Chapter 2
Thoughtful practice
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ultimately leads to appropriate and effective actions that meet
a person’s specifically identified need.
Thoughtful practice requires all the components working in
synchronicity for the benefit of the persons within the thera-
peutic relationship. The following section discusses the actions
of nurses as thoughtful professionals.
CLINICAL REASONING CHALLENGE
An 84-year-old man who is originally from Vietnam is
hospitalised in the neurosurgical intensive care unit with
a cerebrovascular accident (CVA, stroke). His immediate
family members insist on staying with him around the
clock, and many extended family members visit each day,
staying late into the night. His prognosis is poor, and when
his attending doctor discusses discontinuing his life support
therapy with his family members who are his legal next of
kin, they acquiesce but request that all family members be
allowed to remain present to witness his death. Policies
in the intensive care unit do not permit more than three
family members to be with a patient at any given time. The
staff members complain that they have difficulty complet-
ing their tasks with other critically ill patients because of
the distractions they face from the multiple family mem-
bers visiting this man. How can you help the nursing staff
explore the meaning of the family’s behaviour and under-
stand their own negative feelings about this behaviour?
Devise a strategy that will help resolve this situation.
Clinicians’ actions
Decision making, like peoples’ beliefs and values, is often not
overtly expressed but is evident in the behaviour or the action
of the clinician. An action taken by a clinician is simply
defined as ‘the behaviour following on from a judgement or
decision’ (Thompson & Dowding, 2002, p. 14). This action
may be a simple act or a series of actions, it may involve
undertaking a practical task or communicating with another
clinician. Actions resemble clinical reasoning as they are also
dependent on the confidence and competence of the clinician
and the assessment of the risk involved (Levett-Jones et al.,
2010). Decisions include when the action will be undertaken.
This is often referred to as ‘patient prioritisation’ and is a skill
that is enhanced by experience. When there are time pres-
sures, the quality of the decision and hence the action may
be affected. This is a very important consideration in modern
healthcare as time is seen to be inadequate in most clinical
settings (Beckett, Gilbertson & Greenwood, 2007). Although
the actions taken following a judgement and decision can be
diverse and complicated they are not disorganised or unstruc-
tured. The actions can be described through an organised series
of actions called the processes of care that are described in the
following section.
Person-centred process of care
The next component of thoughtful practice, as shown in Figure
2-1, is the series of actions known as the processes of care.
Although each care encounter, or clinical situation, is differ-
ent, clinicians need a structured approach to developing these
processes. It is in the processes of care that the skills in clinical
reasoning and judgement are enacted in a person-centred way,
through the nursing process, a systematic approach to a series
of actions that meet the needs of the person while preserving
their humanity.
The nursing process
The nursing process is a deliberate problem-solving approach
for meeting a person’s healthcare and nursing needs. Although
the steps of the nursing process have been stated in various
ways by different writers, the common components cited are
assessment, diagnosis, planning, implementation, and eval-
uation. These original components can be further enhanced
to include
nursing diagnoses
and
collaborative problems
as
part of assessment and outcome identification as a part of
planning. Therefore for the purpose of this text, although
based on the traditional five steps, the sequences of steps for
the nursing process: assessment, diagnosis, outcome identifi-
cation, planning, implementation, and evaluation are defined
as follows:
1.
Assessment:
The systematic collection of data to
determine the patient’s health status and identify any
actual or potential health problems. (Analysis of data is
included as part of the assessment. For those who wish to
emphasise its importance, analysis may be identified as a
separate step of the nursing process.)
2.
Diagnosis:
Identification of the following two types of
patient problems:
(a)
Nursing diagnoses:
Actual or potential health
problems that can be managed by independent
nursing interventions
(b)
Collaborative problems:
‘Certain physiological
complications that nurses monitor to detect
onset or changes in status. Nurses manage
collaborative problems using doctor-prescribed and
nursing-prescribed interventions to minimise the
complications of the events’ (Carpenito, 2012)
3.
Planning:
Development of goals and outcomes, as well as
a plan of care designed to assist the patient in resolving
the diagnosed problems and achieving the identified goals
and desired outcomes.
4.
Implementation:
Actualisation of the plan of care through
nursing interventions.
5.
Evaluation:
Determination of the patient’s responses to
the nursing interventions and the extent to which the
planned outcomes have been achieved.
Dividing the nursing process into distinct steps serves to
emphasise the essential nursing actions that must be taken to
resolve the patient’s nursing diagnoses and manage any collab-
orative problems or complications. Dividing the process into
separate steps is, however, artificial: the process functions as an
integrated whole, with the steps interrelated, interdependent,
and recurrent (Figure 2-4). Chart 2-7 presents an overview of
the nursing activities involved in applying the nursing process.
Using the nursing process for a
period of care
Assessment
Assessment data are gathered through the health history and
the physical assessment. In addition, ongoing monitoring is
crucial to remain aware of changing patient needs and the
effectiveness of the nursing care.
