Many baccalaureate nursing programs use the hospital as the initial setting for clinical learning, because it offers easy access to a revolving population requiring a variety of basic nursing care. However, hospitals, being acute care oriented and focused on system efficiency, may not provide the best environment for helping beginning students discover the relationship between the nurse's ability to individualize care, and the collaborative role clients play in each phase of the nursing process.
As a community nursing faculty member of a generic baccalaureate program, I recently evaluated senior nursing students' ability to individualize nursing care plans for community clients. Assessment indicated that students followed the basic steps of the nursing process. However, their nursing diagnoses tended to parallel medical diagnoses. Their client goals were based primarily on objective indications of disease control, and nursing actions reflected standardized disease-monitoring behaviors, teaching, and medical treatments.
While students had a basic understanding of the problem-solving method, they failed to integrate the method with a basic understanding of professional nursing's aim, which is to assist clients in developing self-caring behaviors that: 1) reduce their risk of illness; 2) enable them to manage their environmental situation; and 3) promote their ability to function within the limits of their resources (Doona, 1979; Rogers, 1977 ). The collaborative role clients play in nursing's endeavor to provide them with individualized quality care, emphasized in professional practice, had been lost. This finding was very disturbing and cause to reflect on the role nursing education may play in students' inability to effectively use the nursing process, in collaboration with the client, to design individualized quality care.
By design, hospitals do not generally allow clients to actively participate in the actual planning and administration of their care. They are artificially constructed home environments where care providers assume surrogate parent roles, making decisions for and administering care to the client. Hospital clients continue to have limited opportunity to control how, when, or where care will be received, and less control over what care will be delivered and by whom. Consequently, use of the hospital, as the initial practical learning site, may contribute to the beginning student's failure to recognize and value the client as the primary resource in his/her own care.
Student success in involving the hospitalized client in the nursing process is often blocked by unanticipated situational factors, such as tests, visitors, treatments, exacerbation of acute illness symptoms, and unscheduled discharge. Such interruptions reduce students' contact time with the client, and fragment or terminate the process before its completion. Student recognition of the significance of the relationship between the process' sequential steps, and the importance of client involvement in each phase may be inhibited, as a consequence. While practice flexibility is important to learn, such disruption is untimely in students' early use of the nursing process to individualize care. Situational factors and the intense nature of acute care settings may also cause students to perceive the process as too threatening, time consuming, and unimportant to effective care giving.
Impulsive clinical teaching practices employed by faculty may also interfere with students' ability to relate nursing action clearly to a systematic theory-based process. In an attempt to provide students with as much technical practice as possible, faculty often use undesigned spontaneous learning experiences. When faculty allow beginning students to carry out diseaserelated technical procedures not preceded by nursing assessment and planning with the client, medicine's role in directing nursing action may inadvertently be overemphasized.
Student acquisition of knowledge about the nursing process is relatively simple compared to developing the ability to apply it collaboratively with the client. Effective use of the process requires the student to create an atmosphere of trust and open communication by conveying an attitude of caring and respect for the client. Simultaneously, the student must integrate crucial communication skills of observation and listening with leading, open-ended, and probing interview techniques (Yura & Walsh, 1983).
This task can be highly threatening to the new student who, for the first time, is faced with actively seeking answers to intimate questions from strangers in an unfamiliar environment. Vetçran nurses, adept at accomplishing these goals in a short time in spite of repeated interruption, find client assessment and care plan development difficult. Beginning students need extended time and repeated contact with the same client to meet the same objectives. They also need an environment that allows them to fully complete the steps of the process in sequence with minimal disruption. Early student success in using the nursing process with the client will increase the likelihood that it will be valued as the activity fundamental to all future care giving.
Clinical settings and client assignments need to be carefully selected to minimize unnecessary blocks to effective learning. Clients associated with community agencies (like VNAs and home health agencies) and long-term care facilities usually exercise considerable personal control over themselves and their environment. Nursing care, in both types of settings, is often less intense and delivered at a slower pace. Consequently, the student can have extended time and repeated contact with the client, and share greater control over the nursing assessment, care planning, implementation, and evaluation process.
Environmental factors in community settings, like the family and limited resources, tend to complicate client health problems and their solutions. The complexity of such problems, however, should not present the beginning student with major stumbling blocks to learning. On the contrary, the complexity of community client situations can be a basic reason for choosing the setting as the place to introduce students to practical application of the nursing process. When cared for in their own home environment, clients and their situations force students to share responsibility for, and control over, care planning and implementation. In these settings, students' ability to provide individualized care will largely depend on their willingness to collaborate with the client at each phase of the nursing process.
The role nursing education plays in students' failure to use the client and nursing process more effectively in order to provide individualized quality care remains unclear. What is clear is baccalaureate education's claim to equip its graduates with the ability to: 1) assess health status and health potential: plan, implement, and evaluate nursing care in concert with clients; 2) use theoretical and empirical knowledge as a source for making nursing practice decisions; 3) use decision-making theories in determining care plans, designs or interventions for achieving comprehensive nursing goals; and 4) provide clients with care that is culturally acceptable (National League for Nursing, Pub. No. 15-1319).
Therefore, baccalaureate nursing educators must be willing to forsake longstanding tradition, and to move away from use of the hospital toward greater use of the community setting as the initial clinical learning site for beginning students. Clinical faculty must insist that students who are allowed to carry out unplanned technical skills precede their actions with a systematic theory-based process that includes the client. Students should be required to identify the rationale for the procedure and its potential impact on the client; to explain the procedure to the client; and to allow the client to control timing and implementation of the technique. Finally, faculty must recognize, value, and emphasize in their teaching, the significant role the client plays in enabling the nurse to provide individualized, quality care. Students must understand that while nurses bring professional expertise to the client situation, it is the client who best determines how that expertise can and should be used in helping them address their concerns.
- National League for Nursing. Characteristics of baccalaureate education in nursing. Pub. No. 15-1319.
- Rogers, M. E. ( 1977 I. The theoretical basis of nursing. Chap. 11, pp. 83-88. Philadelphia: FA Davis.
- Doona, M. E. (1979). Travelbee's intervention in psychiatric nursing (2nd ed.). Chap. 5, pp. 137-160. Philadelphia: FA Davis.
- Yura. H. & Walsh, M.B. (1984). The nursing process (4th ed.). Chap. 1-3, pp. 1-183. East Norwalk. Connecticut: Appleton Century-Crofts.