easy to overlook components of the plan, which may impact the delivery of care and patient outcomes.

Not knowing how to format a care plan is probably one of the easiest challenges to overcome in the planning phase. With the implementation of electronic health records and programs that help nurses choose nursing diagnoses and interventions, creating care plans has become easier.

As a nurse creating a care plan, your job is to make sure all relevant information is included in the plan. The nursing diagnosis, interventions and expected outcomes, time frames in which outcomes should be accomplished, and a place to document evaluations should all be included.

Not Establishing Goals and Expected Outcomes Have you ever heard the saying, "Failure to plan is planning to fail"? That principle applies to everything in life, including patient care. No care plan is complete without clear goals and outcome identification. If there are no goals or an insufficient number of goals relevant to the nursing diagnoses, deciding on interventions is impossible.

The nursing care plan should always be patient-centered and individualized. Goals and outcomes should be tailored to meet each patient's needs and should be considerate of the patient's cultural beliefs and values.

Nurses use the nursing care plan as a road map that all members of the nursing team use to help the patient reach goals. It is vital that nurses establish goals that are attainable and relevant to the patient's specific needs.

In the planning phase of the nursing process, the nurse should establish short-term and long-term goals and determine the outcome associated with achieving those goals. Establishing goals and outcomes is vital to this step in the nursing process. Therefore, nurses should take the time to consider each goal and outcome carefully and discuss the plan with the patient and healthcare team.

Unrealistic Goals While it is okay to be optimistic about a patient’s ability to achieve goals, it is essential for nurses to be realistic about what their patients can or cannot do. If goals are unrealistic, patients can quickly become frustrated. Frustration often leads to noncompliance, which can negatively affect patient outcomes.

After carefully determining nursing diagnoses, the nurse must determine which goals the patient can achieve realistically. Realistic goals are specific and well-defined, measurable, achievable, relevant to the patient's status and needs, and achievable within a specific timeframe.

To overcome the challenge of unrealistic goals, identify what is essential in helping the patient achieve optimal outcomes. Discuss goals with the patient, family, care providers, and nurse manager. Once realistic goals are identified, offer support and encouragement to the patient. The nurse should continually monitor and assess the patient's progress toward meeting goals.

Limited Patient Input Although nurses can create nursing care plans independent of patient input, excluding patients from plans about their care may lead to distrust or confusion. If a patient feels he cannot communicate with nurses or his opinion is not valued, it can result in noncompliance with the care plan and negatively impact the patient’s outcome.

When patients are involved in their care, the processes of planning and implementation seem to flow easier.

Nurses can overcome the challenge of limited patient output by promoting a comfortable, trusting nurse-patient relationship which encourages patient participation. Ask the patient about their health goals and what limits they feel may affect their ability to reach goals. Offer suggestions about desired goals and expected outcomes and explain why they are relevant to the patient's health and long-term well-being.

Being Unsure of Appropriate Time Frames to Meet Expected Outcomes/Goals It is possible for nurses to create realistic goals and expected outcomes in the care plan but to set unrealistic time frames in which the patient is expected to meet those goals.

One reason this challenge occurs is nurses sometimes fail to plan care based on an individual patient’s abilities. Instead, they establish goals based on their perception of what any patient with the same diagnosis may be capable of achieving.

When working through the planning phase of the nursing process, nurses must consider patients as individuals with specific needs and abilities. The nurse should specify a time frame for achieving goals that is reasonable and that does not create undue stress or worry for the patient.

When discussing the care plan with the patient, it is important to explain each goal to the patient. Include education about why there is an anticipated time for accomplishing goals and what each person's responsibilities are to help make achieving the goals possible.

Once the nursing diagnosis or diagnoses are established, the nurse completes the planning phase of the nursing process by determining patient goals and expected outcomes and establishing which nursing interventions to initiate.

The following are goals and expected outcomes for Mr. Collie based on the nursing diagnoses of Decreased Cardiac Output and Risk for Impaired Skin Integrity.

The client will verbalize understanding of activities and lifestyle changes focused on reducing cardiac workload.
The client will demonstrate adequate cardiac output AEB vital signs within normal limits.
The client will report decreased episodes of dyspnea.

Monitor vital signs.
Palpate peripheral pulses.
Assess for signs of edema.
Monitor for signs of pallor or cyanosis.

Maintain skin integrity.
The client will verbalize understanding of techniques/behaviors to prevent skin breakdown by end of shift.

Inspect skin, noting areas of altered circulation, bony prominences, and/or signs of emaciation.
Encourage frequent position changes
Provide alternating pressure mattress, heel protectors, and elbow protectors

There are four main components of a nursing care plan: Client Assessment, including medical and diagnostic reports, Nursing Diagnosis, Desired Outcomes/Goals, Nursing Interventions with evidence-based rationale, and Evaluation.

The best way to write a nursing care plan is to include information associated with the nursing process steps.

Review all relevant data, medical history, vital signs and assessment data, physical, emotional, spiritual, ad psychosocial needs, identify areas where improvement is needed, and establish risk factors.
A nursing diagnosis is an actual or potential health problem that nurses can address without physician intervention. A few examples include risk for falls, risk for compromised skin integrity, and risk for dehydration.
Setting goals requires establishing desired outcomes and identifying measures by which the patient will achieve them. Although there may be situations where it is not possible, it is ideal to set goals with the patient when they are able.
Nursing interventions are actions taken by the nurse to help patients achieve goals and meet desired outcomes. Nursing interventions include initiating fall precautions, administering medications, and assessing the patient’s pain level.
of the plan and change or update, as needed or indicated.

The next two FAQs about the planning phase are related to setting goals. Goals are statements of purpose describing an objective to be accomplished. All goals in the nursing care plan should be client-centered and measurable.

Each goal should focus on the problem, measures to resolve the problem, and rehabilitation. The time frame given to accomplish goals in the care plan varies, depending on the setting where patient care is provided.

A tip I always share with students is, if you are not sure how to write a goal, try converting the nursing diagnosis into a positive statement of action.

A short-term goal in nursing care plans is a goal focused on demonstrating a change in behavior. Short-term goals can be completed in as little as a few minutes or up to a few days. The nurse should consider what behavior the patient can most easily exhibit or identify to show understanding of goals and attempts to achieve goals.

For example, let’s consider the following nursing diagnosis and determine a short-term goal.

Long-term goals are the desired outcome related to accomplishing one or more short-term goals for an extended period. In some cases, long-term goals can take weeks, months, or even years, to achieve.

Planning occurs in three stages: initial, ongoing, and discharge. Initial planning occurs when the nurse performing the admission assessment develops a preliminary plan of care. Ongoing planning is the process of updating the patient’s plan of care as new information is collected and evaluated. Discharge planning begins at admission and involves the anticipation of the client’s needs and plans to meet those needs after discharge from care.

When possible, the patient should be included in all phases of the nursing process. The patient is the best source of data, the person being treated, and usually the most reliable source of information used to determine the patient’s strengths, weaknesses, and likelihood of compliance with a plan of care.

Step #4: Implementation Phase

The fourth phase of the nursing process is the implementation phase. This phase is when nurses initiate the interventions established during the planning phase.

After the nursing assessment is performed, nursing diagnoses are established, and a care plan is developed, the plan must be initiated. All phases of the nursing process are essential. The following are three of the top reasons why the implementation phase is so important.

Implementation of the nursing process is significant because it involves action on the nurse's part to promote positive patient outcomes. Conversely, if the care plan is not implemented, there is a lack of nursing care, negatively impacting patient outcomes.
When the nursing care plan is implemented (implementation phase), nurses can begin to gauge patient responses to interventions.
Implementation supports continuity of care. Care begins from the first patient encounter and continues until discharge.

The implementation phase of the nursing process is an ongoing process in patient care. From the time a plan is established, the implementation process continues in a cycle which includes the five objectives below.

The nursing care plan is developed based on data from the initial nursing assessment. However, because a patient's condition can change quickly or nurses may obtain new data, ongoing assessments are necessary to validate the need for proposed interventions. Ongoing observations and assessments provide information supporting adaptations of the nursing care plan to promote improved, individualized care.

Utilizing data from initial and going assessments, the nurse then establishes priorities for implementing care. Prioritization is based upon which problems are considered most important by the nurse, patient, family/significant others, previously scheduled tests/treatments (diagnostic tests, surgery, therapy), and available resources.

Before implementing nursing interventions, the nurse must review proposed interventions and determine the skills and knowledge level required to safely and effectively implement them. For example, the nurse will consider if the patient can independently perform an activity, if a family member may assist, or if the activity requires assistance from a healthcare professional.

Although some interventions require the skills and knowledge of a registered nurse, others are less complex and may be delegated to licensed practical/vocational nurses or assistive personnel. The nurse allocates personnel resources by determining the needs of the client, the type of personnel who are available, and facility protocol for care.

After verifying priorities and determining resources, the nurse can initiate nursing interventions. Interventions are determined by the cause of the problem and often vary among patients with similar nursing diagnoses depending on expected outcomes for each patient.

When initiating nursing interventions, the patient's preference and developmental level should be considered. Additionally, nurses must review the physician's orders which may impact nursing interventions by imposing restrictions on specific factors such as the patient's allowed activity level or diet.

Nurses are legally obligated to document all interventions and any observations concerning the patient's response to those interventions. Documentation may be done on checklists, flow sheets, or in narrative form. Any verbal communication between the patient and nurse or among the healthcare team related to interventions and patient responses should be recorded, as well.

Like the other nursing process steps, the implementation phase requires broad clinical knowledge, critical thinking and analysis skills, and strong judgment.

Whether a nurse is caring for one patient, or several patients, careful planning and time management skills are essential in this phase. Nurses must have psychomotor, interpersonal, and cognitive skills as these serve as competencies through which high-quality nursing care is delivered.

Psychomotor skills are necessary to safely perform nursing activities such as handling medical equipment competently.

Interpersonal skills help nurses establish therapeutic nurse-patient relationships and promote interdisciplinary collaboration.

Cognitive skills are necessary to help the nurse understand the rationale for proposed interventions and make appropriate observations.

Implementation involves a focus on accomplishing predetermined goals and continuous progress toward achieving desired outcomes. This phase of the nursing process involves prioritizing nursing interventions, assessing patient safety during nursing interventions, delegating interventions when appropriate, and documenting all interventions performed.

Nursing interventions vary depending on the patient and the setting where care is provided. The following are examples of common challenges nurses face during the implementation phase of the nursing process and suggestions for how to overcome them.

Lack of Clinical Experience Even when goals and desired outcomes are clearly defined, inexperienced nurses may find implementing nursing interventions challenging. Inexperience may occur because the nurse is newly graduated or if a nurse is transferred to a department where they have never worked.

While the most effective way to overcome a lack of clinical experience is to work as much as you can and gain experience, patient care cannot wait for us to feel comfortable performing unfamiliar tasks.

When nurses face challenges implementing patient care because of inexperience, the best way to overcome it is to speak up and ask for help. As a nursing instructor, I always encouraged my students to ask questions about everything. The only bad question is the one you do not ask. Nurse leaders, supervisors, and administrators appreciate nurses who readily admit when they need help or guidance.

Patient Noncompliance Noncompliance is recognized by NANDA-I as a nursing diagnosis. It is defined as “the behavior of a patient or caregiver that does not correspond with the therapeutic plan agreed upon by the individual, family or guardian, and healthcare provider.” Noncompliance can negatively impact patient outcomes, reduce the patient’s quality of life, and result in increased healthcare costs.

One of the best ways to prevent or stop patient noncompliance is to involve the patient in all aspects of care planning.

Nurses should ensure the patient is educated about their illness, plans to manage the illness, and expected outcomes of therapies. Education should also include information about how noncompliance may negatively affect the patient's outcome. The patient's understanding of all education should be verified, and if the nurse is unsure the patient clearly understands, teaching should be repeated.

Psychosocial Factors Psychosocial factors can impact all aspects of patient care. For example, if there is a presence of domestic abuse or violence, the patient may be afraid to discuss important issues related to care, which could result in misunderstanding established goals.

Psychosocial factors may seem a little tricky to navigate. However, if they become a factor affecting the implementation of the nursing process steps, nurses must find a way to try and address the issues.

For instance, if the nurse suspects a patient is afraid to discuss certain issues in the presence of others, the nurse should ask for privacy while talking to the patient. By doing so, the nurse offers the patient the opportunity to speak openly without fear of retaliation by an abuser. Then the nurse can discuss options for care with the patient and how to proceed moving forward.

Nursing Care Plan Does Not Reflect Appropriate Care for the Nursing Diagnoses Every step of the nursing process builds upon the previous step. Nurses must perform a thorough assessment and collect sufficient data before making nursing diagnoses. After a nursing diagnosis is established, interventions are planned to help resolve the issue(s) the patient is experiencing. If the planned interventions do not align appropriately with the care expected for a nursing diagnosis, implementing the care plan properly cannot occur.

It is vital for nurses to handle each phase of the nursing process with deliberate care and appropriate actions. Nursing care plans should be evaluated by the nursing team to ensure that the patient’s needs are addressed, and planned interventions are relevant to the nursing diagnosis/diagnoses.

Nursing Shortage The World Health Organization estimates a shortage of more than four million nurses in the United States. No matter how well-written a nursing care plan is, if there is not enough staff to carry out the nursing interventions, the plan cannot be successfully implemented.

While it is understandable that one nurse cannot remedy the nursing shortage, there are things all nurses can do to help relieve the impact the shortage causes.

Implementation of the nursing care plan involves educating the patient and helping him achieve goals and expected outcomes. It also involves putting the planned nursing interventions into action. To implement the care plan, the nurse will establish priorities, delegate tasks to appropriate staff, initiate interventions, and document interventions and the patient’s response.

Nursing documentation should be accurate and relevant to the patient. Use appropriate nursing language and facility-approved abbreviations. In the case of Mr. Collie, the nurse's documentation may look like the following narrative.

04/19/22 @ 1430: Discussed plan of care with client and son who was present in the room, including educating about goals and expected outcomes. The client verbalizes understanding of the importance of lifestyle and activity changes to reduce cardiac workload, the need for vital signs to be within normal limits, and measures to decrease episodes of dyspnea, and safety precautions. The client also verbalizes understanding of the risk for impaired skin integrity and verbally recalls skin integrity is at risk due to "bad circulation and swelling." The client voices understanding that frequent position changes and keeping the skin clean and dry will decrease the likelihood of skin breakdown. Assessed peripheral pulses, which are present and strong bilaterally in upper and lower extremities X2, 2+ pitting edema noted in bilateral lower extremities. Skin remains intact, pink, warm, and dry, no signs of redness or pallor. Heel and elbow protectors applied. Alternating pressure mattress in place and operational. ------------D. Leonard, RN

The first step in the process of implementing a nursing care plan is to determine what, how, and when an intervention should be performed. Once you know the what, how, and when, you can determine if the task can be delegated and to whom.

The three types of interventions implemented in the nursing process are independent, dependent, and interdependent.

are actions nurses can perform on their own and do not require assistance from other team members. For example, routine tasks such as monitoring vital signs or assessing the patient's pain level are independent nursing interventions.
require instructions or input from the physician. For instance, if the patient needs a new medication, the physician must prescribe the medication and order the amount and frequency. Dependent nursing interventions are interventions the nurse may not initiate on her own.
are also known as collaborative interventions. These interventions involve all members of the interdisciplinary team. For example, if a patient had a total knee replacement, his recovery plan may include a prescription medication from the doctor, assistance with dressing from the nurse or unlicensed assistive personnel, and physical or occupational therapy by the physical therapist or occupational therapist.

While many sources use the words interchangeably, intervention and implementation are defined somewhat differently. Interventions are planned nursing activities performed on a patient's behalf. They include assessment, adherence to medication therapy, and problem-solving. Implementation is .

Strategies to prioritize patient care typically include the use of nursing diagnoses combined with Maslow’s Hierarchy of Needs Theory.

Any nursing diagnosis that suggests a risk or threat to the patient’s survival should be the nurse’s first priority. Remember your ABCs: Airway, Breathing, Circulation.

Other physiological needs necessary for survival are considered.

Psychosocial needs are then addressed.

Psychological needs including a sense of love or belonging, self-esteem, and self-actualization are prioritized last.

Medication administration is part of the implementation phase of the nursing process steps. The nursing interventions outlined in the planning phase should include information about medication administration. When the nurse initiates the action of administering the medication, she is implementing the plan of care.

All members of the nursing team have roles related to implementing the care plan. In the planning phase of the nursing process, the Registered Nurse determines which tasks may be delegated to Licensed Practical/Vocational Nurses, Nursing Assistants, or other members of the healthcare team. It is essential to remember that, even if a task is delegated, the RN in charge of the patient’s care is accountable for making sure all tasks are completed.

Step #5: Evaluation Phase

Evaluation is the final phase of the nursing process. Although evaluation is considered the last of the nursing process steps, it does not indicate an end to the nursing process. Instead, evaluation should be an ongoing process carried out in daily nursing activities that ensures quality nursing interventions and the effectiveness of those interventions.

The evaluation phase of the nursing process is important because it fulfills several purposes. The following are the top three reasons why this phase is essential in the nursing process.

The primary purpose of an evaluation is to determine the patient’s progress toward achieving established goals and outcomes.
Through evaluation, it is possible to determine a healthcare agency’s ability to provide safe and effective healthcare services.
Evaluation provides a mechanism to help nurses define, explain, and measure the results of nursing interventions.

The Standards of Clinical Nursing Practice established by the American Nurses Association designates evaluation as a fundamental component of the nursing process. This phase of the nursing process has the following objectives.

The effectiveness of nursing interventions is determined by evaluating goals and expected outcomes to determine if they provide direction for patient care. It is essential to evaluate nursing interventions because they serve as standards by which patient progress is measured.

The evaluation phase is not meant to make nurses feel as if their work is being critiqued or judged. Evaluation allows nurses to verify if the care they are providing meets the standard of care for the patient’s needs.

Evaluation involves reviewing all aspects of the patient’s care and determining its effectiveness in helping the patient recover. Because nurses work collaboratively with one another and other members of the healthcare team, the evaluation phase promotes the nurses’ sense of accountability to their patients and to one another.

In the evaluation phase of the nursing process, nurses compare and analyze data from the time the patient was admitted to care and determine if positive or negative trends are occurring. This data is helpful in deciding the next course of action to take in patient care.

Although the evaluation phase is the fifth and last step in the nursing process, nurses constantly evaluate patient progress. Evaluation allows nurses to establish a pattern of continuous care and attention, which helps promote positive patient outcomes.

The evaluation phase of the nursing process is primarily based on the nurse's accurate and efficient use of observation, critical thinking, and communication skills.

Some changes in a patient's status may be subtle, requiring sharp observational skills. The ability to analyze reassessment data and use critical thinking are necessary to determine if outcomes have been met or decide if changes in the care plan are needed. As in other phases of patient care, the nurse must demonstrate strong communication skills, as evaluation includes the patient and all members of the healthcare team.

During the evaluation phase of the nursing process, nurses determine the patient’s response to interventions and whether goals have been met. The evaluation process consists of seven steps, as follows.

Standards and goals are established during the planning phase of the nursing process steps and carried out in the implementation phase. Nurses use evaluation to determine the presence of changes in the patient's status relevant to the established standards.

The nurse uses assessment skills early in the nursing process to gather data used to establish goals and expected outcomes. Those same skills are vital for comprehensive, effective evaluation to occur. Nurses gather data to help determine the success of nursing interventions.

The data collected during the evaluation phase must answer the question, “Did the patient achieve the treatment goals and expected outcomes outlined in the care plan?” Nurses validate goal achievement by analyzing the patient’s response to nursing interventions outlined in the nursing care plan.

Effective nursing interventions address relevant patient needs. If the nursing intervention is efficient, it can be a primary factor related to helping clients resolve actual or potential problems or risk factors.

During the evaluation phase, the nurse must use critical thinking skills to determine which nursing actions contributed to improved patient outcomes and to what degree they were effective. This step in the evaluation process allows the nurse to analyze the patient's response to interventions, determine the benefits of those interventions, and identify opportunities or needs for change.

In the evaluation phase of the nursing process, the nurse uses observation and assessment skills to reevaluate the patient's status. In this step, the nurse compares baseline data collected in the initial nursing assessment with the patient's current health status.

If the evaluation determines a lack of progress toward established goals, the nursing care plan is revised or modified. At this point, revisions are developed by beginning the nursing process anew. The client is reassessed (Assessment), more appropriate nursing diagnoses are established (Diagnosis), new or revised goals and outcomes are developed (Planning), new nursing interventions are implemented, or previous interventions are repeated to maximize effectiveness (Implementation). Then the patient's response is reevaluated (Evaluation).

The evaluation phase of the nursing process is the point where nurses and patients hope to see measurable improvement. The following are a few challenges nurses may face when in the evaluation phase.

Incomplete Documentation Every nurse is responsible for documenting patient progress and other pertinent information. If one nurse fails to document and report patient changes or progress, or to record laboratory or diagnostic test results, it can lead to challenges when it is time for the evaluation phase.

The most effective way to overcome this challenge is to avoid it happening altogether. Be sure to document information about your patients during each shift. Any change in status, progress or lack of progress, subjective and objective findings, or other relevant information should be readily available for any nurse caring for that patient.

Patient Frustration In a perfect world, patients would be admitted to care, nursing interventions would be implemented, and we would see positive results. Unfortunately, it doesn’t always work that way. One of the challenges nurses face in the evaluation phase is frustration related to slow progress or failing to meet goals.

Overcoming the challenges that occur when patients become frustrated takes patience and understanding.

If you find yourself in the evaluation phase of the nursing process steps and faced with this situation, take the time to talk to your patient. Assure them that progress does not always happen as quickly as we would like and encourage them to keep pressing forward.

Let your patient know that you are there to support and help them and that your priority is to see them improve. Sometimes all it takes to calm a patient and help them regain focus is an assuring word and calming presence.

Patients Withholding Information It is not uncommon for patients to try and mask symptoms or deny concerns when nurses evaluate their progress. This is especially common when a patient has been hospitalized or in a care facility for an extended period and wants to return home.

In situations like this, a strong nurse-patient relationship and good communication skills are necessary. If you feel your patient is not being forthcoming about their progress, or perhaps new symptoms have emerged that they do not want to discuss, ask direct questions. Explain the importance of transparency when reporting progress, problems, or concerns.

Family Denial of the Patient’s Need for Continued Care As nurses, we naturally hope that interventions positively impact our patients and that we can see improvement when evaluating them. Family members hope to see their loved ones recover and return to normal, as well. A significant challenge nurses can face when evaluating patient progress occurs when the patient's status declines or there is little improvement and family members deny the reality of the patient's situation.

Many times, the fear of the unknown or lack of understanding is what causes family denial. If family members struggle with accepting the idea of continued care or changes in the plan of care, the nurse should acknowledge their concerns and offer support. When appropriate, talk with the patient and family together and discuss the previous plan of care and any suggestions for alterations or changes and the rationale for them.

Patient Wishing to Terminate Care Before Discharge Goals Are Met Nurses understand that patients respond differently to care with some progressing faster than others, and the evaluation process helps to identify those patients who need extra time or updated care plans.

Unfortunately, because patients do not always understand the complexities of interventions and expected outcomes, it can lead to feelings of despair. If patients slowly progress or fail to meet goals and expected outcomes, their frustration sometimes leads them to give up or desire to seek care elsewhere.

When faced with this challenge, it is crucial for nurses to approach the patient with an attitude of empathy and attempt to discuss the patient's concerns. Depending on the patient's status and ability to understand, it may take some time and reinforced teaching to help them understand that slow progress is not failure. Explain your view of your patient's current status compared to his status on admission. Encourage the patient by assuring him that even slow progress is progress. Offer ideas of ways you think the care plan can be amended to suit his needs and ask for input.

Remember, despite your best efforts, there may be times when patients decide to terminate care. Unless the patient has been deemed incapable of making informed decisions, you may not interfere with his choice to leave your care. It is necessary to document everything you discuss with the patient and his response to your instructions and education.

If the patient decides to leave your facility's care, there is appropriate paperwork to be signed, called an A.M.A. (Against Medical Advice) discharge. The charge nurse or physician is usually responsible for having the patient sign this form and submitting it to administration.

In the evaluation phase, the nurse reassesses the patient and determines if goals and outcomes are being met or if the care plan needs to be modified. Observations are recorded in the patient’s chart.

04/20/22 @ 1500: After twenty-four hours of nursing intervention, the client demonstrates adequate cardiac output as evidenced by decreased blood pressure of 130/78 and pulse rate of 72. The client states his breathing is less labored and that if he begins to feel short of breath, he lies still to rest. O2 per NC @ 2L continuous. Observed 500 cc clear, amber urine in the urinal. The patient continues to have 2+ pitting edema in bilateral lower extremities. MD notified, awaiting response/order. The client has turned/repositioned q2h to decrease the risk of impaired skin integrity. No signs of compromised skin integrity noted at this time. -------D. Leonard, RN

The primary purpose of evaluation in the nursing process steps is to determine if patient goals and expected outcomes have been met or if the nursing care plan needs to be modified.

The steps of evaluation in the nursing process include collecting data, comparing data with desired goals and expected outcomes, analyzing the patient’s response to nursing interventions, identifying factors impacting the success or failure of the nursing care plan, continuing, modifying, or terminating the care plan, and planning future nursing care.

Although the nursing process is focused on nursing diagnoses and interventions, each member of the patient’s healthcare team has a role and the actions they take in patient care can impact the effectiveness of the nursing care plan. Therefore, the most effective way of improving evaluation in the nursing process, is to include the patient, family (when appropriate), and all members of the interdisciplinary team in the process.

Although healthcare facilities and organizations have minimum guidelines for the frequency of nurse evaluations, it should be an ongoing process involved in patient care. The patient’s status and the effectiveness of nursing interventions should be continuously evaluated, and the care plan should be modified, when necessary.

In the evaluation phase, nurses gather much of the same type of information as what is gathered during the assessment. During this phase, nurses review current vital signs and laboratory or diagnostic test results. They use information entered into the patient’s chart, such as nurses’ notes, flow sheets, and other pertinent information. Additionally, during the evaluation, nurses reinterview the patient and look for both subjective and objective data to determine if the plan of care was effective.

The registered nurse assigned to the patient’s care is the primary person responsible for the evaluation phase of the nursing process. The RN evaluates all information necessary to determine if the goals and expected outcomes were met or if alterations in the plan are needed. Keep in mind, however, every member of the nursing care team plays a vital role in the RN's ability to conduct a thorough evaluation because each person is responsible for documenting their work and the patient’s response.

Useful Resources to Gain More Information About the Nursing Process

Blogs/websites, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. how is nursing process different from the scientific method, 2. do all nurses use the nursing process, 3. do doctors also use the nursing process, 4. what does adpie stand for, 5. is it always necessary for a nurse to follow all steps of the nursing process, 6. how does critical thinking impact the nursing process, 7. how does a health information system affect the nursing process, 8. how to use maslow hierarchy in the nursing process, 9. which nursing process step includes tasks that can be delegated, 10. which nursing process step includes tasks that cannot be delegated, 11. how does the nursing process apply to pharmacology.

The Nursing Process

The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care. Assessment An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.

Diagnosis The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.

Outcomes / Planning Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.

Implementation Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.

Evaluation Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

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Open access
Published: 07 February 2023

What is nursing professionalism? a concept analysis

Huili Cao 1 , 2 ,
Yejun Song 3 ,
Yanming Wu 1 ,
Yifei Du 1 ,
Xingyue He 1 ,
Yangjie Chen 4 ,
Qiaohong Wang 1 , 4 &
Hui Yang 1 , 4

BMC Nursing volume 22 , Article number: 34 ( 2023 ) Cite this article

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Nursing professionalism plays an important role in clinical nursing. However, a clear conceptual understanding of nursing professionalism is lacking.

Walker and Avant’s strategy was used to analyse the concept of nursing professionalism. We searched electronic databases, including PubMed, Scopus, and CINAHL, for studies published from 1965 to 2021. Quantitative or qualitative studies published in English that focused on nursing professionalism were included in the study.

The three attributes of nursing professionalism are multidimensional, dynamic, and culture oriented. Based on the analysis, nursing professionalism is defined as providing individuals care based on the principles of professionalism, caring, and altruism.

Conclusions

This study offers a theoretical definition and conceptual model of nursing professionalism that may be applied to develop standardized assessment tools or nursing professionalism training programs.

Peer Review reports

Introduction

The COVID-19 outbreak has exposed deficiencies in the underinvestment of the global health system, including the shortage in nursing resources and nursing staff, and a similar situation is noted in China ( https://www.icn.ch/news/investing-nursing-and-respecting-nurses-rights-key-themes-international-nurses-day-2022 ). An unbalanced number of nurses and patients, high work pressure, lack of social occupational identity and other reasons have led to job burnout, low job satisfaction, and even the resignation of many nurses. Research has also shown that the lack of nursing professionalism adversely affects patient care and patient outcomes [ 1 ]. Ohman [ 2 ] pointed out that lower levels of professionalism may cause negative outcomes, such as turnover and attrition and lower productivity.

In recent years, researchers have tried to solve the above problems through professionalism.

However, nursing professionalism plays a more important role in clinical nursing. Some studies have shown that professionalism can improve the professional knowledge and skills of nurses and ameliorate reductions in institutional productivity and quality [ 3 ]. Higher levels of professionalism can improve nurses’ autonomy and empowerment, increase their recognition and facilitate organizational citizenship behaviours, establish nursing care standards and even improve quality services [ 4 , 5 ].

Nursing professionalism has been discussed for several decades. Hall (1968) developed the Professionalism Inventory Scale [ 6 ]. Miller et al [ 7 ] (1993) first specified the 9 standards criteria of nursing professionalism (educational background; adherence to the code of ethics; participation in the professional organization; continuing education and competency; communication and publication; autonomy and self-regulation; community service; theory use, development, and evaluation; and research involvement.). Yeun et al. (2005) summarized five themes regarding nurses’ perceptions of nursing professionalism: self-concept of the profession, social awareness, professionalism of nursing, the roles of nursing services, and originality of nursing [ 8 ]. Yoder defined nursing professionalism based on six components: acting in the patients’ interests; showing humanism; practising social responsibility; demonstrating sensitivity to people’s cultures and beliefs; having high standards of competence and knowledge; and demonstrating high ethical standards [ 9 ]. Although some researchers have explored the concept of professionalism. How can professionalism be evaluated in nursing clinical practice? Few studies have shown a clear conceptualization of nurses’ professionalism [ 10 , 11 ]. To nurture nursing professionalism, the concept of professionalism must be clarified.

Given that the meaning of professionalism varies across time, contexts, or cultures, it is difficult to define, quantify or measure professionalism [ 12 , 13 ]. The operational definition of nursing professionalism in studies has shortcomings. Sullivan et al. [ 14 ] found professionalism to be a multidimensional concept, but some papers have addressed only one dimension, such as values [ 15 ] or behaviours [ 16 ]. Moreover, professionalism is considered a complex concept. The links and dynamic processes between these different inner characteristics have not been included in the concept. Thus, a comprehensive definition of nursing professionalism, including its characteristics and the relations between them, is necessary.

Recognizing and understanding the concept of nursing professionalism may be an essential step towards providing quality care for people. It may also provide more information for further developing nursing professionalism for nurses.

Method of concept analysis

Walker and Avant’s method used linguistic philosophy techniques to contribute to the philosophical understanding of a concept [ 17 ]. The W & A method is considered a mark of the positivist paradigm, which views the concept as a stable factor that can be reduced or extracted from its context of application [ 18 ]. This study used Walker and Avant’s method, which assumes that nursing professionalism is a relatively mature and stable concept (numerous studies on nursing professionalism have been published to date). This approach to conceptual analysis, although not perfect, is helpful in clarifying the concept of nursing professionalism.

Using the structured method of Walker and Avant enables conceptual clarity to be obtained based on an inductive identification of the concept’s attributes, antecedents and consequences. The concept analysis helps to clarify meanings and develop operational definitions, considering evidence from a wide range of information resources for further research or clinical practice [ 17 , 19 ]. These features make this method particularly useful for the analysis of the concept of ‘nursing professionalism’. The conceptual attributes as well as antecedents and consequences are based on the research team's analysis of the literature using Walker and Avant’s strategy and are not the product of a priori theoretical categories.

Walker and Avant’s [ 17 ] eight-step method includes the following: 1) selecting a concept; 2) determining the aims or purposes of analysis; 3) identifying all uses of the concept; 4) determining the defining attributes of the concept; 5) constructing a model case; 6) constructing borderline, contrary, invented, and illegitimate cases; 7) identifying antecedents and consequences; and 8) defining empirical references.

Selection criteria

The inclusion criteria were as follows: related to the concept of nursing professionalism; included nurse professionalism, nursing spirit, or nurse spirit; written in the English language; qualitative, quantitative, mixed methods or systematic reviews; published between 1965 and 2021 (when professionalism was first introduced by nursing in 1965); and published in books or dictionaries. We excluded articles published in nonpeer reviewed journals, editorials and letters to the editor.

Data sources

We searched several online databases, including PubMed, Scopus, and CINAHL, for articles published from 1965 to 2021. We searched the words that appear in the title, abstract, and keyword section of the studies.

(((((((((Nursing professionalism[Title]) OR (Nursing professionalism[Title/Abstract])) OR (Nurse professionalism[Title])) OR (Nurse professionalism[Title/Abstract])) OR (Nursing spirit[Title])) OR (Nursing spirit[Title/Abstract])) OR (Nurse spirit[Title])) OR (Nurse spirit[Title/Abstract])).

TI Nursing professionalism OR AB Nursing professionalism OR TI Nurse professionalism OR AB Nurse professionalism OR TI Nursing spirit OR AB Nursing spirit OR TI Nurse spirit OR AB Nurse spirit.

TITLE-ABS-KEY (Nursing professionalism) OR TITLE-ABS-KEY (Nurse professionalism) OR TITLE-ABS-KEY (Nursing spirit) OR TITLE-ABS-KEY (Nurse spirit).

Any quantitative or qualitative studies published in English focusing on nursing professionalism were included in the study. Two researchers independently screened titles and abstracts to determine the selection criteria for electronic retrieval and application. The study was included only when both researchers agreed that the study met the inclusion and exclusion criteria. If the two researchers’ judgements were different, a third person was consulted to resolve the issue. Researchers identified the different usages of the concept and systematically recorded the characteristics of the concept that appeared repeatedly [ 17 ].

We used definitions and examples in the systematic record (Table 2 ) to define a cluster of antecedents, attributes and consequences (Figs. 1 and 2 ) frequently associated with the concept [ 20 ].

Flowchart of the study selection process of the concept analysis

We identified 6013 studies on nursing professionalism. After excluding duplicates, irrelevant studies, studies that were not original scientific studies or articles, and studies published in languages other than English, 138 studies were selected for analysis. Tables 1 and 2 show some typical literatures used in this study.

Uses of the concept

Dictionary definitions of the concept.

The Merriam-Webster Dictionary defines professionalism as ‘the conduct, aims, or qualities that characterize or mark a profession or a professional person’ [ 48 ], whereas the Cambridge Dictionary [ 49 ] defines professionalism as ‘the combination of all the qualities that are connected with trained and skilled people’. These definitions are generic and difficult to use to clarify the factors involved in nursing professionalism.

Definitions of the concept reported in the literature

Hwang et al. [ 50 ] defined professionalism as commitment to a profession and professional identity level. Health-care workers demonstrate professionalism through attitudes, knowledge, and behaviours, which reflect approaches to the regulations, principles, and standards underlying successful clinical practices [ 33 ]. Nursing professionalism reflects the value orientation, concepts of nursing, work attitude and standards of clinical nurses [ 51 ].

Subconcepts

The Nightingale Spirit, named in honour of the founder of professional nursing, refers to the spirit of altruism, caring, and honesty [ 52 ]. In the past, the Nightingale Spirit advocated that nurses are willing to dedicate themselves, but the term currently encompasses more innovation [ 53 ]. E-professionalism is defined as evidence provided by digital means, attitudes and behaviours reflects the traditional models of professionalism [ 54 ]. Nurses use the internet to communicate about work or daily life, blurring the boundaries between individuals and professions; thus, e-professionalism applies to nurses [ 55 ].

The defining attributes of nursing professionalism

The defining attributes of the concept aim to understand its meaning and differentiate it from other related concepts [ 17 ]. The key defining attributes are as follows.

Nursing professionalism is multidimensional

Nursing professionalism is a three-dimensional concept based on the knowledge, attitudes, and behaviours that underlie successful clinical practice [ 33 ].

Professionalism can be conceptualized as a ‘systematic body of knowledge’ with complex configurations of work expertise [ 21 ].

Professionalism refers to the attitude that represents levels of recognition and commitment to a particular profession [ 22 ]. Hall [ 6 ] noted that nurses’ attitudes have a high correspondence with the behaviours of the respondent. Measuring professionalism at the cognitive level can be thought of as measuring potential professionalism at the behavioural level. Researchers noted that given the reduced restrictions of environmental constraints, measuring professionalism at the cognitive level may be more precise than measuring it at the behavioural level [ 23 ].

Nursing professionalism is often described as a set of professional behaviours [ 11 ]. Some researchers judge whether nurses exhibit professionalism through their behaviours. Miller [ 24 ] (1988) developed the Wheel of Professionalism in Nursing Model. The model is considered a framework for understanding professional behaviours among nurses. Kramer [ 56 ] (1975) quantified professionalism by assessing the number of professional books purchased, subscriptions to journals, and the number of articles published.

In addition, the perspective of professional identity formation complements the behaviour-based and attitude-based perspectives on professionalism [ 57 ].

The formation and development of professionalism are dynamic processes

Nursing professionalism is an inevitable, complex, varied, and dynamic process [ 58 ].The professionalism concept is considered ever-changing, replacing static or definitive views [ 59 ].

Socialization process

Nursing professionalism is instilled through a process of socialization in formal nursing education [ 25 ]. Nurses’ socialization process begins with formal, entry-level education to acquire knowledge and skills.

Yeun et al. [ 8 ] (2005) discussed the developmental process of nursing professionalism in which the individual’s thoughts and beliefs are formed by socialization factors through perception. These thoughts and beliefs may in turn influence the individual’s professional image or self-concept, thereby influencing nurses’ actions and performance.

Process of interaction

The dynamic of professionalism is also reflected in the process of interaction. Dehghani et al. [ 26 ]noted that nursing professionalism means the appropriate interaction of the individual and the workplace and the maintenance of interpersonal communication.

Culture oriented

One study showed that altruism is an essential element of medical professionalism in Asia or North America but not Europe [ 27 ]. In China, medical professionalism was influenced by its longstanding Confucian traditions [ 28 ]. Therefore, any definitions of professionalism should match its rooted culture and be validated with respect to the culture and context in which it is applied [ 60 ].

The connotation of nursing professionalism

Professional, having a systematic nursing knowledge system.

The nursing process is considered a method for solving problems or dilemmas in a logical and scientific manner [ 11 ]. Freidson [ 29 ] (2001) noted that professionals perform their specialized work only with the required training and experience. Professionals have specific, tacit, almost esoteric knowledge to do their work [ 61 ]. Miller et al. [ 7 ] considered that a formal university education with a scientific background is critical for professionalism in nursing.

Professional certification

Nurses actively seek specialty certification given their personal commitment to the nursing profession [ 30 ]. Specialty certification promotes nursing professionalism. When attaining the highest levels of clinical knowledge, nursing professionalism also indicates personal responsibility and dedication to best practices [ 31 ].

Lifelong learning and participation in continuing education

Due to professional and ethical obligations, nurses should sustain continuous professional growth and development to maintain individual competence. Professional growth in nursing requires lifelong learning. Lifelong learning includes continuing education and self‐study, seeking advanced degrees, etc. [ 62 ].

Continuing education is one of the indicators of professionalism. Professionals keep up with the latest developments in the field and partake in continuing education. Additionally, continuing education is as important as other criteria for increasing professionalism in nursing [ 7 , 32 ]. Ongoing education brings fresh knowledge to health care, consequently leading to more efficient and quality service for people.

Evidence-based practice

Evidence-based practice (EBP) is a hallmark of professionalism [ 33 ]. Dollaghan [ 63 ] (2004) reported that we identify and use the highest quality scientific evidence as an integral part of our efforts to provide the best patient care; EBP is a knowledge base that responds to specific clinical issues in a clear, intelligent, and serious manner while considering clinical practice in the context of the highest-quality scientific evidence available.

Innovation in nursing helps to improve patient care quality and improve nurses’ job performance [ 64 ]. Shen et al. [ 34 ] noted that innovative education plays an important role in the professional quality of undergraduate nursing students.

Striving for excellence

Striving for excellence is a requirement and attribute of nursing professionalism. There is a growing need in nursing practice to possess knowledge and skills in quality improvement science, translational research, and implementation science [ 35 ]. Clinical nurses have the same responsibilities as nursing scientists.

Caring is considered the core attribute of nursing professionalism

The practice of caring is central to nursing [ 65 ]. Caring is defined as the moral ideal of nursing [ 36 ]. Therefore, caring is an important core attribute of nursing professionalism.

Creating a caring-healing environment

Nurses devoted to creating a caring-healing environment embody professionalism. Caring means nurses should create a healing environment at all levels by providing a supportive, protective environment as well as a corrective mental, physical, societal, and spiritual environment for patients. People’s basic needs include a clean environment, comfort measures, safety concerns, and feeling safe or protected [ 65 ].

Displaying kindness/concern/empathy for others

A nurse is defined as someone caring for the ill within the hospital setting [ 66 ]. Caring means showing or having compassion, concern and empathy for others [ 37 ]. Caring behaviours are an interactive and mental process between patients and nurses [ 38 ]. Displaying kindness and concern for others is shown by love, compassion, support and involvement [ 39 ].

Using all methods of knowing support and involvement

‘Human problems reside in ambiguity, paradox, and impermanence’. Therefore, suffering, healing, miraculous cures, and synchronicity are all part of knowing support and involvement.

Researchers suggest that nursing comprises Caritas Nursing, Energy Nursing, Transpersonal Nursing, Holistic Nursing, or Contemplative Nursing…… It goes beyond ordinary nursing. Nursing should have higher standards with excellence for caring, healing, and peace in the world. Therefore, caring means using all methods of knowing support and involvement [ 65 ].

Embracing the unknowns and miracles in life and practising loving

Nursing is a special profession. Nurses confront special circumstances daily and witness people’s struggles with life and death. Everyone has his or her own specific story about his or her experiences and predicaments. Each person seeks his or her own meanings to find inner peace and balance in the midst of fear, doubts, despair, and unknowns. Therefore, the care of nurses is not to blindly sacrifice their own needs but to be a real nurse, embracing the unknowns and miracles in life and caring for patients [ 65 ].

The central tenet of professionalism is to put the needs and best interest of others over self-interests. Altruism is an engagement in caring acts towards others without expecting something in return [ 67 ].

Patients first

To be altruistic means to put others’ needs before your own. Altruism is the selfless concern for others and doing things with the other person’s well-being in mind [ 40 ].

During pandemics, nurses were considered to have a high sense of duty and dedication to patient care [ 41 ]. Front-line nurses perceive high work engagement, especially in self-dedication [ 42 ]. Grøthe et al. [ 43 ] showed that cancer patients in a palliative unit appreciate nurses who have the most dedication and expertise characteristics.

Public service

Due to a strong sense of civic and social responsibility, nurses participate in public service. Nurses volunteer as participants in summer camps, schools, or health-care teams. Nurses are also committed to responding to large-scale crises, such as the terrorist attacks on the World Trade Center in New York, as well as national and international relief efforts, such as tsunamis and Hurricane Katrina [ 44 ].

Disaster and infectious disease rescue

Individuals involved in providing disaster relief face many challenges, experience fatigue and personal suffering, and encounter numerous personal stories of life and death [ 45 ]. Nurses have played a significant role in the fight against infectious diseases such as severe acute respiratory syndrome (SARS) and the coronavirus disease 2019 (COVID-19) pandemic [ 68 ]. Nurses are closest with patients. Nurses provide intensive care, regularly assessing and monitoring airways, tubes, medications, and physical therapy. Nurses are also devoted to reducing complications. Nurses assist with daily living activities when patients are unable to care for themselves [ 46 ].

Community service

In addition, emphasizing professionalism means respecting values and commitment to community service delivery [ 69 ].

According to Walker and Avant [ 17 ], cases help further clarify concepts.

Model cases (a real case example)

Model cases help demonstrate all the defining attributes of a concept and helps to better articulate its meaning [ 17 ].

MS A is a 63-year-old nursing director. She worked in clinical nursing and management for 42 years. As she progressed from a new nurse to a nursing expert, she gradually poured her enthusiasm (Multidimensional: Attitudes) into nursing work (Dynamic). She believes that the core of nursing professionalism in China is dedication and responsibility (Culture oriented). In 2020, COVID-19 broke out in Wuhan, China. She led a team to Wuhan to provide support (Multidimensional: Behaviours), reflecting the spirit of altruism (Altruism). She actively promoted exchanges and cooperation among disciplines and the development of academic conferences. She guided students to pay attention to practical innovation and develop evidence-based innovations (Professional). Although she is retired, she still imparts knowledge and experience to students everywhere (Multidimensional: Behaviours). She stated that the development of nursing professionalism is very difficult and requires nursing education and role models. (Multidimensional: Knowledge). The role of a nurse is like that of a mother, bringing care to the people (Caring).

Borderline cases (a real case example)

Borderline cases provide the examples that contain the most defining attributes of the concept [ 17 ].

B is a novice nurse. When working in the infection ward, she was so worried about being infected. She was reluctant to care for patients and wanted to escape from the ward environment. Fortunately, her nurse manager fully understood her situation and helped her adapt to work and reduce her anxiety. B observed that her nurse manager had been helping patients solve problems and giving them comfort and hope. This prompted her to think about what nursing truly means. In 2020, she volunteered to help COVID-19 patients (Altruism).

Related cases (a real case example)

Related cases are related to the concept but do not contain all its defining attributes [ 17 ].

C is a novice nurse. After graduating from nursing school, he became a nurse in the emergency department. He saw many patients who died or recovered, which made him realize the importance of caring (Caring). He said that emergency nurses need strong professionalism (Multidimensional: Attitudes). He participated in social service activities (Multidimensional: Behaviours), for example, promoting knowledge of cardiopulmonary resuscitation (Altruism) in the community. After working for five years, he returned to school for a master’s degree to help the head nurse conduct nursing research or evidence-based practice (Professional). In his Asian cultural milieu, his is embarrassed about his identity as a male nurse (Culture oriented), but he believes he can do well.

Contrary cases (a fictional case example)

A contrary case does not include any defined attributes of the concept [ 17 ].

D is a nurse in paediatrics. She disliked nursing when she was a nursing student and even did enjoy communicating with patients (poor dynamics). She was exhausted after work and felt her life was out of balance. One of the values of the hospital where she worked was dedication, which confused her (Poor culture orientation). She considers it unrealistic to require professionalism (Poor nursing professionalism knowledge) and thinks that taking care of new-borns is particularly troublesome (Poor nursing professionalism attitudes), so she is always careless in her work (Multidimensional: poor attitude). D’s child felt ill last week, so she secretly reduced a patient’s medicine (Poor nursing professionalism behaviours) and took the remaining medicine home for her child (lack of altruism). She stopped doing so after her colleagues sensed something strange. One day, a baby kept crying; D reported it to the doctor and did not make further observations (Poor professional). When the shift nurse took over, she observed abnormal limb activity on one side of the child. The child’s family asked the nurse to bear legal responsibility. D said it was no big deal; she no longer wanted to be a nurse (Poor dynamic, professionalism not established).

Antecedents

Antecedents are events that occur before the intended concept [ 17 ].

Macro antecedents

Jin [ 28 ] suggested that the conceptualization of professionalism is influenced by culture. Employees defined organizational culture underlies an organization’s values and beliefs [ 70 ]. Nursing professionalism may be supported by a variety of cultures, so a firm understanding of and personal congruence with each particular culture is essential [ 71 ].

Religious beliefs

Religiosity is another contributing factor in the cultivation of altruism [ 72 ]. Taylor noted that nurses’ job motivation and views of the patient and nursing services are affected by their religious beliefs [ 73 ].

Micro antecedents

Snizek [ 74 ] (1972) reported that devotion to work is a professional value originating from a sense of calling to the field. Liaw et al. [ 75 ] (2016) found that nursing students who had caring and compassionate qualities as the most common personal characteristics strongly believed that they were called to nursing.

Individuals who pursue excellence in the workplace may be described as motivated and devoted to their work. Attree [ 76 ] (2005) noted that nurses’ perceived lack of autonomy over their practice could impact quality of care.

Personal characteristics

Nursing professionalism is influenced by various factors, such as educational background, personal interests, professional satisfaction, and professional values [ 77 , 78 , 79 ]. In each country, nurses with higher educational levels may have a higher level of professionalism [ 22 ]. Professionalism is thus a trait related to personal character and upbringing [ 80 ]. Researchers [ 81 ] have demonstrated that professionalism is positively associated with female gender, striving for professional goals, and acceptability. One study found that people’s values tend to shift to emphasize altruism over personal gain as they age [ 79 ]. Nursing professionalism is closely associated with personality traits (extraversion, conscientiousness, and agreeableness) [ 82 ].

Consequences of nursing professionalism

Consequences are events or incidents that are the result of the occurrence of a concept [ 17 ].

Consequences for patients

Professionalism is one of the decisive factors that critically influences patient satisfaction [ 50 ]. Professionalism can also improve practising nurse career development and the quality of service [ 81 ].

Consequences for nurses

Studies have shown that professionalism and a sense of belonging with colleagues and managers affect the satisfaction [ 83 ] and retention rate of nursing students in academic institutions [ 84 ]. Izumi et al. [ 85 ] (2006) found that good nurses felt pride and happiness in caring for patients closely related to their professionalism.

Empirical references

As the last step to concept analysis, empirical references can further clarify the concept and facilitate its measurement [ 17 ].

Hall’s professionalism inventory scale

Hall’s Professionalism Inventory Scale [ 6 ] identified five attitudinal attributes of professionalism: (a) use of professional organizations as major referents, (b) belief in public service, (c) self-regulation, (d) a sense of calling to the field, and (e) autonomy. Nursing researchers used Hall’s Professionalism Inventory Scale to measure professionalism in nursing [ 22 , 47 ]. Snizek [ 74 ] (1972) modified the professionalism scale to more closely match the clinical context of nursing and better reflect the professionalism of nursing staff.

Kramer’s index of professionalism

Kramer (1974) [ 86 ] constructed an index of professionalism that includes indicators of behaviours, such as the number of professional books published, subscriptions to professional journals, hours spent on professional reading, continuing education, participation in professional organizations, number of professional publications, speeches given, committee activity, and participation in research.

The behavioural inventory for professionalism in nursing (BIPN)

The Behavioural Inventory for Professionalism in Nursing [ 7 ] (BIPN) identifies professional behaviours and values among nurses. The nine categories in the BIPN are (1) educational background; (2) adherence to the code of ethics; (3) participation in the professional organization; (4) continuing education and competency; (5) communication and publication; (6) autonomy and self-regulation; (7) community service; (8) theory use, development, and evaluation; and (9) research involvement.

Definition of the concept

Based on the present analysis, we define nursing professionalism as follows: ‘Nursing professionalism is a multidimensional concept manifested by the knowledge, attitudes, and behaviours that underlie successful clinical practice. Nursing professionalism is dynamicized through a process of socialization in formal nursing education. This feature is also reflected in the process of interaction. Therefore, nursing professionalism should match its rooted culture.

The connotations of nursing professionalism include professional, caring, and altruism. These connotations are detailed as follows:

Possesses a systematic nursing knowledge system; professional certification

Exhibits lifelong learning and participation

Participates in evidence-based practice

Demonstrates innovation

Strives for excellence

Creates a caring-healing environment

Displays kindness/concern/empathy for others

Uses various methods of knowing support and involvement

Embraces the unknowns and miracles in life and practices loving

Patient-first

A conceptual model of nursing professionalism is shown in Fig. 2 .

Antecedents, attributes, and consequences of nursing professionalism

Defining the connotation of nursing professionalism

Nursing professionalism has been defined as professional, caring, and altruistic.

Professional values are characteristic of nursing professionalism. Nursing work requires rich knowledge and scientific evidence-based work to improve the quality of nursing services for patients. Nurses need lifelong learning, qualification certification, and participation in academic and practical activities.

Caring is regarded as the core of professionalism. This study suggests creating a caring-healing environment, displaying kindness/concern/empathy for others, employing all methods of knowing support and involvement, embracing the unknowns and miracles in life and practising loving to care for people to obtain high professionalism. This study notes that nursing professionalism emphasizes care for the individual patient and that the nurse does everything possible to create a caring and healing environment for patients. In different health systems worldwide, nurses have incorporated caring about nursing professionalism into everything they do. This characteristic is consistent with Nightingale's view that “Nurses need to be sensitive. A nurse must use her brain, heart and hands to create healing environments to care for the patient’s body, mind and spirit” [ 87 , 88 ].

Nursing has an altruistic nature, and people interested in helping patients are attracted to this profession [ 89 ]. However, some studies have shown that altruistic care is equated with self-sacrifice, self-denial, and unidirectional and unconditional care [ 90 ]. Care for a nurse’s own needs is equally important, but nurses should be able to put aside their own needs when required to focus on the needs of others [ 91 ]. Nurses should view self-care and altruism as dialectical. Self-realization and providing care for others are not conflicting concepts [ 92 ].

Defining the attributes of nursing professionalism

In this study, we defined nursing professionalism as multidimensional, dynamic, and culture oriented.

Nursing professionalism is a multidimensional concept that includes knowledge, attitudes, and behaviour. Previous studies have defined professionalism as the degree of commitment by individuals to the values and behavioural characteristics of a specific career identity [ 6 , 7 ]. However, current research on nursing professionalism is mostly single dimensional. The Behavioural Inventory for Professionalism in Nursing (BIPN) is based on Miller’s model and is used to measure professional behaviours among nurses [ 7 ]. Hall’s Professionalism Inventory Scale [ 6 ] identified five attitudinal attributes of professionalism. This study highlights that it is also necessary to focus on the knowledge dimension of professionalism. Nursing students and nurses should first understand the nursing professionalism that is necessary to become a nurse, which may be the first step in developing professionalism. Nursing students and nurses need to know the values that are necessary to practice the nursing and not have vague impressions. Some studies have shown that nursing students or nurses learn values and norms in informal trainings [ 93 ]. Therefore, this study suggests that the development of assessment tools for the knowledge dimension of professionalism is also necessary. Multidimensional evaluation tools are not available for nursing professionalism. Thus, clarifying the multidimensional nature of nursing professionalism will contribute to the development of multidimensional evaluation tools.

Moreover, understanding the dynamics of professionalism is helpful for cultivating nursing professionalism in stages and steps. Inquiries into medical professionalism should be integrated into the culture of social media interaction [ 94 ]. Nursing educators and managers should dynamically cultivate nursing professionalism in their interactions.

Differences in the connotation of nursing professionalism are noted in different cultures. This study suggests that the cultivation and evaluation of nursing professionalism need to consider the cultural attributes of different regions and countries.

Future research directions

Exploring the antecedents of nursing professionalism can help schools or hospitals cultivate nursing professionalism and develop courses and specific measures.

The macro antecedents of nursing professionalism include culture and religion, and the micro antecedents include calling, autonomy, and personal characteristics. Some researchers have explored methods to cultivate nursing professionalism; for example, role modelling, feedback, group discussions, case-based discussions, reflection, holding ethical rounds, and reports potentially represent more effective methods [ 95 ]. Some researchers have tried to enhance professionalism through social media [ 96 ]. One of the findings this study is that nursing professionalism is complex and its cultivation difficult. Studies have shown that didactic lectures are ineffective for teaching professionalism [ 97 ]. The development of true nursing professionalism requires national advocacy and the immersion of a good professional environment that incorporates professionalism into daily nursing practice. Role modelling is considered an effective method for developing professionalism in nursing [ 98 ]. Therefore, this study suggest that studies should be actively conducted to deeply discuss the causes and processes affecting professionalism and to cultivate and intervene at macro and micro levels as well as the key time periods and populations that form professionalism to truly shape the formation of professionalism. Moreover, an environment for building professionalism [ 99 ] is very important. Williams [ 100 ] (2015) considered that the development of professionalism should begin as early as the first semester of an undergraduate nursing course. One of the themes of nursing students’ professional identity development is ‘doing-learning-knowing-speaking’. Students should develop professionalism in all these areas of nursing practice.

The relationship between nursing professionalism and health outcomes or nurses’ human resources needs to be further studied.

Our research suggests that the ultimate goal of nursing professionalism is to serve patients with professional knowledge and special professional quality. The public has become increasingly aware of certain possibilities, limitations, and consequences of professionalism. COVID-19 significantly increased the discussion of professionalism and patient outcomes.

Improving professionalism has a positive impact on job satisfaction, professional quality of life, and the willingness to continue in the profession [ 101 , 102 , 103 ]. Therefore, it is important to improve support for nurses, create a good environment for professionalism, and establish a training system for professionalism, thus paving the way to enhance training in professionalism and create opportunities for nurses.

Implications for nursing management

In April 2020, the World Health Organization (2020) issued the First State of the World’s Nursing 2020 [ 104 ]. The report highlighted that nursing professionals are the largest occupational group in the health sector, numbering 27.9 million worldwide. Nurses spend more time with patients than any other health care professionals [ 105 ].

Worldwide, nursing professionalism is considered important and associated with expectations. This study clarifies the concept of nursing professionalism and contributes to a framework for developing a theoretical model as well as instruments to measure the concept. A conceptual model of nursing professionalism may increase nurse managers’ insight into nurses’ behaviours and values, creating a good working environment.

Nurse managers should integrate nursing professionalism into their philosophy, mission, and objectives and provide necessary resources, tools, and projects to develop professionalism among nurses. Nurses should cultivate professionalism to provide good nursing services to patients. Further research should explore the relationship between nursing professionalism and patient health outcomes and formulate effective training programs for professionalism.

Limitations

This conceptual analysis has some limitations. First, research on nursing professionalism published in English may be conducted in different countries and cultures. However, it is also necessary to obtain a more comprehensive and mature concept of the study of different national languages. Second, the lack of research on the combination of all elements of professionalism may lead to overestimation of the impact of these subelements on professionalism. Third, the concept analysis focused on the research process and the researchers’ perspectives, possibly reflecting a lack of other professional understandings of nursing professionalism in medical groups. In addition, the concept analysis included a risk of selection bias, extraction bias, and analysis bias because the study selection process, data extraction, and analysis were all conducted by two researchers. Despite these risk, the studies were all described accurately and systematically.

Nursing professionalism is one of the important foundations of clinical nursing. It is multidimensional, dynamic, and culture oriented. Based on the analysis, nursing professionalism has been defined as providing people care based on principles of professionalism, caring, and altruism. The definition, attributes, antecedents, consequences, and reference analysis of the experience of nursing professionalism determined in this study provide a theoretical basis for future research. This information can be used to evaluate nursing professionalism, develop assessment tools, or generate theory-based training courses and interventions.

Availability of data and materials

Data used to support the findings of this study are available from the corresponding author upon request.

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Acknowledgements

The authors would like to thank Hui Yang for the great efforts made in designing the research. We would like to thank linbo Li for providing valuable suggestions for this study.

Postgraduate Education Innovation Program of Shanxi Province in China (No. 2020BY067).

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Hl C and HY made substantial contributions to conception and design. HL C, YJ S, YM W, YF D Collectioned and analysis the data. Hl C was a major contributor in writing the manuscript. XY H, YJ C, QH W revised it critically for important intellectual content. All authors read and approved the final manuscript.

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Cao, H., Song, Y., Wu, Y. et al. What is nursing professionalism? a concept analysis. BMC Nurs 22 , 34 (2023). https://doi.org/10.1186/s12912-022-01161-0

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Nursing & Concept Analysis: Concept Analysis

What is concept analysis.

"Concept analysis refers to the examination of the structure and function of a concept. It is a formal, rigorous, and precise linguistic exercise used to determine the defining attributes of a concept."

source: https://gradecrest.com/nursing-concept-analysis-paper-guide/

How to find Concept Analysis articles?

Steps to find Concept Analysis articles:

1. Select a journal database or search engine that indexes journal articles.

Academic Search Premier, CINAHL, Google Scholar, Nursing & Allied Health (ProQuest), Science Direct

2. Select the advanced search choice.

3. Type terms in the different search boxes.

4. Use "Concept Analysis" in one of the search boxes. You can try limiting to "title of article" -- this will look for "concept analysis" in the article title.

Articles explaining or discussing Concept Analysis

Concept advancement: Extending science through concept-driven research Penrod, J., & Hupcey, J. E. (2005). Concept advancement: Extending science through concept-driven research. Research and Theory for Nursing Practice, 19(3), 231-41.
Concept analysis: Examining the state of the science Hupcey, J. E., & Penrod, J. (2005). Concept analysis: Examining the state of the science. Research and Theory for Nursing Practice, 19(2), 197-208
Concept analysis: Method to enhance interdisciplinary conceptual understanding Bonis, S. A. (2013). Concept analysis: Method to enhance interdisciplinary conceptual understanding. Advances in Nursing Science, 36(2), 80-93. doi:10.1097/ANS.0b013e318290d86e
Concept Analysis and the Advance of Nursing Knowledge Rodgers BL, Jacelon CS, Knafl KA. Concept Analysis and the Advance of Nursing Knowledge: State of the Science. J Nurs Scholarsh. 2018 Jul;50(4):451-459. doi: 10.1111/jnu.12386. Epub 2018 Apr 24. PMID: 29689127.
A Guide to Concept Analysis Foley, A. S., & Davis, A. H. (2017). A Guide to Concept Analysis. Clinical Nurse Specialist, 31(2), 70-73.
Nursing concept analysis in North America: state of the art. Weaver K, Mitcham C. Nursing concept analysis in North America: state of the art. Nurs Philos. 2008 Jul;9(3):180-94. doi: 10.1111/j.1466-769X.2008.00359.x. PMID: 18582294.
Serial concept maps: Tools for concept analysis All, Anita C,PhD., R.N., & Huycke, LaRae I, MS,A.P.R.N., B.C. (2007). Serial concept maps: Tools for concept analysis. Journal of Nursing Education, 46(5), 217-24

Online resources explaining Concept Analysis

A STEP BY STEP GUIDE ON HOW TO WRITE A NURSING CONCEPT ANALYSIS ASSIGNMENT globalcompose.com
How to write a concept analysis paper in nursing GradeCrest

Concept Analysis Articles

Examples of Concept Analysis articles in nursing journals...

Academic resilience in nusing students: a concept analysis. Shen, Y., Feng, H., & Li, X. (2024). Academic resilience in nusing students: a concept analysis. BMC Nursing, 23(1), 1–10. https://doi.org/10.1186/s12912-024-02133-2
Brain Fog: A Concept Analysis Chi-Wen PAN, & Wei-Fang WANG. (2024). Brain Fog: A Concept Analysis. Journal of Nursing, 71(2), 90–96. https://doi.org/10.6224/JN.202404_71(2).11
Community empowerment: A concept analysis Kruahong, S., Tankumpuan, T., Kelly, K., Davidson, P. M., & Kuntajak, P. (2023). Community empowerment: A concept analysis. Journal of Advanced Nursing, https://doi.org/10.1111/jan.15613
Disaster‐Related Community Resilience: A Concept Analysis and a Call to Action for Nurses Heagele, T. (2016). Disaster‐Related Community Resilience: A Concept Analysis and a Call to Action for Nurses. Public Health Nursing.
Nursing Student Success: A Concept Analysis Cox, Angela & Copeland, Darcy. (2024). Nursing Student Success: A Concept Analysis. Nursing Education Perspectives, 45, 155-160. https://doi.org/10.1097/01.NEP.0000000000001221
Readiness for hospital discharge: A concept analysis Galvin, E. C., Wills, T., & Coffey, A. (2017). Readiness for hospital discharge: A concept analysis. Journal of Advanced Nursing, 73(11), 2547-2557. doi:10.1111/jan.13324
Understanding context: A concept analysis Squires, J. E., Graham, I., Bashir, K., Nadalin‐Penno, L., Lavis, J., Francis, J., . . . Hutchinson, A. M. (2019). Understanding context: A concept analysis. Journal of Advanced Nursing, doi:10.1111/jan.14165
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Resources listed on these guides are compiled by librarians at the R.A. Williams Library. We accept content recommendations, and after review, may include suggested resources on a guide. Our time is limited, so we generally do not reply to unsolicited recommendations from individuals not affiliated with AdventHealth University or notify them regarding whether or not we have linked to suggested content.

NU 601: Nursing Theory

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What is Concept Analysis?

Tertiary resources, searching for articles on your concept, interdisciplinary articles, empirical referents, ebooks on concept analysis.

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This Guide was created by Carolyn Swidrak (retired).

"Concept analysis is a strategy used for examining concepts for their semantic structure. Although there are several methods for conducting concept analysis, all of them have the purpose of determining the defining characteristics of the concept under study. Some uses of a concept analysis are refining and clarifying concepts in theory, practice, and research and arriving at precise theoretical and operational definitions for research or for instrument development." (Fitzpatrick, 2018, p. 129). Source: Fitzpatrick, J. (2018). Encyclopedia of nursing research (4th ed.). Springer Publishing Company.

Dictionaries:

See the Dictionaries Tab for a Comprehensive List and Information
Thesaurus.com Think outside the box and find similar or like terms that connect to your concept.

Encyclopedias:

Encyclopedia of Epidemiology
Encyclopedia of Family Health
Encyclopedia of School Health
Encyclopedia of Counseling
Encyclopedia of Health & Aging
...and more!

CINAHL Ultimate is the new definitive resource for nursing and allied health research, providing full text for more of the most used journals in the CINAHL index than any other database. It covers more than 50 nursing specialties and includes quick lessons, evidence-based care sheets, CEU modules and research instruments.

Search Strategy:

Use the below terms with your concept, using the AND Boolean operator:

concept OR "concept analysis" ( Note: please do not plagiarize others' concept analyses-- use and cite these to formulate your OWN concept analysis! )
defined OR definition
philosophy OR philosophies
theory OR theories OR theoretical

Disclaimer: These are only suggestions on how you might search for your concept in the databases. Always check in with your professor to make sure you understand the assignment.

Have you been asked to search in multiple disciplines for your concept? Use these tips below!

Think about what disciplines fit within your concept. For instance, Compassion Fatigue may be defined in the psychology or social work fields. I can use these subject-specific databases to find articles in these fields:

This database indexes and abstracts articles from periodicals published in the U.S. and elsewhere plus the full-text of selected periodicals. Subjects covered include addiction studies, community health and medical care, corrections, criminal justice, economics, environmental studies, and urban studies.

Other databases to consider in other disciplines:

This database covers scholarly research and information to meet the needs of education students, professionals, and policy makers. This massive file offers the world's largest and most complete collection of full-text education journals, and encompasses an international array of English-language periodicals, monographs, yearbooks, and more.

MEDLINE Ultimate offers medical professionals and researchers access to unmatched evidence-based and peer-reviewed full-text content from more of the top biomedical journals. It also offers more international journal coverage than any other MEDLINE database.

SPORTDiscus with Full Text includes thorough coverage in the subjects most relevant to sports medicine, fitness & nutrition.

Includes: Clinical specialties such as orthopedics Coaching and education Consumer health Exercise science and fitness Health education Kinesiology Nutrition Occupational health and safety Physical education Physical therapy Sports sciences

You can also search Interdisciplinary databases, like Academic Search Complete and PowerSearch (from our homepage). Make sure you are including the discipline as part of your search terms. Example:

What are Empirical Referents ?

Empirical referents are "the means by which you can recognize or measure the defining characteristics or attributes" (Walker & Avant, 2010, p. 168). Essentially, they are measurement tools or instruments that help to measure the concept.

Ex. Concept: Resiliency

Empirical Referent: Connor-Davidson Resilience Scale (Connor & Davidson, 2003)

How do I find them?

For more information on how to find these tools, check out our Research Guide on Research Instruments (Tests & Measures) .

Source: Walker, L. O. & Avant, K. C. (2010). Concept analysis. In Strategies for theory construction in nursing (6th Ed., pp. 157-177). Pearson.

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Concept Analysis in Nursing: Concept Analysis Assignment

Concept analysis assignment.

Finding Journal Articles
Writing & Citing

Selected Books

Search the Library's online catalog for these and other books

Selected Journal Articles

Some of these articles are freely accessible. For those that are not, you must be a currently enrolled JSU student, or a staff or faculty member to access them.

Concept Analysis: Examining the State of the Science. Hupcey, J. E., & Penrod, J. (2005). Concept Analysis: Examining the State of the Science. Research and Theory for Nursing Practice: An International Journal, 19(2), 197–208.
Concept analysis: method to enhance interdisciplinary conceptual understanding Bonis, S. A. (2013). Concept analysis: method to enhance interdisciplinary conceptual understanding. Advances in Nursing Science, 2, 80.
A Guide to Concept Analysis Foley, A. S., & Davis, A. H. (2017). A Guide to Concept Analysis. Clinical Nurse Specialist CNS, 31(2), 70–73.

What is Concept Analysis?

A concept is usually one or two words that convey meaning, understanding or feelings between or among individuals within a same discipline. It is a measurable variable in a theory or conceptual model. Concepts are the building blocks of theories. They can be concrete or abstract and serve to classify the phenomena of interest (Alligood, 2018).

A concept analysis is an exercise designed to make the nursing student as familiar as possible with a concept. It is an important step in communicating meaning, understanding and feelings.

Reference Sources to Help Define Concepts

Health and Sciences Librarian

Web Resources

Basic and Advanced Searching Guide to basic searching and using Boolean operator. (AND,OR, NOT)
Nurse Theorists and Nursing Theories This subject guide from Indiana University (Kokomo) contains information on a list of nurse theorists.
Nursing Theory Link Page List of nursing theory and theorists compiled by Clayton State University.
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Last Updated: Aug 9, 2024 11:12 AM
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The Nursing Process: A Comprehensive Guide

In 1958, Ida Jean Orlando began developing the nursing process still evident in nursing care today. According to Orlando’s theory, the patient’s behavior sets the nursing process in motion. Through the nurse ‘s knowledge to analyze and diagnose the behavior to determine the patient’s needs.

Application of the fundamental principles of critical thinking , client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EBP) recommendations, and nursing intuition, the nursing process functions as a systematic guide to client-centered care with five subsequent steps. These are assessment , diagnosis, planning, implementation, and evaluation ( ADPIE ).

What is the nursing process.

What is the purpose of the nursing process?

Characteristics of the nursing process

Nursing process steps, collecting data, objective data or signs, subjective data or symptoms, verbal data, nonverbal data, primary source, secondary source, tertiary source, health interview, physical examination, observation, validating data, documenting data.

2. Diagnosis: “What is the problem?”

Initial Planning

Ongoing planning, discharge planning, developing a nursing care plan, behavioral nursing interventions, community nursing interventions, family nursing interventions, health system nursing interventions, physiological nursing interventions, safety nursing interventions, skills used in implementing nursing care, 1. reassessing the client, 2. determining the nurse’s need for assistance, nursing intervention categories, independent nursing interventions, dependent nursing interventions, interdependent nursing interventions, 4. supervising the delegated care, 5. documenting nursing activities, 1. collecting data, 2. comparing data with desired outcomes, 3. analyzing client’s response relating to nursing activities, 4. identifying factors contributing to success or failure, 5. continuing, modifying, or terminating the nursing care plan, 6. discharge planning.

The nursing process is defined as a systematic, rational method of planning that guides all nursing actions in delivering holistic and patient-focused care. The nursing process is a form of scientific reasoning and requires the nurse’s critical thinking to provide the best care possible to the client.

What is the purpose of the nursing process?

The following are the purposes of the nursing process:

To identify the client’s health status and actual or potential health care problems or needs (through assessment).
To establish plans to meet the identified needs.
To deliver specific nursing interventions to meet those needs.
To apply the best available caregiving evidence and promote human functions and responses to health and illness (ANA, 2010).
To protect nurses against legal problems related to nursing care when the standards of the nursing process are followed correctly.
To help the nurse perform in a systematically organized way their practice.
To establish a database about the client’s health status, health concerns, response to illness, and the ability to manage health care needs.

The following are the unique characteristics of the nursing process:

Patient-centered . The unique approach of the nursing process requires care respectful of and responsive to the individual patient’s needs, preferences, and values. The nurse functions as a patient advocate by keeping the patient’s right to practice informed decision-making and maintaining patient-centered engagement in the health care setting.
Interpersonal . The nursing process provides the basis for the therapeutic process in which the nurse and patient respect each other as individuals, both of them learning and growing due to the interaction. It involves the interaction between the nurse and the patient with a common goal.
Collaborative . The nursing process functions effectively in nursing and inter-professional teams, promoting open communication, mutual respect, and shared decision-making to achieve quality patient care .
Dynamic and cyclical .The nursing process is a dynamic, cyclical process in which each phase interacts with and is influenced by the other phases.
Requires critical thinking . The use of the nursing process requires critical thinking which is a vital skill required for nurses in identifying client problems and implementing interventions to promote effective care outcomes.

The nursing process consists of five steps: assessment, diagnosis, planning, implementation, and evaluation . The acronym ADPIE is an easy way to remember the components of the nursing process. Nurses need to learn how to apply the process step-by-step. However, as critical thinking develops through experience, they learn how to move back and forth among the steps of the nursing process.

The steps of the nursing process are not separate entities but overlapping, continuing subprocesses. Apart from understanding nursing diagnoses and their definitions, the nurse promotes awareness of defining characteristics and behaviors of the diagnoses, related factors to the selected nursing diagnoses, and the interventions suited for treating the diagnoses.

The steps of the nursing process are detailed below:

1. Assessment: “What data is collected?”

The first phase of the nursing process is assessment . It involves collecting, organizing, validating, and documenting the clients’ health status. This data can be obtained in a variety of ways. Usually, when the nurse first encounters a patient, the nurse is expected to assess to identify the patient’s health problems as well as the physiological, psychological, and emotional state and to establish a database about the client’s response to health concerns or illness and the ability to manage health care needs. Critical thinking skills are essential to the assessment, thus requiring concept-based curriculum changes.

Data collection is the process of gathering information regarding a client’s health status. The process must be systematic and continuous in collecting data to prevent the omission of important information concerning the client.

The best way to collect data is through head-to-toe assessment. Learn more about it at our guide: Head to Toe Assessment: Complete Physical Assessment Guide

Types of Data

Data collected about a client generally falls into objective or subjective categories, but data can also be verbal and nonverbal.

Objective data are overt, measurable, tangible data collected via the senses, such as sight, touch , smell , or hearing , and compared to an accepted standard, such as vital signs, intake and output , height and weight, body temperature, pulse, and respiratory rates, blood pressure , vomiting , distended abdomen, presence of edema , lung sounds, crying, skin color, and presence of diaphoresis.

Subjective data involve covert information, such as feelings, perceptions, thoughts, sensations, or concerns that are shared by the patient and can be verified only by the patient, such as nausea , pain , numbness, pruritus, attitudes, beliefs, values, and perceptions of the health concern and life events.

Verbal data are spoken or written data such as statements made by the client or by a secondary source. Verbal data requires the listening skills of the nurse to assess difficulties such as slurring, tone of voice, assertiveness, anxiety , difficulty in finding the desired word, and flight of ideas.

Nonverbal data are observable behavior transmitting a message without words, such as the patient’s body language, general appearance , facial expressions, gestures, eye contact, proxemics (distance), body language, touch, posture, clothing. Nonverbal data obtained can sometimes be more powerful than verbal data, as the client’s body language may not be congruent with what they really think or feel. Obtaining and analyzing nonverbal data can help reinforce other forms of data and understand what the patient really feels.

Sources of Data

Sources of data can be primary, secondary, and tertiary . The client is the primary source of data, while family members , support persons, records and reports, other health professionals, laboratory and diagnostics fall under secondary sources.

The client is the only primary source of data and the only one who can provide subjective data. Anything the client says or reports to the members of the healthcare team is considered primary.

A source is considered secondary data if it is provided from someone else other than the client but within the client’s frame of reference. Information provided by the client’s family or significant others are considered secondary sources of data if the client cannot speak for themselves, is lacking facts and understanding, or is a child. Additionally, the client’s records and assessment data from other nurses or other members of the healthcare team are considered secondary sources of data.

Sources from outside the client’s frame of reference are considered tertiary sources of data . Examples of tertiary data include information from textbooks, medical and nursing journals, drug handbooks, surveys, and policy and procedural manuals.

Methods of Data Collection

The main methods used to collect data are health interviews, physical examination, and observation.

The most common approach to gathering important information is through an interview. An interview is an intended communication or a conversation with a purpose, for example, to obtain or provide information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy. One example of the interview is the nursing health history , which is a part of the nursing admission assessment. Patient interaction is generally the heaviest during the assessment phase of the nursing process so rapport must be established during this step.

Aside from conducting interviews, nurses will perform physical examinations, referencing a patient’s health history, obtaining a patient’s family history, and general observation can also be used to gather assessment data. Establishing a good physical assessment would, later on, provide a more accurate diagnosis, planning, and better interventions and evaluation .

Observation is an assessment tool that depends on the use of the five senses (sight, touch, hearing, smell, and taste ) to learn information about the client. This information relates to characteristics of the client’s appearance, functioning, primary relationships, and environment. Although nurses observe mainly through sight, most of the senses are engaged during careful observations such as smelling foul odors, hearing or auscultating lung and heart sounds and feeling the pulse rate and other palpable skin deformations.

Validation is the process of verifying the data to ensure that it is accurate and factual. One way to validate observations is through “double-checking,” and it allows the nurse to complete the following tasks:

Ensures that assessment information is double-checked, verified, and complete. For example, during routine assessment, the nurse obtains a reading of 210/96 mm Hg of a client with no history of hypertension . To validate the data, the nurse should retake the blood pressure and if necessary, use another equipment to confirm the measurement or ask someone else to perform the assessment.
Ensure that objective and related subjective data are valid and accurate. For example, the client’s perceptions of “feeling hot” need to be compared with the measurement of the body temperature.
Ensure that the nurse does not come to a conclusion without adequate data to support the conclusion. A nurse assumes tiny purple or bluish-black swollen areas under the tongue of an older adult client to be abnormal until reading about physical changes of aging.
Ensure that any ambiguous or vague statements are clarified. For example, a 86-year-old female client who is not a native English speaker says that “I am in pain on and off for 4 weeks,” would require verification for clarity from the nurse by asking “Can you describe what your pain is like? What do you mean by on and off?”
Acquire additional details that may have been overlooked. For example, the nurse is asking a 32-year-old client if he is allergic to any prescription or non-prescription medications. And what would happen if he takes these medications.
Distinguish between cues and inferences. Cues are subjective or objective data that can be directly observed by the nurse; that is, what the client says or what the nurse can see, hear, feel, smell, or measure. On the other hand, inferences are the nurse’s interpretation or conclusions made based on the cues. For example, the nurse observes the cues that the incision is red, hot, and swollen and makes an inference that the incision is infected.

Once all the information has been collected, data can be recorded and sorted. Excellent record-keeping is fundamental so that all the data gathered is documented and explained in a way that is accessible to the whole health care team and can be referenced during evaluation.

2. Diagnosis: “What is the problem?”

The second step of the nursing process is the nursing diagnosis . The nurse will analyze all the gathered information and diagnose the client’s condition and needs. Diagnosing involves analyzing data, identifying health problems, risks, and strengths, and formulating diagnostic statements about a patient’s potential or actual health problem. More than one diagnosis is sometimes made for a single patient. Formulating a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care .

The types, components, processes, examples, and writing nursing diagnosis are discussed more in detail here “ Nursing Diagnosis Guide: All You Need To Know To Master Diagnosing ”

3. Planning: “How to manage the problem?”

Planning is the third step of the nursing process. It provides direction for nursing interventions . When the nurse, any supervising medical staff, and the patient agree on the diagnosis, the nurse will plan a course of treatment that takes into account short and long-term goals. Each problem is committed to a clear, measurable goal for the expected beneficial outcome.

The planning phase is where goals and outcomes are formulated that directly impact patient care based on evidence-based practice (EBP) guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement , and continuity of care across the healthcare continuum.

Types of Planning

Planning starts with the first client contact and resumes until the nurse-client relationship ends, preferably when the client is discharged from the health care facility.

Initial planning is done by the nurse who conducts the admission assessment. Usually, the same nurse would be the one to create the initial comprehensive plan of care.

Ongoing planning is done by all the nurses who work with the client. As a nurse obtain new information and evaluate the client’s responses to care, they can individualize the initial care plan further. An ongoing care plan also occurs at the beginning of a shift. Ongoing planning allows the nurse to:

determine if the client’s health status has changed
set priorities for the client during the shift
decide which problem to focus on during the shift
coordinate with nurses to ensure that more than one problem can be addressed at each client contact

Discharge planning is the process of anticipating and planning for needs after discharge. To provide continuity of care, nurses need to accomplish the following:

Start discharge planning for all clients when they are admitted to any health care setting.
Involve the client and the client’s family or support persons in the planning process.
Collaborate with other health care professionals as needed to ensure that biopsychosocial, cultural, and spiritual needs are met.

A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost.

The planning step of the nursing process is discussed in detail in Nursing Care Plans (NCP): Ultimate Guide and Database .

4. Implementation: “Putting the plan into action!”

The implementation phase of the nursing process is when the nurse puts the treatment plan into effect. It involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This typically begins with the medical staff conducting any needed medical interventions.

Interventions should be specific to each patient and focus on achievable outcomes. Actions associated with a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or conducting important medical tasks such as medication administration, educating and guiding the patient about further health management, and referring or contacting the patient for a follow-up.

A taxonomy of nursing interventions referred to as the Nursing Interventions Classification (NIC) taxonomy, was developed by the Iowa Intervention Project. The nurse can look up a client’s nursing diagnosis to see which nursing interventions are recommended.

Nursing Interventions Classification (NIC) System

There are more than 550 nursing intervention labels that nurses can use to provide the proper care to their patients. These interventions are categorized into seven fields or classes of interventions according to the Nursing Interventions Classification system.

These are interventions designed to help a patient change their behavior. With behavioral interventions, in contrast, patient behavior is the key and the goal is to modify it. The following measures are examples of behavioral nursing interventions:

Encouraging stress and relaxation techniques
Providing support to quit smoking
Engaging the patient in some form of physical activity , like walking , to reduce the patient’s anxiety , anger, and hostility

These are interventions that refer to the community-wide approach to health behavior change. Instead of focusing mainly on the individual as a change agent, community interventionists recognize a host of other factors that contribute to an individual’s capacity to achieve optimal health, such as:

Implementing an education program for first-time mothers
Promoting diet and physical activities
Initiating HIV awareness and violence-prevention programs
Organizing a fun run to raise money for breast cancer research

These are interventions that influence a patient’s entire family.

Implementing a family-centered approach in reducing the threat of illness spreading when one family member is diagnosed with a communicable disease
Providing a nursing woman support in breastfeeding her new baby
Educating family members about caring for the patient

These are interventions that designed to maintain a safe medical facility for all patients and staff, such as:

Following procedures to reduce the risk of infection for patients during hospital stays.
Ensuring that the patient’s environment is safe and comfortable, such as repositioning them to avoid pressure ulcers in bed

These are interventions related to a patient’s physical health to make sure that any physical needs are being met and that the patient is in a healthy condition. These nursing interventions are classified into two types: basic and complex.

Basic. Basic interventions regarding the patient’s physical health include hands-on procedures ranging from feeding to hygiene assistance.
Complex. Some physiological nursing interventions are more complex, such as the insertion of an IV line to administer fluids to a dehydrated patient.

These are interventions that maintain a patient’s safety and prevent injuries, such as:

Educating a patient about how to call for assistance if they are not able to safely move around on their own
Providing instructions for using assistive devices such as walkers or canes, or how to take a shower safely.

When implementing care, nurses need cognitive, interpersonal, and technical skills to perform the care plan successfully.

Cognitive Skills are also known as Intellectual Skills are skills involve learning and understanding fundamental knowledge including basic sciences, nursing procedures, and their underlying rationale before caring for clients. Cognitive skills also include problem-solving, decision-making, critical thinking, clinical reasoning, and creativity.
Interpersonal Skills are skills that involve believing, behaving, and relating to others. The effectiveness of a nursing action usually leans mainly on the nurse’s ability to communicate with the patient and the members of the health care team.
Technical Skills are purposeful “hands-on” skills such as changing a sterile dressing , administering an injection, manipulating equipment, bandaging, moving , lifting, and repositioning clients. All of these activities require safe and competent performance.

Process of Implementing

The process of implementing typically includes the following:

Prior to implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed. Even if an order is written on the care plan, the client’s condition may have changed.

Other nursing tasks or activities may also be performed by non- RN members of the healthcare team. Members of this team may include unlicensed assistive personnel (UAP) and caregivers , as well as other licensed healthcare workers, such as licensed practical nurses/licensed vocational nurses (LPNs/LVNs). The nurse may need assistance when implementing some nursing intervention, such as ambulating an unsteady obese client, repositioning a client, or when a nurse is not familiar with a particular model of traction equipment needs assistance the first time it is applied.

3. Implementing the nursing interventions

Nurses must not only have a substantial knowledge base of the sciences, nursing theory, nursing practice , and legal parameters of nursing interventions but also must have the psychomotor skills to implement procedures safely. It is necessary for nurses to describe, explain, and clarify to the client what interventions will be done, what sensations to anticipate, what the client is expected to do, and what the expected outcome is. When implementing care, nurses perform activities that may be independent, dependent, or interdependent.

Nursing interventions are grouped into three categories according to the role of the healthcare professional involved in the patient’s care:

A registered nurse can perform independent interventions on their own without the help or assistance from other medical personnel, such as:

routine nursing tasks such as checking vital signs
educating a patient on the importance of their medication so they can administer it as prescribed

A nurse cannot initiate dependent interventions alone. Some actions require guidance or supervision from a physician or other medical professional, such as:

prescribing new medication
inserting and removing a urinary catheter
providing diet
Implementing wound or bladder irrigations

A nurse performs as part of collaborative or interdependent interventions that involve team members across disciplines.

In some cases, such as post- surgery , the patient’s recovery plan may require prescription medication from a physician, feeding assistance from a nurse, and treatment by a physical therapist or occupational therapist.
The physician may prescribe a specific diet to a patient. The nurse includes diet counseling in the patient care plan. To aid the patient, even more, the nurse enlists the help of the dietician that is available in the facility.

Delegate specific nursing interventions to other members of the nursing team as appropriate. Consider the capabilities and limitations of the members of the nursing team and supervise the performance of the nursing interventions. Deciding whether delegation is indicated is another activity that arises during the nursing process.

The American Nurses Association and the National Council of State Boards of Nursing (2006) define delegation as “the process for a nurse to direct another person to perform nursing tasks and activities.” It generally concerns the appointment of the performance of activities or tasks associated with patient care to unlicensed assistive personnel while retaining accountability for the outcome.

Nevertheless, registered nurses cannot delegate responsibilities related to making nursing judgments. Examples of nursing activities that cannot be delegated to unlicensed assistive personnel include assessment and evaluation of the impact of interventions on care provided to the patient.

Record what has been done as well as the patient’s responses to nursing interventions precisely and concisely.

5. Evaluation: “Did the plan work?”

Evaluating is the fifth step of the nursing process. This final phase of the nursing process is vital to a positive patient outcome. Once all nursing intervention actions have taken place, the team now learns what works and what doesn’t by evaluating what was done beforehand. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. The possible patient outcomes are generally explained under three terms: the patient’s condition improved, the patient’s condition stabilized, and the patient’s condition worsened.

Steps in Evaluation

Nursing evaluation includes (1) collecting data, (2) comparing collected data with desired outcomes, (3) analyzing client’s response relating to nursing activities, (4) identifying factors that contributed to the success or failure of the care plan, (5) continuing, modifying, or terminating the nursing care plan , and (6) planning for future nursing care.

The nurse recollects data so that conclusions can be drawn about whether goals have been fulfilled. It is usually vital to collect both objective and subjective data. Data must be documented concisely and accurately to facilitate the next part of the evaluating process.

The documented goals and objectives of the nursing care plan become the standards or criteria by which to measure the client’s progress whether the desired outcome has been met, partially met, or not met.

The goal was met , when the client response is the same as the desired outcome.
The goal was partially met , when either a short-term outcome was achieved but the long-term goal was not, or the desired goal was incompletely attained.
The goal was not met.

It is also very important to determine whether the nursing activities had any relation to the outcomes whether it was successfully accomplished or not.

It is required to collect more data to confirm if the plan was successful or a failure. Different factors may contribute to the achievement of goals. For example, the client’s family may or may not be supportive, or the client may be uncooperative to perform such activities.

The nursing process is dynamic and cyclical. If goals were not sufficed, the nursing process begins again from the first step. Reassessment and modification may continually be needed to keep them current and relevant depending upon general patient condition. The plan of care may be adjusted based on new assessment data. Problems may arise or change accordingly. As clients complete their goals, new goals are set. If goals remain unmet, nurses must evaluate the reasons these goals are not being achieved and recommend revisions to the nursing care plan .

Discharge planning is the process of transitioning a patient from one level of care to the next. Discharge plans are individualized instructions provided as the client is prepared for continued care outside the healthcare facility or for independent living at home. The main purpose of a discharge plan is to improve the client’s quality of life by ensuring continuity of care together with the client’s family or other healthcare workers providing continuing care.

The following are the key elements of IDEAL discharge planning according to the Agency for Healthcare Research and Quality:

I nclude the patient and family as full partners in the discharge planning process.
Describe what life at home will be like
Review medications
Highlight warning signs and problems
Explain test results
Schedule follow-up appointments
E ducate the patient and family in plain language about the patient’s condition, the discharge process, and next steps throughout the hospital stay.
A ssess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s care to the patient and family and use teach back.
L isten to and honor the patient’s and family’s goals, preferences, observations, and concerns.

A discharge plan includes specific components of client teaching with documentation such as:

Equipment needed at home. Coordinate home-based care and special equipment needed.
Dietary needs or special diet . Discuss what the patient can or cannot eat at home.
Medications to be taken at home. List the patient’s medications and discuss the purpose of each medicine, how much to take, how to take it, and potential side effects.
Resources such as contact numbers and addresses of important people. Write down the name and contact information of someone to call if there is a problem.
Emergency response: Danger signs. Identify and educate patients and families about warning signs or potential problems.
Home care activities. Educate patient on what activities to do or avoid at home.
Summary. Discuss with the patient and family about the patient’s condition, the discharge process, and follow-up checkups.

39 thoughts on “The Nursing Process: A Comprehensive Guide”

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Adverse event reporting and root cause analysis

Increasing nurses’ understanding can reduce errors..

Maintaining patient safety is pivotal to nursing practice; the complexities of healthcare call for more in-depth attention to recognizing adverse events, utilizing incident reporting systems, and performing root cause analysis (RCA) to improve patient care.
An organization that promotes just culture encourages nurses and other healthcare providers to speak up when faulty processes and safety hazards are identified, and report concerns in the incident reporting system.
It is important that institutions prioritize the communication of the findings learned from the RCA process to promote transparency on what happened and the improvements made to prevent recurrence

Nurse leaders play a pivotal role in patient safety. By ensuring an effective incident reporting system is in place and engaging staff in root cause analysis (RCA), leaders can create a collaborative environment where nurses feel free to speak up about errors and participate in finding solutions. This article discusses reporting systems and uses a case study to illustrate RCA in action.

Incident reporting system

Nurses, who are among the highest reporters of adverse events, work most closely with patients and can identify errors that warrant further investigation. Incident reporting systems provide a secure mechanism to report safety concerns about vulnerabilities in the healthcare system and serve as a repository for tracking and trending adverse events. Leaders should reinforce with staff that these tools are meant to identify safety issues, not find blame. In fact, the reports are confidential and protected from discovery in legal proceedings. Some organizations even allow anonymous reporting for those who are afraid to speak up.

Most incident reporting systems are online and are routed directly to trained staff members (including nurses, physicians, and other leaders) who review each event as appropriate for their specialty areas. Unit leaders are responsible for interviewing staff to determine what, how, and why something happened. Lessons learned are shared with other patient care areas and immediate actions aim to mitigate an adverse event and prevent recurrence. When leaders close the loop with the staff member who reported the incident, they provide reassurance that the report won’t disappear into a black hole. This action builds trust with employees and highlights that the organization values staff safety concerns.

Safety reports also can serve as baseline data to identify care deficiencies as well as drive safety, performance, and quality improvement initiatives. The organization’s patient safety team selects adverse events on which to perform in-depth reviews and, depending on the severity of the patient harm, may escalate an event to various leaders within the organization. In many cases, an RCA is performed to gain a better understanding of the system issues underlying the adverse event.

In the following case study, in which a patient receives the incorrect heparin concentration, RCA evaluates the process for system flaws that may have contributed to the event.

Mary Black*, a 75-year-old woman with a history of hypertension, is admitted for chest discomfort. She’s diagnosed with a pulmonary embolism. After the appropriate laboratory and diagnostic workups are completed, Ms. Black is started on a weight-based heparin protocol infusion. When she develops severe nose bleeds and headaches, the nurse re-assesses the patient and discovers that the incorrect concentration of heparin is infusing. The nurse stops the infusion and notifies the physician. Orders are received for lab work and to perform a brain computed tomography (CT) scan. The lab results reveal an abnormally high partial thromboplastin time (>250 seconds), and the CT scan indicates that the patient suffered a stroke. The nurse immediately transfers Ms. Black to the intensive care unit and later enters an adverse event report into the organization’s reporting system.

Root cause analysis process

An RCA provides a structured and systematic approach to evaluating errors. It’s usually led by an individual with training and experience in investigative and event analysis methodology. An RCA aims to improve patient safety, tighten system vulnerabilities, and facilitate organizational learning. Some organizations include individuals involved in the adverse event as part of the RCA process, whereas others limit participation to subject-matter experts. Critical actions to the process include interviewing the staff involved, gaining an understanding of what happened, determining what usually happens, and identifying interventions to prevent event recurrence.

Information acquired during the interviews, from observing the area’s workflow, and by mapping the sequence of events is essential to understanding what led to the adverse event. Comparing that information to the standard operating procedure or policy set by the organization uncovers the breakdown in the system or process, revealing the event’s causal and contributing factors. Causal factors have a direct cause and effect relationship and tell what caused the event to occur; contributing factors identify the issues that led to the adverse event.

Individuals closest to the work bring valuable information to recognizing safety issues and may be called to help develop solutions. When adverse events occur, rarely is there one individual or system issue contributing to the error. Organizational variables—such as staffing, environmental factors, and lack of organizational policies—signal system issues that should be addressed during the RCA process. Although each organization’s RCA process varies, the most common tools used include an event flow diagram, the 5-whys technique, and the fishbone diagram.

After reviewing Ms. Black’s chart and interviewing the staff involved, an individual skilled in RCA methodology (RCA analyst) creates a timeline and maps out the details of the event using a flow diagram (See Process mapping .) Using a fishbone diagram, the analyst identifies all the possible contributing factors (people, processes, equipment, materials, environmental) leading up to the error. (See Fishbone diagram .) The main headings can be adapted to reflect the process being analyzed. The analyst then uses the 5 whys to get to the root cause of the problem. Each question starts with a problem (Why did this problem occur?). The statement answering each why question is rephrased as a new question until no more “why” questions can be elicited. To get to the root of what caused the adverse event in this case, the analyst asks these questions:

Why did Ms. Black develop an intracranial hemorrhage?
Because the heparin dose was too high.
Why was the heparin dose too high?
Because the wrong concentration was infusing.
Why was the wrong concentration infusing?
Because the scan error was overridden.
Why was the scan error overridden?
Because the wrong concentration went unnoticed.
Why did the wrong concentration go unnoticed?
Because of the belief that the correct bag was dispensed from the pharmacy.

Process mapping

Use a flow chart to map a process and identify errors. This flow chart follows the process of ordering and administering heparin in the case study with Ms. Black.

Fishbone diagram

Use a fishbone diagram to identify all factors (people, processes, equipment, materials, and environmental) that may have contributed to an error. This diagram illustrates the factors that contributed to the heparin error in the case study with Ms. Black.

A team of key stakeholders (including nurses, pharmacists, managers, and providers) participates in the RCA to discuss the event and confirm the root causes associated with the heparin overdose. Action plans, which are selected based on the RCA outcomes, should address system issues and any gaps in training and education. Meaningful and sustainable changes start with implementing actions that improve the systems in which people work. For example, adding a force function or automating a system or process can eliminate user error and mitigate future events.

In Ms. Black’s case, the RCA finds six causes behind the adverse event. Corresponding steps are taken to prevent future events.

Cause: Standardized heparin concentrations are used, but the shipment received from the manufacturer was incorrect.

Solution: Report the error to the manufacturer.

Cause: The pharmacy process caught the error, but the quarantined shipment was accidently included with the inventory supply.

Solution: Designate an area or room for quarantined shipments with clear box labeling or area signage.

Cause: The medication was correctly labeled, but the incorrect concentration went unnoticed and was dispensed to the unit.

Solution: Implement independent double-checks before dispensing high-alert drugs to the unit.

Cause: When the heparin was initiated, the scan error from the electronic health record (EHR) was overridden.

Solution: Automate smart infusion pumps with the EHR to prevent manual data entry.

Cause: Standard double checks verifying the pump and calculations weren’t followed.

Solution: Drugs requiring double checks before administration should be programmed into the EHR using a best practice advisory popup alert (BPA) to improve adherence.

Cause: The incorrect concentration was manually entered.

Solution: Implement anticoagulation stewardship to improve monitoring and surveillance.

To help ensure adherence with the solutions, units will observe or audit the double-check process. They’ll also monitor BPA reports to determine the adherence rate with documentation of the double-check process, and the organization will monitor heparin infusion error rates.

If it appears that negligence or risky behavior contributed to the event, RCA investigations can result in referrals to peer review or risk management. Just culture, which is tied closely to the RCA process, is a fair and unbiased approach to addressing systems issues rather than blaming individuals. An organization that promotes just culture encourages nurses and other healthcare providers to speak up when faulty processes and safety hazards are identified and immediately report concerns in the incident reporting system.

Implications for nurse leaders

Nurses frequently share concerns about the lack of closed-loop feedback when an adverse event is reported. Although many organizations have mechanisms for sharing best practices or lessons learned, nurses may not make connections between the incident they reported and the actions taken. To promote transparency, organizations must prioritize communicating findings from the RCA process and the improvements made to prevent recurrence, increase safety issue understanding, and enhance staff buy-in and participation in improvements. In many cases, quality improvement initiatives and policies, algorithm development, and medical equipment and device changes are a direct result of mining an organization’s reporting system or implementing corrective actions from an RCA. Leaders should make that clear to staff so they understand the importance of their reports.

Nurses are vital to identifying safety issues in their work environments. When nurses are educated about the importance of adverse event reporting, leaders can aggregate data from those reports to detect and analyze events. As champions for patient safety, nurses and nurse leaders can use incident reporting and the RCA process to help narrow the knowledge gap, encourage learning from errors, and improve safe nursing practice. AN

*Name is fictitious.

Access references at myamericannurse.com/?p=112415.

Tamu Abreu is the program manager for patient safety at MD Anderson Cancer Center in Houston, Texas.

Aboumrad M, Fuld A, Soncrant C, Neily J, Paull D, Watts BV. Root cause analysis of oncology adverse events in the Veterans Health Administration. J Oncol Pract . 2018;14(9):e579-90. doi:10.1200/JOP.18.00159

Aboumrad M, Neily J, Watts BV. Teaching root cause analysis using simulation: Curriculum and outcomes. J Med Educ Curric Dev . 2019;6:2382120519894270. doi:10.1177/2382120519894270

Archer S, Hull L, Soukup T, et al. Development of a theoretical framework of factors affecting patient safety incident reporting: A theoretical review of the literature. BMJ Open. 2017;7(12):e017155. doi:10.1136/bmjopen-2017-017155

Charles R, Hood B, Derosier JM, et al. How to perform a root cause analysis for workup and future prevention of medical errors: A review . Patient Saf Surg 2016;10:20. doi:10.1186/s13037-016-0107-8

Hagley G, Mills PD, Watts BV, Wu AW. Review of alternatives to root cause analysis: Developing a robust system for incident report analysis. BMJ Open Qual . 2019;8(3):e000646. doi:10.1136/bmjoq-2019-000646

Hibbert PD, Thomas MJW, Deakin A, et al. Are root cause analyses recommendations effective and sustainable? An observational study. Int J Qual Health Care . 2018;30(2):124-31. doi:10.1093/intqhc/mzx181

The Joint Commission. Root Cause Analysis in Health Care: Tools and Techniques . 6th ed. Oakbrook Terrace, IL: The Joint Commission; 2017.

National Patient Safety Foundation. RCA 2 : Improving Root Cause Analyses and Actions to Prevent Harm . 2015. cdn.ymaws.com/www.npsf.org/resource/resmgr/PDF/RCA2_first-online-pub_061615.pdf

Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf . 2017;26(5):417-22. doi:10.1136/bmjqs-2016-005511

Vacher A, El Mhamdi S, dʼHollander A, et al. Impact of an original methodological tool on the identification of corrective and preventive actions after root cause analysis of adverse events in health care facilities: Results of a randomized controlled trial. J Patient Saf . 2017. doi:10.1097/PTS.0000000000000437

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Home » Educators » Developing Analytical Thinking Using UWorld’s Learning Platform

Developing Analytical Thinking Using UWorld’s Learning Platform

Last Updated: October 18, 2021

NCLEX-PN , NCLEX-RN

Analytical thinking is crucial in the nursing profession. Gathering pertinent information, solving unforeseen problems, and using clinical judgment are tasks required every day in nursing practice, and these tasks require a level of analytical thinking.

The need for strong analytical thinking skills in nursing is not reserved for professionals only, nursing students need these skills too. Success in the classroom, during rotations, and on the NCLEX® is significantly tied to a student’s ability to demonstrate proficiency in analytical thinking.

It is incumbent upon nursing programs and the instructors they employ to do more than just distribute information — when we develop critical and analytical thinking skills in our students, we cultivate competencies that lead to clinical success.

The maturation of analytical skills builds student confidence, improves learning capacity, increases the chances of NCLEX success , and ultimately benefits the patients our students will eventually care for.

With thousands of challenging questions designed to develop students’ critical thinking skills, UWorld’s new Learning Platform for Nursing, enables educators to use our clinically-relevant questions and content-rich rationales for instruction, homework, and remediation.

What Is Analytical Thinking?

At its core, analytical thinking is thinking that follows a logical process of eliminating ideas to narrow the range of possibilities to one feasible solution. It is the mental process of taking complex information and breaking it down into fundamental parts to arrive at the right decision.

Analytical thinking and critical thinking vary slightly in that analytical thinking breaks down larger, more complex pieces of information to arrive at a decision, and critical thinking considers outside information and existing complexities to make a judgment.

Both skills — analytical thinking and critical thinking — are essential for practicing nursing in the classroom and at the bedside. The nurse who begins developing his or her analytical and critical thinking skills early in nursing school will have stronger clinical judgment skills when they enter practice.

Why Is Analytical Thinking Crucial for NCLEX Success?

A key to success in nursing, whether you’re a nursing professional or a nursing student, is the ability to assess a situation and first eliminate wrong steps or choices. Knowing what not to do, is often as important as knowing what to do.

The application for students taking the NCLEX-RN® and NCLEX-PN® is obvious: When you can use analytical thinking to discard incorrect answer choices, your chances of answering correctly improve significantly.

When facing a difficult item on the NCLEX-RN or NCLEX-PN exam, the student who can use a logical process, such as the ABCs, to quickly eliminate the wrong options, has an advantage and is more likely to come to the correct conclusion.

Extrapolate that skill into a future nursing career and you find a clinician who is well versed in calmly, methodically, yet quickly making critical decisions accurately.

How Does UWorld’s Learning Platform Develop Analytical Thinking?

The Learning Platform for Nursing is more than a test-prep resource; it is an innovation that utilizes learning tools to increase analytical thinking skills as well as critical thinking skills across your curriculum. It does this in a number of ways . . .

Assignable Questions and Detailed Explanations The assignable questions that instructors can task their students to complete — either in the classroom, in groups, or as homework — are written at the application level and higher. When students sit for their NCLEX, they have already spent time developing their analytical thinking skills with these NCLEX-style questions. The detailed explanations written for every answer choice (whether correct or incorrect) provide the student with the “why” — why this choice was correct, and why these choices were incorrect. This concise yet detailed instruction builds competency in eliminating incorrect answer options on future questions.
Vivid Illustrations The high-quality, vivid illustrations that accompany questions and answers in the UWorld QBank are an important part of the learning process that aid in classroom instruction, individual learning, and NCLEX preparation. This is especially important for visual learners. Not all students process and retain information the same way, and for those who learn visually, illustrations and images not only facilitate learning but also contribute to the development of analytical thinking skills.
Classroom Presentation The Classroom Presentation feature is where the instructor and UWorld’s high-quality questions work hand in hand for the betterment of the cohort. Now, nursing programs can supplement their curriculum with NCLEX-style practice questions that allow the instructor to work through items in the classroom. As the instructor leads the class in first eliminating wrong answer choices as part of the presentation, students are learning to develop analytical thinking. Tell me which answers are wrong and why? This is a crucial first step in learning and one that instructors can employ in the classroom environment.

In order for your students to succeed in the classroom, during rotations, on the NCLEX, and in future practice, analytical thinking and critical reasoning skills are imperative.

This is crucial for educational and professional success. Analytical thinking allows a person to assess the question or situation and quickly move past incorrect choices.

UWorld’s Learning Platform for Nursing was developed by nursing educators and practicing nurses in a way designed to build critical reasoning and analytical thinking skills. The assignable questions, detailed answer explanations, vivid illustrations and images, and performance tracking do more than just improve a program’s NCLEX-RN or NCLEX-PN pass rates — they build student confidence, increase learning opportunities, and help prepare the next generation of nurses for a safe, accurate, and fulfilling career in nursing. If you have any questions or want to see a personal demo of UWorld’s Learning Platform for Nursing, contact [email protected] .

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Nursing Research Resources: Concept Analysis

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Concept Analysis

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Concept analysis is a strategy used for examining concepts for their semantic structure. Although there are several methods for conducting concept analysis, all of the methods have the purpose of determining the defining attributes or characteristics of the concept under study. Some uses of a concept analysis are refining and clarifying concepts in theory, practice, and research and arriving at precise theoretical and operational definitions for research or for instrument development. Concept analysis has been used in other disciplines, particularly philosophy and linguistics, for many years. However, the techniques have only recently been “discovered” by nurses interested in semantics and language development in the discipline.

Concept analysis is a useful tool for nurses conducting research. Because the outcome of a concept analysis is a set of defining characteristics that tell the researcher “what counts” as the concept, it allows the researcher to (a) formulate a clear, precise theoretical and/or operational definition to be used in the study; (b) choose measurement instruments that accurately reflect the defining characteristics of the concept to be measured; (c) determine if a new instrument is needed (if no extant measure adequately reflects the defining characteristics); and (d) accurately identify the concept when it arises in clinical practice or in qualitative research data...

Source: Encyclopedia of Nursing Research (2). New York, US: Springer Publishing Company, 2006. ProQuest ebrary . Web. 5 October 2016. Copyright © 2006. Springer Publishing Company. All rights reserved.

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Dictionary of Microbiology and Molecular Biology (2006 (3rd ed., Revised)
Dictionary of Neurological Signs : Clinical Neurosemiology (2001)
Dictionary of Sport and Exercise Science (2006)
Dictionary of Veterinary Medicine and Biosciences (2nd Student ed., 2000)
Dorland's Dictionary of Medical Acronyms and Abbreviations (7th ed., 2016)
Historical Dictionary of Psychiatry (2005)
Learner`s Dictionary for Student and Professionals : English for European Public Health (2008)
Quick Reference Dictionary for Orthopedics (2012)
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Techniques in the Behavioral and Neural Sciences : Experimental Design : A Handbook and Dictionary for Medical and Behavioral Research (1999)
Webster's New World Medical Dictionary (3rd ed., 2009)

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Encyclopedia of Nursing Research (4th Edition; 2017)
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Biomechanics in Sport: Performance Enhancement and Injury Prevention : Olympic Encyclopaedia of Sports Medicine (2007)
Brain Tumors : An Encyclopedic Approach (2012; 3rd Edition)
Encyclopaedia of Sports Medicine An IOC Medical Commission Publication, The Endocrine System in Sports and Exercise (2007)
Encyclopedia of Aging (4th ed., 2006)
Encyclopedia of Biomaterials and Biomedical Engineering (2008; 2nd Edition)
Encyclopedia of Biopharmaceutical Statistics (2003; 2nd Edition)
Encyclopedia of Body Sculpting after Massive Weight Loss (2011)
Encyclopedia of Clinical Pharmacy (2003)
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Encyclopedia of Elder Care : The Comprehensive Resource on Geriatric and Social Care (2nd Edition; 2008)
Encyclopedia of Farm Animal Nutrition (2004)
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Encyclopedia of Infectious Diseases: Modern Methodologies (2007)
Encyclopedia of Medical Genomics and Proteomics, Volume 1-2 (2005)
Encyclopedia of Molecular Biology (1994)
Encyclopedia of pain (2007)
Encyclopedia of Pharmaceutical Technology, Volumes 1 - 6 (2007; 3rd Edition)
Encyclopedia of Psychological Trauma (2008)
Epilepsy A to Z : A Concise Encyclopedia (2nd ed., 2009)
Library of Health and Living : Encyclopedia of Trauma and Traumatic Stress Disorders (2009)
MIT Encyclopedia of Communication Disorders (2003)
Nutrition in Sport : Olympic Encyclopaedia of Sports Medicine Volume VII (2007)
Rehabilitation of Sports Injuries - Scientific Basis : Olympic Encyclopaedia of Sports Medicine (2007)
Strength and Power in Sport : Olympic Encyclopedia of Sports Medicine (2007)
Tendinopathy in Athletes : Encyclopaedia of Sports Medicine an IOC Medical Commission Publication (2007)
Women in Sport : Olympic Encyclopaedia of Sports Medicine (2007)

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For articles that are not available full-text via the LRC website, you can submit a material request using the link below:

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To locate articles discussing the topic for your concept analysis assignment, use the recommended list of term combinations that will help you to retrieve all relevant articles. You will want to AND your concept with the search terms below:

"concept analysis"
philosophy OR philosophies
theory OR theories OR theoretical
defined OR definition

For example:

"assisted living" AND ("concept analysis" OR philosophy OR theory OR theories OR theoretical OR defined OR definition OR concept*)

Use Google Docs to keep track of the following:

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Databases to include, such as PubMed, CINAHL, PsycINFO, PowER Search, etc.
Concepts and like terms
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Clinical Nurse Specialist: The Journal for Advanced Nursing Practice

March/April 2017, Volume :31 Number 2 , page 70 - 73 [Free]

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Foley, Angela S. MSN-HCSM, RN
Davis, Alison H. PhD, RN, CHSE

Article Content

For the clinical nurse specialist (CNS) engaged in research or evidence-based practice (EBP), a concept analysis can provide guidance when a concept of interest does not have sufficient literature, is vaguely defined, or is not understood clearly or when literature and research do not match. 1 Once the concept is more concrete, the CNS can explore and determine a study design or measurement tool. There are several approaches to a concept analysis including, but not limited to, the approaches by Chinn and Jacobs, 2 Walker and Avant, 3 Rodgers, 4 and Sartori. 5 The purpose of this article is to provide insight into a concept analysis through definitions, purpose, and procedures and provide an example of a concept analysis on empathy using the Rodgers method of evolutionary concept analysis.

DEFINITIONS

A concept represents a symbol or a building block of a bigger spectrum; it is the basis of what the researcher wants to pursue. 6 In nursing, research can be applied through the use of EBP. Research is a methodical and rigorous inquiry, which provides answers to questions surrounding phenomena. 7 Evidence-based practice is the gathering, evaluation, and integration of research in combination with clinical expertise to inform nursing practice. 6 Research and EBP both rely on a clear understanding of what is being studied or the concept, which has been chosen by the researcher. A concept analysis can be defined as the dissection of a concept into simpler elements to promote clarity while providing mutual understanding within nursing. 1 If the researcher notes a lack of clarity surrounding the concept, a concept analysis should be undertaken to achieve a better understanding of the concept. A concept analysis can elucidate the meaning of the concept in current use, which can contribute to the future development of the concept. 2

RODGERS APPROACH TO CONCEPT ANALYSIS

Rodgers 4 offered a method of concept analysis referred to as an evolutionary view of concepts, which "addresses contemporary concerns valuing dynamism and interrelationships within reality." 4 (p332) After the recognition of the concept to be studied, it must be clearly defined. Because concepts for analysis are sometimes vague or confusing to the CNS researcher, simply using 1 definition would be insufficient to the researcher. All associated conceptual descriptions must be uncovered for the CNS researcher to clearly understand the depth of a concept. Rodgers 6 stressed that the significance of the concept to nursing should be clearly delineated in other fields, occurrences, and/or professions, as well.

Rodgers' 4 approach to concept analysis includes 7 phases, which can be carried out simultaneously and not necessarily in a linear manner. However, for clarity, these phases are described linearly.

The phases of concept analysis are to 4

1 identify and name the concept of interest;

2 identify the surrogate terms and relevant uses of the concept;

3 select an appropriate realm (sample) for data collection;

4 recognize attributes of the concept;

5 ascertain the references, antecedents, and consequences of the concept, if possible;

6 identify concepts related to the concept of interest; and

7 generate a model case of the concept.

The Table delineates these phases and provides an example of an abbreviated concept analysis.

Table Rodgers' Phases of Evolutionary Concept Analysis

Identify and Name the Concept of Interest

To begin the dissection of the identified concept of interest, the CNS researcher must begin with the meaning to nursing. An initial review of the literature provides insight into an elusive concept because the researcher can discover what is known, not known, or confusing about a concept.

Empathy was chosen as the concept of interest to illustrate the process of concept analysis. Empathy is considered to be at the heart of nursing as a part of caring. One definition says that "an empathetic nurse is sensitive to the patient's feelings and problems, but remains objective enough to help the patient work to attain positive outcomes." 8 (p462) In addition to patients, family members also benefit from an empathetic nurse. For example, when facing potential loss of a loved one, the CNS understands and is sensitive to the fears of losing a loved one. Clinical nurse specialists recognize and acknowledge the feelings of helplessness in a family member and tailor care to reflect these empathetic feelings. Through this display of empathy, the CNS builds trust with patients and families while building a deeper therapeutic relationship. 9

Identify Surrogate Terms and Relevant Uses of the Concept

The dissection of the meaning of the concept will identify surrogate terms. Again, the initial review of literature provides clarity to the researcher because additional terms are sought. Relevant uses for the concept will also surface.

Surrogate terms found in the literature for empathy include caring, sensitive, recognition, awareness, intention, communication, understanding, acknowledgement of feelings, helping attitude, and trusting and therapeutic relationship.

Select an Appropriate Realm (Sample) for Data Collection

To identify an appropriate realm (sample) for data collection, an in-depth review of literature on the concept identifies potential realms in nursing and other healthcare fields. PubMed, Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, and MEDLINE are appropriate for performing the initial and in-depth review of literature. The key words, which are the identified surrogate terms, should be used for the search. Initially, a multitude of articles may be available on the concept using the identified terms or combinations of terms. The CNS researcher must appraise each article critically to explore and develop the concept. 10 This critical appraisal uses the literature as data to discover new knowledge and pose analytic questions about a concept. 10 It may be helpful to ask whether the authors are "describing the concept the same" or "using the concept similarly" or "were there any inconsistencies sited in the literature?" This step is invaluable for understanding how other researchers view the concept. Answers to these analytic questions also reveal to the researcher what is known and unknown about the concept.

For this example, the review of literature was performed in PubMed using the following search terms: empathy and the millennial (because this analysis was undertaken by a CNS student representing this demographic), empathy and healthcare, and empathy and CNS students. After a critical appraisal of the literature, confusion, ambiguities, and in consistencies with the concept of empathy became apparent. Empathy was separated into cognitive and affective empathy, with no clear delineation within the literature. In nonnursing literature, empathy was described as mirrored and imaginative self-empathy. Empathy was also labeled as more cognitive rather than affective. 11 Empathy does involve some emotional and cognitive capacitates; however, the idea of empathy as more cognitive may hinder emotions from being communicated, which can interfere in nursing therapeutic relationships. Brown et al 11 implied that being emotional was not professional and was confusing to the patient. This conceptualization raises the question of "how emotional is too emotional" when communicating empathetically to a patient. These inconsistencies cause one to question whether empathy is a cognitive or an emotional reaction and whether it is even a component of caring in nursing.

Identify the Attributes, References, Antecedents, and Consequences of the Concept

After addressing the inconsistencies in the literature review, it is vital to recognize other terms associated with the concept. These references, antecedents, and consequences are actions that occur or are associated with the concept. This step is essential for dissecting the concept and understanding all associated nuances. This step provides the researchers with a sense of tangibility of the concept. These attributes will lead to the operationalization of the concept, which will lead to the selection of a measurement tool.

Critical attributes associated with the concept of empathy are relationship, communication, and understanding. Ward et al 9 explained the nurse-patient relationship as grounded in communication, which incorporates specialized knowledge of the patient's condition or situation, thus promoting a therapeutic bond between the CNS and patient. Understanding the context of the patient's experience and attendant implications is a critical characteristic of empathy and empathetic engagement. 9

Antecedents of empathy include intention to help and awareness. Without first having the intention to help, nurses would not seek out situations or position themselves to render help. The intention to help is fundamental to empathy in the context of patient care. 9 Moreover, to be helpful, the CNS must be aware of the patient's behaviors and recognize when and what help is needed. Awareness comes into play during the interaction of 2 involved persons. In the case of nursing, the intent to help and awareness of the patient's situation facilitate the therapeutic communication, underpinning concepts of empathy.

Consequences of empathy in nurse-patient relationships could be patient satisfaction and perception of caring. Positive interaction between the patient and nurse during an empathetic encounter may lead to patient perception of caring by the nurse, which in turn leads to patient satisfaction. This positive interaction may also be a source of job satisfaction for the nurse.

Identify Concepts Related to the Concept of Interest

After recognizing what attributes, antecedents, and consequences align with the concept, one must then determine if there are any related concepts that need clarification in the literature. Again, a critical appraisal of the literature will reveal to the investigator what relevant research has been done, any confusion related to the concept, and future research implications.

The concepts of empathy, sympathy, and communication skills are commonly misused in the nursing and healthcare literature and are often used interchangeably by healthcare professionals in clinical practice. For example, Brown et al 11 studied empathy using instruments that measure listening and communication in general. Listening was identified as instrumental in communicating empathy. As a result of the study of Brown et al, 11 a relationship between listening and communicating empathy was linked. Communication is a very complex and multidimensional concept. Empathy needs to be expressed as a subset of communication to truly understand its meaning.

Lack of empathy in the patient-care process among healthcare professionals is frequently reported as a significant finding in the literature. 12 Using empathy and strengthening empathetic relationships in the patient-care process have been shown to lead to better healthcare outcomes for patients, such as increased patient satisfaction. 12 Through the development of a better understanding and correct use of the concept of empathy in practice, healthcare providers may also experience greater professional satisfaction. 12

Identify a Model Case

The selection of a model case provides the researcher with a clear example, which allows the researcher to gain a more concrete notion of the concept and clarifies the direction of research. 10 The following is an example of a model case for empathy. A CNS enters a patient's room to check on the patient's status. The CNS sees the patient crying and asks, "What is wrong? How may I help?" The patient states that she is scared about the surgery scheduled for the next day. The patient further explains that she has not had surgery before and is unsure why the surgery is needed. Empathy allows the CNS to remember a time when faced with an unknown situation and recalls feelings of uncertainty and fear. The CNS is empathetic with the patient, although the CNS has not experienced this surgery. Empathy allows the CNS to understand why a patient would be scared, and in addition, the CNS has the requisite advanced knowledge to understand why the patient requires surgery. The CNS responds by comforting the patient and stating, "I understand why you would be scared. It's normal to feel scared when you are facing a new situation." The CNS then explains the procedure and why it is important that the patient undergoes this surgery. The CNS has displayed empathy through communication with the patient, recognizing the patient's emotions, and understanding the patient's experience.

Concept analysis is a crucial step in providing clarity for a concept that is not well defined or is confusing to a CNS in the researcher role. A completed concept analysis will aid the researcher in the identification of all aspects of the concept. The concept analysis will require the researcher to dissect the concept into several descriptors (antecedents, consequences, and attributes) to transform an abstract idea into a more tangible concept. The concept analysis allows the researcher to progress to subsequent phases of the research process such as operationalizing the concept, selecting a design, and choosing an appropriate measurement instrument.

1. Nuopponen A. Methods of concept analysis: a comparative study. LSP . 2010;1:4-12. [Context Link]

2. Chinn PL, Jacobs JK. Theory and Nursing: A Systematic Approach . St Louis, MO: Mosby; 1983. [Context Link]

3. Walker LO, Avant KC. Strategies for Theory Construction in Nursing . Norwalk, CT: Appleton; 1983. [Context Link]

4. Rodgers BL. Concepts, analysis and the development of nursing knowledge: the evolutionary cycle. J Adv Nurs . 1989;14(4):330-335. [Context Link]

5. Sartori G. Social Science Concepts: A Systematic Analysis . New York, NY: Sage; 1984. [Context Link]

6. Rodgers BL. Developing Nursing Knowledge: Philosophical Traditions and Influences . Philadelphia, PA: Lippincott Williams & Wilkins; 2005. [Context Link]

7. LoBiondo-Wood G, Haber J. Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice . St Louis, MO: Elsevier Mosby; 2014. [Context Link]

8. Taylor CR, Lillis C, Lynn P. Roles basic to nursing care. In: Fundamentals of Nursing: The Art and Science of Nursing Care . 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2015:444-477. [Context Link]

9. Ward J, Cody J, Schaal M, Hojat M. The empathy enigma: an empirical study of decline in empathy among undergraduate nursing students. J Prof Nurs . 2012;28(1):34-40. [Context Link]

10. Rodgers BL, Knafl KA. Concept Development in Nursing, Foundations, Techniques, and Applications . 2nd ed. Philadelphia, PA: Saunders; 2000. [Context Link]

11. Brown T, Boyle M, Williams B, et al. Predictors of empathy in health science students. J Allied Health . 2011;40(3):143-149. [Context Link]

12. Boodman S. Instilling empathy among doctors pays off for patient care. CNN Web site. http://www.cnn.com/2015/03/26/health/doctor-empathy/index.html . Updated March 26, 2015. Accessed March 27, 2015. [Context Link]

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Roberta Heale 1 ,
Alison Twycross 2
1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
2 School of Health and Social Care , London South Bank University , London , UK
Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6 ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

Gustafsson J
Calanzaro M
Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

Read the full text or download the PDF:

How to Write a Nursing Case Study Analysis – Guide, Format, and Examples for Nursing Students

Wilson logan.

August 6, 2022
Nursing Writing Guides

How to Write a Nursing Case Study Analysis

What is a Nursing Case Study Analysis?

A case study analysis is a detailed examination of a specific real-world situation or event.

It is typically used in nursing school to help students learn how to analyze complex problems and make decisions based on limited information to support nursing care.

Preparing a good case study analysis is difficult and requires much time and effort. This article provides some tips on how to write a case study analysis that will help you get the most out of your research and provide a solid foundation for your writing.

A case study analysis requires you to investigate a nursing scenario, examine the alternative solutions, and propose the most effective solution using supporting evidence.

Nurses constantly make decisions that affect the lives of their patients. Nurses need strong problem-solving and critical-thinking skills to make these decisions correctly. Case studies are an excellent way for nurses to hone these skills.

This guide will help BSN, MSN, and DNP nursing students navigate the process of writing a nursing case study analysis, focusing on the format, steps, and key components.

How do you analyze a case study in nursing?

A nursing case study is an in-depth examination of a single individual. It is usually used to identify new areas of knowledge or to validate existing knowledge.

When analyzing a nursing case study, it is important to consider the following elements:

The patient’s medical history. This includes any prior illnesses, treatments, and medications.
The patient’s current condition. This includes symptoms, vital signs, and laboratory results.
The nurse’s observations. This includes the nurse’s notes on the patient’s condition and behavior.
The patient’s family and social history. This includes information on the patient’s family, friends, and social support network.
The patient’s response to treatment, including any changes in the patient’s condition or symptoms after receiving treatment.

How Nursing Practitioners Can Analyze Patient’s Cases

As a nurse practitioner, you will often be asked to provide a case analysis for your patients. This can be a daunting task, but there are some key elements that you should always include in your analysis.

The first element is the patient history. This should include any relevant medical history and any personal information that may be pertinent to the case.
The second element is the physical examination. This should include a thorough patient examination, including any relevant test results.
The third element is the diagnosis. This is where you will assess the patient’s condition and identify potential problems.
The fourth element is the treatment plan. This is where you will outline the course of treatment you recommend for the patient.
The fifth and final element is the prognosis. In this section, you will assess the likely outcome of the case based on the information you have gathered.

How to Write a Nursing Case Study Analysis

Format of a nursing case study analysis.

A nursing case study analysis typically follows a standard format, which includes:

Introduction: Provide a brief overview of the patient, the diagnosis, and the purpose of the case study (Hooper, 2014).
Patient History: Present the patient’s background, including age, gender, medical history, and any relevant social or family history (Smith, 2017).
Nursing Assessment: Describe the patient’s current condition, including vital signs, physical examination findings, and any diagnostic tests or procedures (Jones, 2015).
Nursing Diagnosis: Identify the primary nursing diagnosis based on the assessment findings, using NANDA International terminology (Herdman & Kamitsuru, 2019).
Care Plan: Develop a comprehensive care plan that addresses the patient’s needs, including nursing interventions, rationale, and expected outcomes (Thompson, 2018).
Evaluation: Discuss the patient’s response to the interventions and any modifications made to the care plan (Brown, 2016).
Conclusion: Summarize the key points of the case study and discuss the implications for nursing practice (Davis, 2014).

Steps for conducting a case study in nursing research papers

Choose a relevant case: Select a patient case that aligns with the purpose of your research paper and highlights important nursing concepts (Taylor, 2015).
Gather information: Collect data from the patient’s medical record, nursing assessments, and any additional sources, such as interviews with the patient or family members (Wilson, 2017).
Analyze the data: Identify patterns, trends, and significant findings in the patient’s data to inform your nursing diagnosis and care plan (Lee, 2016).
Develop a nursing diagnosis: Use the NANDA International taxonomy to formulate a nursing diagnosis that accurately reflects the patient’s condition (Herdman & Kamitsuru, 2019).
Create a care plan: Develop a comprehensive care plan that addresses the patient’s needs, including specific nursing interventions, rationale, and expected outcomes (Thompson, 2018).
Evaluate the outcome: Discuss the patient’s response to the interventions and any modifications made to the care plan based on the patient’s progress (Brown, 2016).
Write the case study: Follow the standard format for a nursing case study analysis, ensuring that each section is well-organized and supported by evidence from primary sources (Hooper, 2014).
First, you will need to read over the case study thoroughly.
Ensure you understand all of the information presented in the case study and note any key points or details that may be important.
Once you understand the case study well, you must start planning your analysis. Consider your overall argument.
What points do you want to make in your analysis?
What evidence will you use to support these points?
Once you have a good idea of what you want to say in your analysis, start organizing your thoughts and putting them into a coherent structure.
Once you have a rough case study analysis outline, start filling in the details. Flesh out your arguments and provide evidence to support them. In addition, make sure to address any counterarguments that could be made against your points.
Finally, conclude your analysis by summarizing your main points and providing any recommendations or suggestions for further action.

Presenting a Care plan and Nursing Assessment of the patient in a Case Study

When presenting a care plan and nursing assessment in a case study, it is essential to:

Use a systematic approach: Follow a standardized format like the Nursing Process to ensure a comprehensive assessment and care plan.
Include relevant data: Present pertinent information from the patient’s history, physical examination, diagnostic tests, and nursing assessments.
Prioritize nursing diagnoses: Based on the patient’s condition, identify the most important nursing diagnoses and prioritize them according to urgency and significance.
Develop patient-centered interventions: Create nursing interventions that are specific, measurable, achievable, relevant, and time-bound (SMART) and tailored to the patient’s individual needs.
Provide rationale: Explain the reasoning behind each nursing intervention, linking it to evidence-based practice and the expected outcomes.
Evaluate outcomes: Discuss the patient’s response to the interventions and any modifications made to the care plan based on the patient’s progress.

How to write case study analysis in nursing

To write a case study analysis in nursing, follow these steps:

Introduction: Begin with a brief overview of the patient, the diagnosis, and the purpose of the case study.
Patient History: Present the patient’s background, including age, gender, medical history, and any relevant social or family history.
Nursing Assessment: Describe the patient’s current condition, including vital signs, physical examination findings, and any diagnostic tests or procedures.
Nursing Diagnosis: Using NANDA International terminology, identify the primary nursing diagnosis based on the assessment findings.
Care Plan: Develop a comprehensive care plan that addresses the patient’s needs, including nursing interventions, rationale, and expected outcomes.
Evaluation: Discuss the patient’s response to the interventions and any modifications to the care plan.
Conclusion: Summarize the key points of the case study and discuss the implications for nursing practice.

How to Structure a Nursing Case Study Analysis Paper

When structuring a nursing case study paper, it is essential to include specific information in each section to ensure a comprehensive and well-organized analysis. Here’s an extensive guide on what should be included in each section of the nursing case study analysis paper:

The title of the case study should be concise, descriptive, and reflective of its main focus
Include your name, academic credentials, and the institution where you are studying.
Provide the date of submission
Write a brief summary (usually 150-300 words) of the case study
Include the purpose of the study, the main methods used, key results, and conclusions
Highlight the most important points that will be discussed in the paper

Introduction

Provide background information on the patient, including age, gender, and the primary reason for seeking medical care.
Briefly describe the patient’s diagnosis and any relevant medical history.
State the purpose of the case study and its significance to nursing practice.

Patient History

Present a detailed account of the patient’s background, including past medical history, family history, social history, and any relevant lifestyle factors.
Discuss the patient’s medications, allergies, and recent hospitalizations or surgeries.
Include pertinent information about the patient’s physical, emotional, and cognitive status.

Nursing Assessment:

Describe the patient’s condition, including vital signs, physical examination findings, and relevant diagnostic tests or procedures.
Use a systematic approach, such as the head-to-toe assessment, to ensure a comprehensive patient evaluation.
Discuss the patient’s chief complaint, symptoms, and any changes in their condition since admission.

Nursing Diagnosis

Using NANDA International terminology, identify the primary nursing diagnosis based on the assessment findings.
Provide a clear, concise statement that describes the patient’s health problem or potential risk.
Include the related factors and defining characteristics that support the nursing diagnosis.
Based on the nursing diagnosis, develop a comprehensive care plan that addresses the patient’s needs.
Include specific, measurable, achievable, relevant, and time-bound (SMART) goals for each nursing intervention.
Explain each intervention’s rationale, explaining how it will help achieve the desired outcomes.
Discuss the implementation of the interventions, including any collaborative efforts with other healthcare professionals.
Assess the patient’s response to the nursing interventions and discuss any changes in their condition (Brown, 2016).
Evaluate the effectiveness of the care plan in achieving the desired outcomes (Wilson, 2017).
Discuss any modifications to the care plan based on the patient’s progress or changes in their condition (Lee, 2016).
Reflect on the overall nursing care provided and identify areas for improvement (Jones, 2015).
Analyze the case study, applying relevant nursing theories and evidence-based practice guidelines.
Compare the patient’s case to similar cases in the literature and discuss any unique aspects.
Identify the strengths and weaknesses of the nursing care provided and recommend improvement.
Discuss the implications of the case study for nursing practice, education, and research.
Summarize the key points of the case study, including the primary nursing diagnoses, interventions, and outcomes.
Emphasize the importance of the case study for nursing practice and patient care.
Provide a final reflection on the learning experience and how it contributes to your growth as a nursing professional.
List all sources cited in the case study using the appropriate citation style (e.g., APA, MLA).
Ensure that all references are current, reliable, and relevant to the case study.
Include a mix of primary and secondary sources, such as research articles, textbooks, and clinical guidelines.

10 Nursing Case Study Examples for Nursing Students

Title	Description	Purpose
1.	The case analysis explores some of the ways in which the curriculum development leader can adopt measures that enhance faculty support and development in the task of curriculum development.	Problem-solving case analysis
2.	The case analysis explores the issues that the Dean of a nursing school should do to ensure a new curriculum is developed	Problem-solving case analysis
	This post includes benchmark patients’ spiritual needs: case analysis benchmark, how would a spiritual needs assessment helps the physician, how would a spiritual needs assessment help the physician assistant Mike, definition of spiritual care, and ethical decision-making and intervention in the event of a difficult situation.	Explores the spiritual needs of patients and how to address them.
	The post includes a case study, fetal abnormality gcu, and discussions on the Christian concept of the imago Dei and what value a human person has. How does your position affect your stance on controversial bioethical issues, such as abortion, designer babies, and stem cell research?	Explores ethical and spiritual influences to decision-making
	Utilizing the systematic problem-solving method, nurses can determine the health care needs of an individual and provide personalized care.	Improve care planning and decision making.
	The post includes Case Study: Healing and Autonomy Case Study, applying the four principles: case study, answer questions about a patient’s spiritual needs in light of the Christian worldview, describes how principals would be applied according to the Christian worldview, the importance of each of the four principles, and What do the four parts of the Christian biblical narrative (i.e., creation, fall, redemption, and restoration) say about the nature of God and of reality in relation to the reality of sickness and disease?	It helps nurses learn how to analyze a case ethically
	Evaluate the Health History and Medical Information for Mr. C. and expect the nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.	Improves the
	The paper proposes a change project at ABC Medical Center (ABC-MC) in response to the prevailing forces, identifies the need for change before developing a vision that inspires the change, and provides a rationale for the change.	Case
	The example on Death and Dying and answers questions on Suffering and the Fallenness of the World, Suffering and the Hope of Resurrection, Value of Life, Euthanasia, and Morally Justified Options, also offers an analysis of the sin of suicide.	Explores Ethical end of life decision making.
	Case analysis of a scenario	Improves the decision making of nurses

Tips for Writing a Nursing Case Study Analysis

When writing a nursing case study analysis, applying your theoretical knowledge, critical thinking skills, and clinical reasoning is essential to provide a thorough and evidence-based evaluation of the patient’s condition. Here are some tips to help you write a comprehensive nursing case study analysis:

Start with a clear introduction that includes patient information, such as age, gender, and chief complaint. This will give the reader a clear picture of the patient’s background and medical situation.
Provide a detailed medical history, including any chronic conditions, medications, allergies, and surgeries. This information will help you formulate nursing diagnoses and develop an appropriate nursing care plan.
Include a family history section to identify any genetic diseases or chronic conditions that may be relevant to the patient’s current condition. This will help you understand potential complications and adjust treatment accordingly.
Discuss the patient’s social history, including employment status, living situation, and alcohol/drug use. This information can provide insight into the patient’s lifestyle and its impact on their health.
Perform a thorough physical examination and review of symptoms to identify any abnormalities contributing to the patient’s condition. This will help you determine the need for further medical attention or diagnostic testing.
Analyze diagnostic test results, such as blood work, imaging tests, and biopsies, to confirm or rule out a diagnosis. This will help you develop an evidence-based treatment plan.
Develop a comprehensive nursing care plan that includes nursing diagnoses, interventions, and expected outcomes. Ensure that the plan is based on evidence-based guidelines and tailored to the patient’s specific needs.
Describe the rationale behind each intervention in the nursing care plan. This will demonstrate your application of theoretical knowledge and clinical reasoning skills.
Evaluate the patient’s response to treatment and discuss any changes in their condition. This will help you assess the effectiveness of the nursing care plan and make necessary adjustments.
Conclude with a clear prognosis based on your analysis of the patient’s condition and response to treatment. This will demonstrate your ability to synthesize information and make informed predictions about the patient’s outcomes.
Use a logical and organized structure throughout your case study analysis. This will ensure that your document flows logically and is easy to follow.
Engage in reflective practice by discussing what you found interesting or challenging about the case study. This will help you identify areas for further learning and professional growth.
Collaborate with the healthcare team to ensure the patient receives comprehensive and coordinated care. This will help bridge the gap between theory and practice and promote optimal patient outcomes.

By following these tips, you can write a thorough and evidence-based nursing case study analysis demonstrating your critical thinking skills, clinical reasoning, and application of theoretical knowledge. Whether you are working on a free nursing case study or a more complex case, these tips will help you comprehensively evaluate the patient’s condition and develop an appropriate care plan.

Brown, S. (2016). Evaluating nursing interventions in case studies. Journal of Nursing Education, 55(6), 345-351.
Davis, L. (2014). Writing effective case study conclusions. Nursing Education Perspectives, 35(4), 268-269.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nursing care plans: Guidelines for individualizing client care across the life span. F.A. Davis.
Herdman, T. H., & Kamitsuru, S. (Eds.). (2019). NANDA International nursing diagnoses: Definitions & classification, 2021-2023. Thieme Medical Publishers.
Hooper, V. D. (2014). How to write a nursing case study. American Nurse Today, 9(8), 44-47.
Jones, C. (2015). The importance of nursing assessments in case studies. Nursing Standard, 29(50), 42-48.
Lee, J. (2016). Analyzing nursing care in case studies: A beginner’s guide. Nursing Education Today, 45, 142-146.
Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (2019). Fundamentals of nursing. Elsevier.
Smith, J. (2017). Presenting patient history in nursing case studies. Journal of Nursing Education and Practice, 7(11), 44-49.
Taylor, C. R. (2015). Selecting relevant cases for nursing case studies. Nurse Educator, 40(4), 204-206.
Thompson, C. J. (2018). Developing patient-centered care plans in nursing case studies. Nursing Education Perspectives, 39(3), 158-161.
Wilson, L. (2017). Gathering data for nursing case studies: Best practices. Journal of Nursing Education, 56(10), 609-614.

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What is nursing professionalism? a concept analysis

1 Nursing College of Shanxi Medical University, Taiyuan, 030001 Shanxi People’s Republic of China

2 Linfen Hospital Affiliated to Shanxi Medical University (Linfen People’s Hospital), Linfen, 041000 Shanxi People’s Republic of China

3 The Third Peoples Hospital of Taiyuan, Taiyuan, 030001 Shanxi People’s Republic of China

Yangjie Chen

4 The First Hospital of Shanxi Medical University, Taiyuan, 030001 Shanxi People’s Republic of China

Qiaohong Wang

Associated data.

Data used to support the findings of this study are available from the corresponding author upon request.

Nursing professionalism plays an important role in clinical nursing. However, a clear conceptual understanding of nursing professionalism is lacking.

Conclusions

This study offers a theoretical definition and conceptual model of nursing professionalism that may be applied to develop standardized assessment tools or nursing professionalism training programs.

Introduction

In recent years, researchers have tried to solve the above problems through professionalism.

Method of concept analysis

Selection criteria

Data sources

TI Nursing professionalism OR AB Nursing professionalism OR TI Nurse professionalism OR AB Nurse professionalism OR TI Nursing spirit OR AB Nursing spirit OR TI Nurse spirit OR AB Nurse spirit.

TITLE-ABS-KEY (Nursing professionalism) OR TITLE-ABS-KEY (Nurse professionalism) OR TITLE-ABS-KEY (Nursing spirit) OR TITLE-ABS-KEY (Nurse spirit).

We used definitions and examples in the systematic record (Table (Table2) 2 ) to define a cluster of antecedents, attributes and consequences (Figs. (Figs.1 1 and 2 ) frequently associated with the concept [ 20 ].

An external file that holds a picture, illustration, etc.
Object name is 12912_2022_1161_Fig1_HTML.jpg

Flowchart of the study selection process of the concept analysis

The connotations of nursing professionalism

Nursing professionalism	Author	Country
Have a systematic nursing knowledge system	Freidson,(2001) [ ] Hinshaw, A. S.(1987) [ ]	USA USA
Professional certification	Lamonte M. (2007) [ ] Stucky, C. H., & Wymer, J. A. (2020) [ ]	USA USA
Lifelong learning and participation	Hinshaw, A. S.et al,. (1987) [ ] Karadağ, A.,et al.(2007) [ ]	USA Turkey
Evidence-based practice	Cornett B. S. (2006) [ ]	USA
Innovate	Shen et al. (2021) [ ]	China
Striving for excellence	Boehm, L. M.,et al. (2020) [ ]	USA
Creating a caring-healing environment	Watson, J. (1988) [ ]	USA
Displaying kindness/ concern/empathy for others	Collins, H., (2014) [ ] Papastavrou E., et al. (2011); [ ] Jooste, K., (2010), [ ]	UK Greek South Africa
Using all ways of knowing support and involvement	Watson, J. (1988) [ ]	USA
Embracing the unknowns and miracles in life and practicing loving	Watson, J. (1988) [ ]	USA
Patient-first	Kubsch, S, et al. (2021) [ ]	USA
Dedication	Fernandez, R., et al. (2020) [ ] Zhang, M, et al.(2021) [ ] Goldie J. (2013) [ ]	Australia China UK
Public service	Riley, J. M etal (2010) [ ]	UK
Disaster and infectious disease rescue	McDonald L. (2014) [ ] Liu, Q., et al. (2020) [ ]	Canada China
Community service	Kim-Godwin, Y. S(2010) [ ]	USA

An external file that holds a picture, illustration, etc.
Object name is 12912_2022_1161_Fig2_HTML.jpg

Antecedents, attributes, and consequences of nursing professionalism

We identified 6013 studies on nursing professionalism. After excluding duplicates, irrelevant studies, studies that were not original scientific studies or articles, and studies published in languages other than English, 138 studies were selected for analysis. Tables 1 and and2 2 show some typical literatures used in this study.

The attributes of the nursing professionalism

Nursing professionalism	Author	Country
Knowledge	Fogarty, T. J., et al. (2001) [ ]	USA
Attitude	Wynd C. A. (2003) [ ] Hall, R. H.. (1968) [ ] Takada, N., et al. (2021) [ ]	USA USA Japan
Behaviours	Schwirian P.M. (1998)? [ ] Miller, B. K.. (1988) [ ]	USA USA
Socialization process	Hinshaw, A.S. (1976) [ ]	USA
process of interaction	Swick H. M. (2006) [ ] Dehghani, A(2016) [ ]	USA Iranian
Cultural attribute of nursing professionalism	Chandratilake, M., et al.(2012) [ ] Jin P. (2015) [ ]	UK China

Uses of the concept

Dictionary definitions of the concept.

Definitions of the concept reported in the literature

Subconcepts

The defining attributes of nursing professionalism

The defining attributes of the concept aim to understand its meaning and differentiate it from other related concepts [ 17 ]. The key defining attributes are as follows.

Nursing professionalism is multidimensional

Nursing professionalism is a three-dimensional concept based on the knowledge, attitudes, and behaviours that underlie successful clinical practice [ 33 ].

Professionalism can be conceptualized as a ‘systematic body of knowledge’ with complex configurations of work expertise [ 21 ].

In addition, the perspective of professional identity formation complements the behaviour-based and attitude-based perspectives on professionalism [ 57 ].

The formation and development of professionalism are dynamic processes

Nursing professionalism is an inevitable, complex, varied, and dynamic process [ 58 ].The professionalism concept is considered ever-changing, replacing static or definitive views [ 59 ].

Socialization process

Process of interaction

Culture oriented

The connotation of nursing professionalism

Professional, having a systematic nursing knowledge system.

Professional certification

Lifelong learning and participation in continuing education

Evidence-based practice

Striving for excellence

Caring is considered the core attribute of nursing professionalism

The practice of caring is central to nursing [ 65 ]. Caring is defined as the moral ideal of nursing [ 36 ]. Therefore, caring is an important core attribute of nursing professionalism.

Creating a caring-healing environment

Displaying kindness/concern/empathy for others

Using all methods of knowing support and involvement

‘Human problems reside in ambiguity, paradox, and impermanence’. Therefore, suffering, healing, miraculous cures, and synchronicity are all part of knowing support and involvement.

Embracing the unknowns and miracles in life and practising loving

Patients first

To be altruistic means to put others’ needs before your own. Altruism is the selfless concern for others and doing things with the other person’s well-being in mind [ 40 ].

Public service

Disaster and infectious disease rescue

Community service

In addition, emphasizing professionalism means respecting values and commitment to community service delivery [ 69 ].

According to Walker and Avant [ 17 ], cases help further clarify concepts.

Model cases (a real case example)

Model cases help demonstrate all the defining attributes of a concept and helps to better articulate its meaning [ 17 ].

Borderline cases (a real case example)

Borderline cases provide the examples that contain the most defining attributes of the concept [ 17 ].

Related cases (a real case example)

Related cases are related to the concept but do not contain all its defining attributes [ 17 ].

Contrary cases (a fictional case example)

A contrary case does not include any defined attributes of the concept [ 17 ].

Antecedents

Antecedents are events that occur before the intended concept [ 17 ].

Macro antecedents

Religious beliefs

Micro antecedents

Personal characteristics

Consequences of nursing professionalism

Consequences are events or incidents that are the result of the occurrence of a concept [ 17 ].

Consequences for patients

Consequences for nurses

Empirical references

As the last step to concept analysis, empirical references can further clarify the concept and facilitate its measurement [ 17 ].

Hall’s professionalism inventory scale

Kramer’s index of professionalism

The behavioural inventory for professionalism in nursing (BIPN)

Definition of the concept

The connotations of nursing professionalism include professional, caring, and altruism. These connotations are detailed as follows:

Possesses a systematic nursing knowledge system; professional certification
Exhibits lifelong learning and participation
Participates in evidence-based practice
Demonstrates innovation
Strives for excellence
Creates a caring-healing environment
Displays kindness/concern/empathy for others
Uses various methods of knowing support and involvement
Embraces the unknowns and miracles in life and practices loving
Patient-first

A conceptual model of nursing professionalism is shown in Fig. 2 .

Defining the connotation of nursing professionalism

Nursing professionalism has been defined as professional, caring, and altruistic.

Defining the attributes of nursing professionalism

In this study, we defined nursing professionalism as multidimensional, dynamic, and culture oriented.

Future research directions

Exploring the antecedents of nursing professionalism can help schools or hospitals cultivate nursing professionalism and develop courses and specific measures.

The relationship between nursing professionalism and health outcomes or nurses’ human resources needs to be further studied.

Implications for nursing management

Limitations

Acknowledgements

The authors would like to thank Hui Yang for the great efforts made in designing the research. We would like to thank linbo Li for providing valuable suggestions for this study.

Author’s contributions

Postgraduate Education Innovation Program of Shanxi Province in China (No. 2020BY067).

Availability of data and materials

Declarations.

Our study was approved by the ethical committee of The First Hospital of Shanxi Medical University,Shanxi, China,(approval no. 2020K061).

Not applicable.

There is no conflict of interest in this study.

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Critical practice in nursing care: analysis, action and reflexivity

Affiliation.

1 School of Nursing and Midwifery, Trinity College, Dublin. [email protected]
PMID: 16786927
DOI: 10.7748/ns2006.06.20.39.49.c4172

This article examines critical practice and its underlying principles: analysis, action and reflexivity. Critical analysis involves the examination of knowledge that underpins practice. Critical action requires nurses to assess their skills and identify potential gaps in need of professional development. Critical reflexivity is personal analysis that involves challenging personal beliefs and assumptions to improve professional and personal practice. Incorporating these aspects into nursing can benefit nursing practice.

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Open access
Published: 07 August 2024

Assessment during clinical education among nursing students using two different assessment instruments

Nilsson Tomas 1 ,
Masiello Italo 2 , 3 , 4 ,
Broberger Eva 3 &
Lindström Veronica 5 , 6

BMC Medical Education volume 24 , Article number: 852 ( 2024 ) Cite this article

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Metrics details

Assessment of undergraduate students using assessment instruments in the clinical setting is known to be complex. The aim of this study was therefore to examine whether two different assessment instruments, containing learning objectives (LO`s) with similar content, results in similar assessments by the clinical supervisors and to explore clinical supervisors’ experiences of assessment regarding the two different assessment instruments.

A mixed-methods approach was used. Four simulated care encounter scenarios were evaluated by 50 supervisors using two different assessment instruments. 28 follow-up interviews were conducted. Descriptive statistics and logistic binary regression were used for quantitative data analysis, along with qualitative thematic analysis of interview data.

While significant differences were observed within the assessment instruments, the differences were consistent between the two instruments, indicating that the quality of the assessment instruments were considered equivalent. Supervisors noted that the relationship between the students and supervisors could introduce subjectivity in the assessments and that working in groups of supervisors could be advantageous. In terms of formative assessments, the Likert scale was considered a useful tool for evaluating learning objectives. However, supervisors had different views on grading scales and the need for clear definitions. The supervisors concluded that a complicated assessment instrument led to limited very-day usage and did not facilitate formative feedback. Furthermore, supervisors discussed how their experiences influenced the use of the assessment instruments, which resulted in different descriptions of the experience. These differences led to a discussion of the need of supervisor teams to enhance the validity of assessments.

The findings showed that there were no significant differences in pass/fail gradings using the two different assessment instruments. The quantitative data suggests that supervisors struggled with subjectivity, phrasing, and definitions of the LO´s and the scales used in both instruments. This resulted in arbitrary assessments that were time-consuming and resulted in limited usage in the day-to-day assessment. To mitigate the subjectivity, supervisors suggested working in teams and conducting multiple assessments over time to increase assessment validity.

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Introduction

During undergraduate studies to become a registered nurse (RN), the assessment of clinical competence includes an assessment of both theoretical knowledge and practical skills [ 28 ]. The importance of high-quality clinical education for students that provides constructive and adapted feedback is a key factor affecting the student’s learning process and should not be understated [ 28 , 30 ]. Historically, different assessment instruments have been designed aiming both to support the clinical supervisors and to provide standardised, fair assessments of students’ achievement of the learning objectives (LOs) [ 10 ]. However, the assessment of nursing students’ skills and competence using assessment instruments is known to be complex and affected by several varied factors [ 29 ]. The assessment instrument, Assessment of Clinical Education (ACIEd), that is used in this study context, is used in a summative fashion to verify that the students earn a passing grade during clinical education. Formative assessment aims to support the students through continuous feedback. To support the student’s development towards becoming a RN, an assessment instrument that facilitates both summative and formative assessment is needed [ 1 ].

A well-educated RN is essential to achieve good health care. To realise this, supervisors, as well as students, need support during clinical education in facilitating student learning [ 12 ]. Nevertheless, supporting, and supervising students is known to be complex since learning in the clinical setting is affected by several factors, such as the clinical context, the student’s own strengths, workplace challenges, expectations, and the student’s social network and prior knowledge and skills [ 3 , 4 ]. For the students to succeed in their learning, an un-bias assessment with LO`s that are relevant for the student’s progression is necessary.

Assessment in clinical education

Assessment is a vital part of clinical education and should include both skills and theoretical knowledge reflecting the requirements of the RN everyday work and having a close connection to the university curriculum [ 17 ]. The assessment of nursing students can be accomplished in a formative or summative way. The formative assessment is meant to guide the nursing students in their learning progress and is a joint discussion between the student and the supervisor where strengths and areas of improvement are identified and addressed [ 6 ]. The summative assessment’s prime objective is to ensure that LOs are achieved, and it commonly occurs on one or two occasions during a period/session of clinical education with a university teacher present [ 15 ]. However, clinical assessment is sometimes hampered by the clinical supervisors’ lack of training in assessing students’ nursing skills and competence and/or the supervisors’ lack of competence in using a standard assessment instrument [ 17 ]. In addition, a heavy workload and staff shortages in the clinical setting make it difficult for the clinical supervisors to find time to assess students properly. It is also known that the relationship between supervisor and student can affect the assessment [ 11 ]. To aid the assessment of students’ nursing skills and competence, assessment instruments need to be reliable, valid, easy to use and adapted to the clinical setting [ 7 ]. Today, several different assessment instruments exist which all have strengths and weaknesses and focus on various aspects of the student’s learning. These instruments utilize different approaches to assessment where for example Observed Structural Clinical Examination (OSCE) uses checklists and Assessment of Clinical Education (ACIEd) uses more complex LO`s that require subjective assessments [ 22 , 26 , 27 ]. ACIEd, is used by several universities in Sweden for assessment of LO`s during clinical education. The ACIEd was designed for a mid and final assessment, where the mid assessment results in: “In line with expected achievement” or “Plan of action is needed”. The final assessment results in a “Pass” or “Fail” grade on each LO. In clinical education, every LO needs to be passed to get a final pass grade [ 26 , 27 ]. Criticism has been raised in the ambulance services in Stockholm, Sweden, towards ACIEd, claiming that it is ill adapted for daily use and has a summative character where progression is hard to visualize. Therefore, a new assessment instrument was developed from the ACIEd and named the Ambulance Assessment Instrument (AAI). The intent of the construction of AAI was to provide alternatives to the existing assessment instrument that was designed for digital use in the clinical setting.

The AAI was constructed with more distinct and phrased LOs listed one by one, instead of using complex LOs with several sub-LOs imbedded in one. A seven graded Likert scale facilitated formative assessment. The rationale for clarifying LOs was that earlier research has shown that complex LOs lead to interpretations and inconsistencies in assessment [ 17 ]. Therefore, this was considered when the AAI was developed, resulting in one-sentence LOs without sub-criteria. The assessment instruments can be found in appendix 1. However, to incorporate a new assessment instrument in clinical education, it needs to be validated. In this case the research group choose to validate the developed AAI instrument against the existing instrument ACIEd. The aim of this study was therefore to examine whether two different assessment instruments, containing LO´s with similar content, results in similar assessments by the clinical supervisors and to explore clinical supervisors’ experiences of assessment regarding the two different assessment instruments.

Clinical education in the ambulance service

The clinical setting in this study was the ambulance services in Stockholm, Sweden. Care in an ambulance is characterised by short patient encounters, ever-changing environments, and patients seeking care for all varieties of complaints [ 19 , 25 , 31 ]. Typical is also a lack of preparation time and little or no chance for the students to pause and step out of the care encounter to discuss strategies or reflect on care situations that have occurred. The ambulance service has similar challenges to those faced in ambulatory care [ 9 ]. Historically, the ambulance service is an uncommon placement for clinical education in undergraduate nursing education due to the environment and lack of RNs working in the service. At present, every ambulance in Sweden is staffed by at least one RN [ 16 ], and it is stated that nursing students have the possibility to learn nursing skills in the ambulance services [ 17 , 18 , 20 , 21 ]. In the region of Stockholm, the nurses have at least one year of additional training which, for example, could be prehospital care, anesthesiology, emergency care, psychiatric care, or midwifery. The amount of work experience can vary greatly. Among the employed nurses its almost an even split between males and females.

Material and method

A mixed-method study design was used [ 23 ]. Quantitative data was generated from supervisors when assessing pre-recorded, simulated patient encounters performed by students. Individual interviews, conducted directly after the assessments, were completed in accordance with a mixed-method design.

Assessment instruments

The ACIEd used in this study consists of five LOs with sub-criteria concerning what the student needs to achieve to receive a Pass grade during a course in emergency care. The LOs are designed to cover all aspects of the six-week clinical education in relation to the course objectives resulting in LOs with several goals embedded in one, for example, LO 1, which translated reads:

Approach and support patients and their relatives in respectful consultation and perform nursing care based on the patient's experience of the situation.

To clarify this LO and reduce the risk of inconsistencies in assessment one-sentence LOs without sub-criteria was reconstructed in the AAI, and one example of this reads as follows:

1.1. To what extent was the patient treated with respect?

1.2. To what extent was the patient allowed to describe his or her situation?

1.3. To what extent did the student create a safe care situation?

The complete list of LO´s used can be found in appendix one. To enable formative assessment by displaying progress using the assumption that students’ performances will generate higher grades as their clinical education progresses, the AAI has a seven-point Likert scale with a pass grade marked as 5, meaning that scores 1 to 4 results in a fail grade. The Likert scale was given descriptions from 1 = “ Not at all” to 7 = “ To a great extent”. Furthermore, the ACIEd separates midterm assessment from final assessment, where grades in midterm are referred to as “In line with objective” or “Plan of action is required”. The final assessment using ACIEd results in a pass or fail grade. The AAI provides a formative assessment, which is meant to be repeated frequently but can also act as a basis for grading in an equivalent way as the ACIEd.

Simulated patient encounters

Four different recorded simulated scenarios were used in the study (recorded time: 6min 58 s, 3min 14s, 5min 58s, 2min 32 s). The scenarios had variations of student performances with the intention of generating variations in supervisor assessments. Differences were seen in both students’ assessments of the patient and in their treatment strategies. Two scenarios included a student interacting with a standardised patient, while two scenarios had a student interacting with a patient simulator manikin. The standardised patient was a middle-aged woman with fatigue and dizziness. The patient simulator manikin was a young man with abdominal pain. The nursing students participating in the simulation scenarios were recruited from the fifth semester of the nursing study programme at one university in Stockholm, Sweden, after they had finished their six-week clinical education in the ambulance services and all grades had been made official. Both male and female students participated in the simulations.

Participants

A convenience sample of 50 clinical supervisors, all RN in the ambulance service, participated in the study, having varying experience of supervisorship. The participants were recruited at three different emergency departments by the main author. By selecting different emergency departments, it was possible to include participants with different ambulance service employers (private and public). The clinical supervisors from the ambulance service were asked to participate in the study after they arrived at the emergency department and the hand-over of the patient was completed. The convenience sampling of clinical supervisors was used due to the difficulty in recruiting participants at the ambulance station, as they were constantly mobile during their shifts. The supervisors were provided with both written and oral information about the study as well as a letter of consent for participation in the study. No participants were excluded due to experience, gender, educational level, or other factors.

Data collection

In total, 50 clinical supervisors from the ambulance service assessed and graded four recorded simulations in accordance with the LO described in the ACIEd and the AAI instrument. No supervisor declined the offer to participate in this part of the study. Before the assessment started, a randomisation process was conducted. Firstly, the order of the simulations was randomised using a lottery (standardised patient vs. patient simulator manikin.). Secondly, the two scenarios were randomised using lottery (scenarios 1 and 2). No power calculations were performed. The recorded simulations were watched in one sequence without time to reflect or discuss the assessment and grading with others. All supervisors had prior knowledge of the assessment instrument ACIEd but had never used AAI.

The qualitative data consisted of interviews, conducted after the participants had assessed the simulated patient encounters. The interviews started with the open question “What are your thoughts about the assessment instruments?” Probing questions were then used to explore the participants’ experience of using the assessment instruments when grading the student's performance in the recorded simulations. The interviews varied in length from a few minutes up to 30 min. In total, 28 interviews were conducted (Female: 11 Male: 17). Fieldnotes were used during the interviews and after every finished interview the fieldnotes were summarized and reviewed. Theses reviews were used to make changes to the probing questions in relations to the aim of the study. In 22 cases there were no interviews conducted due to participants’ shortage of time. The supervisors were not informed about the questions prior to the interview.

Data analysis

The data was analysed in two parts, a quantitative and qualitative. The quantitative data was analysed by compiling the assessments generated by the two assessment instruments and compared in a simple figure where the difference was described from the perspective of how many pass grades the assessment instrument generated. Secondly, a logistic binary regression analysis was used to examine whether the grades generated by two different assessment instruments was affected by the supervisor’s gender and/or experience. To explore whether work experience as an RN affected the grading of student’s performance, a dichotomisation of the work experience variable was carried out. The variables were dichotomised into $\le$ 6 and 6 > years of working experience as RNs (Dichotomised 1 for $\le$ 6 and 2 for 6 >). This dichotomisation was based on the theory by Benner, that experienced nurses can use their experience, knowledge, and additional perspectives instead of relying on standardised guidelines, tests, and regulations [ 2 ] to assess the students according to the LO`s. A gender dichotomisation was also performed to investigate if there was any difference in grading related to gender which was defined as male or female with no consideration to other gender definitions (Gender was coded 1 for males and 2 for females). This dichotomisation was based on the diversity of the staff in the ambulance service. The independent variables for both instruments were coded as 1 for a pass grade and 2 for fail. After considering the number of included supervisors in the study the p value was set to 0.05. The data was analysed using Statistical Package for the Social Sciences, version 24, Chicago, IL, USA in combination with Microsoft Excel 2010 (Microsoft Corp, Richmond, WA, USA).

The interviews were analysed using a thematic analysis approach [ 5 ]. The method was chosen due to its flexible nature. The themes constructed was done in a “theory driven way” meaning that the research question was clearly present in the coding in contrast to an inductive analysis approach. First, in the analysis the field notes were read several times to gain familiarity with the content. Secondly, codes were identified that described clinical supervisors’ experience of using the two different assessment instruments were identified. Thirdly, the codes were examined, and by identifying broader patterns of meaning, potential themes were constructed. Fourthly, a thematic map was constructed, and the themes were checked on two levels. First the codes were checked against the theme making sure that the codes formed a coherent pattern. In the second level the themes were checked against the entire dataset and in relations to the other themes to ensure that the themes did not intertwine with each other and finally, the themes were named.

In the fifth step the themes and sub-themes were related back to the narrative making sure that the themes captured the full story and that each theme was unique and contained valid information. The “story” that the themes and sub-themes were checked against, was the researcher’s contextual knowledge and experience. Lastly, the report was written up using the themes and the sub- themes. The first author initiated the analysis and the corresponding author participated in the analysis process.

Quantitative results

In total, 34 (68%) male and 16 (32%) female clinical supervisors participated in the study. The work experience as an RN ranged from four months to 19 years, with a mean of 7.95 years. The work experience from the ambulance services ranged from 2.5 months to 35 years with a mean of 6.63 years (missing data n = 5). All participants had experience of clinical supervision and assessing nursing students during clinical education. The logistic binary regression analysis showed that there was no significant difference in 23 out of 24 LOs as displayed in Tables 1 , 2 , 3 and 4 . One significant difference was found in the ACIEd LO 2 ( p = 0.021) when the length of experience among the clinical supervisors was used as a dependent variable (Table 4 ). LO 2 assessed the students’ knowledge of the technical equipment and how they interacted with the patient while using the equipment.

Qualitative results

The thematic analysis used to explore clinical supervisors’ experience of assessment in relation to the two different assessment instruments resulted in three themes: Learning objectives , Assessment and Supervisorship.

Learning objectives

Supervisors described a variety of experiences relating to the LO`s in the two sub-themes: Phrasing of the LOs, subjectivity in the LOs, Complexity of the LO`s. The subthemes describe the supervisors’ view of the learning objectives in relation to how the LO`s are constructed and how they are interpreted as well as how they are used in the daily activities.

Phrasing of the learning objectives

The supervisors discussed the language used in the ACIEd to describe the LO`s and that the academic writing created confusion and was complex and hard to understand. They also discussed the lack of clear definitions, and difficulties using the ACIEd with several sub-criteria embedded in one LO, which resulted in individual interpretation of the LO and a risk of subjective assessment. According to the supervisors’ reasoning, several sub-criteria in the same LO complicated the assessment when students performed well according to some of the sub-criteria and poorly according to others. The supervisors expressed that the LOs used in AAI had a clearer phrasing making it easier to use. LO`s related to communication and patient relations were considered complicated to assess using the ACIEd in contrast to LO`s regarding medical procedures where right and wrong was clearly defined. Medical procedures were considered easier to assess in both instruments.

Complexity of the learning objective

When assessing the students’ nursing and care skills in the simulations, the supervisors claimed that the complexity of ACIEd made it challenging to explaining why they assessed as they did. In the clinic setting the supervisors said that the complexity of the LO`s made the usage of ACIEd time-consuming and poorly adapted to everyday work, which resulted in limited use, and only used in a summative way right before mid and end assessments. Altogether, the ACIEd was considered by the supervisors to be time-consuming, and leading to subjective interpretations and sometimes, conflicting assessments. The AAI was considered more relevant due to the “simplified” LO`s. However, AAI was thought to be difficult to use due to the Likert scale ranging from 1–7 were lack of clear definitions of the grading steps increased the complexity of assessing the LO`s.

Supervisors described assessment from different perspectives as presented below in the following sub-themes: Summative Vs Formative assessment, Subjectivity in assessment, Pass/Fail or Likert scale, and Supervisors experience related to assessments. Within the sub-themes there were variations in how the supervisors described their experiences.

Summative Vs Formative assessment

The supervisors discussed if and how the assessment instruments could be used for formative or summative assessment and concluded that both instruments could be used for both purposes. However, the supervisors discussed whether ACIEd was harder to use as a formative instrument due to the sub-criteria in the LO`s and that the pass/fail scale were less useful then the 7 graded Likert scale when it came to displaying progress. The supervisors discussed whether displaying the student’s progression had a positive pedagogical value and they concluded as preferable relating it to formative feedback. Supervisors also discussed the frequency of formative assessments. Some supervisors raised concerns related to the increased workload generated by daily documented, formative feedback.

Subjectivity in assessment

To decrease the subjectivity, the supervisors discussed involving the patients in the assessments of students’ performance. They argued that the only persons who could assess the LOs concerning the patients’ own perception were the patients themselves. The supervisors concluded that more care encounters, with assessments between every encounter would probably produce a more accurate assessment of the student’s nursing skills. The supervisors also discussed the risk that the students would only be assessed according to the supervisor’s interpretation of what is a pass performance in relation to the assessment instrument.

The supervisors found that the assessments with a Likert scale could be beneficial but that the grading steps needed to be carefully defined to avoid subjective assessments. The definitions could be made clearer by using examples in relations to the grading steps and the LO`s where requirements could be listed for each step.

Supervisors said that assessments using a Pass/Fail grading was too definite. Supervisors described that assessing the care encounters became complicated since student’s performances may contain good and bad performances and with Pass/Fail grading the nuances did not become clear.

Supervisors experience related to assessments

Supervisors’ description of their relationship to the LO`s varied where some had more issues than others. Supervisors with less experience were more critical towards the LO`s then experienced supervisors. Furthermore, supervisors with less experience discussed that the student were obligated to display skills and knowledge and that supervisors were obligated to assess in accordance with the LO`s, meaning responsibility for demonstrating knowledge and skills fell on the student.

The more experienced supervisors argued that the LO`s were more like guidelines than specific goals to achieve, and that they used LO`s as a basis for discussions with the students. They argued that their clinical experience and understanding were the basis for the assessment, making the challenge with the LO`s less important, which contrasted with the view of the less experienced supervisors who interpreted the LO´s more literally. Furthermore, the more experienced supervisors discussed that complex care encounters offered scarce opportunities for the students to display knowledge and skills and that several care encounters were needed to assess knowledge and skills over time.

Supervisorship

The supervisorship was described by the supervisors in the following two sub-themes: Relationship with the students and Teams of supervisors.

Relationship with the students

All supervisors said that a relationship with the student could be a confounder when assessing students. They discussed whether a good relationship with the student would probably result in a more favourable assessment. The supervisors also claimed that a troubled relationship with the student might result in disinterest from their perspective which could result in diminishing feedback and lowered clinical education quality resulting in higher risk for failure. The supervisors discussed that formative feedback could help detect a lack of progression at an early stage and that measures could be taken to improve the situation for the student. Among the female supervisors a recurring statement was that it was difficult to assess the student negatively in the simulations because it felt harsh or even cruel to fail a student. Among the male supervisor’s similar feelings were described, but they related to the fact that assessments are not carried out on single occasions but over time, making the assessment instrument unfit for this kind of assessment. Male supervisors argued to a greater extent that it was hard to assess the student in the simulation due to lack of information about both patients and students. They argued that although some simulations were not as described in “textbook” examples, guidelines were bent daily and therefore it would be unfair to expect “textbook” care from the students. Hence, the male supervisors argued that the assessment instrument was a tool used for discussion and could not stand alone which it did in the simulations.

Teams of supervisors

The supervisors highlighted continuity as something important for the student’s learning, but it could also complicate their assessment since they may develop a relationship with the student. The desire for continuity in supervisorship could also create a problem when working schedules changed. This could result in the involvement of other supervisors, and disruption in the individual learning plan. The supervisors with longer experienced argued that it could be favourable with more than one supervisor involved in the assessment of the student, due to different perspectives. They argued that a supervisor team with different combinations of knowledge could be beneficial for the student, but that such teams must be coordinated and documented to ensure that the student’s learning progress was not hindered.

The findings showed that there were no significant differences in pass/fail gradings using the two different assessment instruments with the same content in the LOs, meaning that no matter what instrument was used the grade was the same when supervisors assessed the students in the simulated scenarios. However, there were significant differences within the assessment instruments, but the differences were consistent between the instruments, meaning that the quality of the assessment was considered equal. The differences within the assessment instrument can be explained by supervisor bias. Chong et al. showed in their study that seniority was a source for bias in LO`s related to communication but that the bias did not persist in LO`s related to physical examinations which is in line with the findings in this study [ 8 ]. The interviews with the clinical supervisors provided a more vivid picture of the complexity of assessments. Firstly, the intention of the assessments must be made clear for everyone. If the objective is formative assessment, the data indicates that using Likert scales is preferable to display progression. The complexity, phrasing and definition were recurring in the interviews, and it is a worth discussing why this is an issue. Supervisors rarely had any training in how to use the assessment instruments and as described, the more experience supervisors did not excel in their knowledge of the instruments but used their clinical experience to assess students from their own perspective. With this logic it would be wise to invest in training the supervisors rather than simplifying the LO´s. Prior research has shown that support from the supervisors during the clinical training is crucial to create a positive learning environment and to improve assessments [ 31 ].

However, the need for supervisor training and support does not mean that improving the assessment instrument is unnecessary. If a Likert scale is used, a clear definition of the grading steps is important as well as the layout of the instrument. As described by Immonen et al., it is important that the instrument is adapted to the every-day work, and fast and easy to use without losing its reliability and validity [ 14 ].

Subjectivity and complexity were reoccurring statements during the interviews. The supervisors highlighted this in all aspects regarding the clinical education. The supervisors’ own experience’ and expectations play a vital part in the clinical education as well as the relationship between the supervisor and the students which is supported in prior research [ 24 ]. To decrease subjectivity, an increase in the number of assessments made by more than one supervisor could be beneficial. Assessments after every care encounter in the ambulance service would generate a good basis for an overall assessment of the students’ performance. By organising the supervisors in teams, the different knowledges of the supervisors could be effectively utilized and possibly decrease subjectivity resulting in an improvement of the validity of the assessment. In contrast to this, prior research has shown that the relationship between the student and the supervisor is important to build trust and thereby a positive learning environment [ 30 ]. With documented, formative assessments accessible for both students and supervisors, continuity could be created through communication between supervisors. By using digital devices with LO`s and a Likert scale prepared in a mobile application, the assessments could be made easier to access, faster to use and the results could be displayed as a progression curve visible for students and supervisors. Digitalization of the assessment instrument also holds advantages concerning student possibility to argue for their grades. Without documented progress the students are in the hands of the supervisors as the only source of information about their performances. To further strengthen the validity of the assessments, other sources of feedback could be used. The supervisors discussed involving patients in the assessments and concluded that this could reduce subjectivity in the assessments and add other perspectives to the assessment. Further research is needed to fully understand the complexity of assessments and what methods to use to improve the quality of the assessment and strengthen the students learning.

Methodological considerations

There are several limitations to this study. The number of supervisors included in the study was decided in discussion with the research team and a statistician after considering the availability of clinical supervisors and the extent of data needed for analysis. No power calculations were performed. Using standardised patients and simulation for assessing and grading students’ ability to care for patients may not reflect the clinical reality. However, since every care encounter is unique it would have been difficult to conduct a similar study in a clinical setting. Another limitation concerns the qualitative data collection. The interviewer is well known in the ambulance service, and this may have affected how the participants’ discussions concerning their experiences of using the assessment instruments in both a positive and negative way and increase the risk of bias. Conducting interviews between ambulance missions may also be considered as a limitation since the time for interviews was limited which could have resulted in participants not being able to develop their reasoning. The interviews were documented through field notes, and important information could have been missed. Field notes limit the possibility of quotations, which could have strengthened the validity of the findings in the interviews. Lastly, a limitation regarding the definition of experience needs mentioning. Experience in describe according to Benner but no data was collected regarding the supervisor’s experience of supervisorship. To supervise students is a natural part of the nursing profession but in hindsight, data concerning the quantity of students supervised during the supervisor’s clinical career would have offered clarity on the supervisor’s experience.

The findings showed that there were no significant differences in pass/fail gradings using the two different assessment instruments containing the same LOs. However, the qualitative data suggests that supervisors struggled with subjectivity in the assessments as well as phrasing and definitions of the LO´s and the scales used in both instruments. This resulted in arbitrary assessments that were time-consuming and resulted in limited usage in the day-to-day assessment. The supervisors argued that the AAI was better adapted for formative assessment due to its Likert scale and simplified LOs, but a clear definition of the grading scales was considered important. Further research is needed concerning the validity of the assessments and how teams of supervisors can utilize different perspectives to improve the quality of the assessments. Digitalization could play a vital role in documenting feedback from multiple sources to enhance the formative feedback given to students during their clinical training. Transparency of documented feedback from multiple sources using a Likert scale provides an opportunity for the students to monitor their progress in situ. More research is needed to fully understand the mechanism behind the subjectivity of assessments and what methods could be used to strengthen the quality of the assessments and improve the quality of the clinical education.

Availability of data and materials

The dataset generated and analysed in this study is available from the corresponding author on reasonable request.

Abbreviations

Ambulance assessment instrument

Assessment of clinical education

Observed structural clinical examination

Registered nurses

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Acknowledgements

I’ve would like to send a special thanks to my family for their never wavering support and to all participants how made this paper possible. I also wanted to extend my gratitude’s towards Ambulansen I StorStockholm AB for facilitating my studies and this paper.

Open access funding provided by Karolinska Institute. Funding for this study was provided by the Karolinska Institute.

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Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 11883, Stockholm, Sweden

Nilsson Tomas

Department of Pedagogy, Linnaeus University, Växjö, Sweden

Masiello Italo

Department for Neurobiology, Care Sciences, and Society, Division of Nursing, Karolinska Institutet, Huddinge, Sweden

Masiello Italo & Broberger Eva

Department of Computer Science and Media Technology, Linnaeus University, Växjö, Sweden

Department of Nursing, Division of Ambulance Service, Region Västerbotten, Umeå University, Umeå, Sweden

Lindström Veronica

Department of Health Promotion Science, Sophiahemmet University, Stockholm, Sweden

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All authors contributed significantly to the study design in terms of the choice of analytic methods and interview design. All authors played an active role in reading and providing feedback about the material throughout the entire process. TN, EB and VL were involved in carrying out group interviews of the students and contributed significantly by reading and providing feedback about the manuscript. All authors reviewed and approved the submitted manuscript.

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Correspondence to Nilsson Tomas .

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The study was designed according to the ethical principles for research described by the International Council of Nurses [ 13 ]. The study was approved by the Swedish Ethical Review Authority, Stockholm, Sweden (2016/594–31). All methods were performed in accordance with the relevant guidelines and regulations stipulated in the Helsinkideclaration.

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Tomas, N., Italo, M., Eva, B. et al. Assessment during clinical education among nursing students using two different assessment instruments. BMC Med Educ 24 , 852 (2024). https://doi.org/10.1186/s12909-024-05771-x

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DOI: 10.1016/j.nedt.2024.106330
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The effectiveness of serious games in nursing education: A meta-analysis of randomized controlled studies

Burcu Demircan , Yasemin Kıyak , Hatice Kaya
Published in Nurse Education Today 1 August 2024
Education, Medicine, Computer Science

47 References

Entry to practice nursing students' experiences of debriefing during clinical practice: a qualitative meta-synthesis., causes and effects of theory-practice gap during clinical practice: the lived experiences of baccalaureate nursing students, effectiveness of game-based virtual reality phone application and online education on knowledge, attitude and compliance of standard precautions among nursing students, digital serious games in developing nursing clinical competence: a systematic review and meta-analysis., effectiveness of serious games in nurse education: a systematic review., effects of simulation technology-based learning on nursing students' learning outcomes: a systematic review and meta-analysis of experimental studies., the effects of a virtual simulation-based, mobile technology application on nursing students' learning achievement and cognitive load: randomized controlled trial., comparative effectiveness of simulation versus serious game for training nursing students in cardiopulmonary resuscitation: a randomized control trial, focusing on explicit debriefing for novice learners in healthcare simulations: a randomized prospective study., efficacy of serious games in healthcare professions education, related papers.

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