Nursing Process, Nursing Skills

and Clinical Reasoning Characteristics of the Nursing Process

• Systematic — part of an ordered sequence of activities
• Dynamic — great interaction and overlapping among the
five steps
• Interpersonal — human being is always at the heart of
• Outcome oriented — nurses and patients work together
to identify outcomes
• Universally applicable — a framework for all nursing

Joannes Paulus T. Hernandez, BS (Human) Biology, BS Nursing, R.N.

Characteristics of the Nursing Process
The Nursing Process (Continued)

• One of the major guidelines for nursing practice It is a GOSH approach for efficient and effective provision
of nursing care.
• Helps nurses implement their roles
• Integrates art and science of nursing
G – oal-oriented
• Allows nurses to use critical thinking
O – rganized
• Defines the areas of care that are within the domain of
nursing S – ystematic
• It is a systematic method that directs the nurse and H – umanistic care
client as they together determine the need for nursing
care, plan and implement the care, and evaluate the

Historical Development of the Nursing
• 1955 — nursing process term was first used by Lydia
Problem solving and the Nursing Process
• Trial-and-error problem solving
• 1960’s — specific steps delineated
• Scientific problem solving
• 1967 — Yura and Walsh published first comprehensive
book on nursing process • Intuitive thinking
• 1973 — ANA Congress for Nursing Practice developed • Critical thinking
Standard of Practice
• 1982 — state board examinations for professional
nursing uses nursing process as organizing

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 1
Overview of the Five Steps of the Nursing Process:

Benefits of the Nursing Process

• Patient
– Scientifically based, holistic individualized patient
– Continuity of care
– Clear, efficient, cost-effective plan of action
• Nurse
– Opportunity to work collaboratively with other
healthcare workers
– Satisfaction of making a difference in lives of patients
– Opportunity to grow professionally

Overview of the Five Steps of the Nursing Process:
Five Steps of the Nursing Process
It is the systematic and continuous collection, validation, and communication of client data as
compared to standard.
• Activities:
1. Collection of data
2. Validation of data – data confirmation/comparing to standards
3. Organizing data
4. Analyzing data
5. Recording/documentation of data
• Types of data:
1. Subjective data (symptoms) – described by person experiencing it
2. Objective data (signs) – can be observed and measured
• Sources of data:
1. Primary Data – data directly gathered from the client
2. Secondary data – data gathered from client’s significant others, client’s
medical records, patient’s chart, other members of the health team, and
related health care literature
• Methods of collecting data:
1. Interview – a planned communication with the client
2. Observation – the use of five senses and instruments
3. Physical Assessment – assessment for objective data and is focused primarily
on the client’s functional abilities

Assessing is primarily focused on the client’s response to health problem.

Five Steps of the Nursing Process

• Assessing — collecting, validating and communicating of Four Types of Nursing Assessments
patient data
• Comprehensive initial
• Diagnosing — analyzing patient data to identify patient
strengths and problems • Focused
• Planning — specifying patient outcomes and related • Emergency
nursing interventions
• Time-lapsed
• Implementing — carrying out the plan of care
• Evaluating — measuring extent to which patient achieved

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 2
Comprehensive Initial Assessment Time-Lapsed Assessment
• Performed shortly after admittance to hospital • Performed to compare a patient’s current status to
baseline data obtained earlier
• Performed to establish a complete database for problem
identification and care planning • Performed to reassess health status and make necessary
revisions in plan of care.
• Performed by the nurse to collect data on all aspects of
patient’s health • Performed by the nurse to collect data about current
health status of patient

Focused Assessment Establishing Assessment Priorities
• May be performed during initial assessment or as routine • Health orientation
ongoing data collection
• Developmental stage
• Performed to gather data about a specific problem
already identified, or to identify new or overlooked • Need for nursing
• Performed by the nurse to collect data about the specific

Emergency Assessment Medical vs. Nursing Assessments
• Performed when a physiologic or psychological crisis • Medical assessments
– Target data pointing to pathologic conditions
• Performed to identify life-threatening problems
• Nursing assessments
• Performed by the nurse to gather data about the life-
threatening problem – Focus on the patient’s response to health problems

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 3
The Skill of Nursing Observation Successful Interview Techniques
• Determines the patient’s current responses (physical and • Focus on the patient during the interview
• Listen to the patient attentively
• Determines the patient’s current ability to manage care
• Ask about patient’s main problem first
• Determines the immediate environment and its safety
• Pose questions and comments in appropriate manner
• Determines the larger environment (hospital or
community • Avoid comments and question that impede
• Use silence and touch appropriately

Five Parts of Communication
Four Phases of a Nursing Interview Process (Berlo)
• Preparatory phase • The stimulus or referent
• Introduction • The sender or source of message (encoder)
• Working phase • The message itself
• Termination • The medium or channel of communication
• The receiver

Purpose of a Nursing Physical Assessment Four Levels of Communication
• Appraisal of health status • Intrapersonal
• Identification of health problems • Interpersonal
• Establishment of a database for nursing intervention • Small-group
• Organizational

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 4
Roles of Group Members The Helping Relationship
• Task-oriented — focus on work to be done • Does not occur spontaneously
• Maintenance — focus on well-being of people doing work • Characterized by an unequal sharing of information
• Self-serving — advance the needs of individual members • Built on the patient’s needs
at group’s expense

Characteristics of the
Forms of Communication Helping Relationship
• Verbal (language) • Dynamic
• Nonverbal (body language) • Purposeful and time limited
– Facial expressions • Person providing assistance is professionally accountable
– Posture, gait for the outcomes
– Gestures
– General physical appearance
– Mode of dress and grooming
– Sounds
– Silence

Factors Influencing Communication Phases of the Helping Relationship
• Developmental level • Orientation phase
• Gender • Working phase
• Sociocultural differences • Termination phase
• Roles and responsibilities
• Space and territoriality
• Physical, mental, and emotional state
• Environment

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 5
Factors that Promote Effective
Goals of the Orientation Phase Communication
• Establish tone and guidelines for the relationship • Dispositional traits
• Identify each other by name • Rapport builders
• Clarify roles of both people
• Establish an agreement about the relationship
• Provide the patient with orientation to the healthcare

Goals of the Working Phase Dispositional Traits
• Work together to meet the patient’s needs • Warmth and friendliness
• Provide whatever assistance is needed to achieve each • Openness and respect
• Empathy
• Provide teaching and counseling
• Honesty, authenticity, trust
• Caring
• Competence
• Genuineness

Rapport Builders
Goals of the Termination Phase
• Specific objectives
• Examine goals of helping relationship for attainment
• Comfortable environment
• Make suggestions for future efforts if necessary
• Privacy
• Encourage patient to express his or her emotions about
the termination • Confidentiality
• Patient versus task focus
• Utilization of nursing observations
• Optimal pacing
• Providing personal space

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 6
Developing Conversation Skills Basic Components of Assertiveness
• Control the tone of your voice • Having empathy
• Be knowledgeable about the topic of conversation • Describing one’s feelings or the situation
• Be flexible • Clarifying one’s expectations
• Be clear and concise • Anticipating consequences
• Avoid words that might have different interpretations
• Be truthful
• Keep an open mind
• Take advantage of available opportunities

Developing Listening Skills

• Sit when communicating with a patient. Blocks to Communication
• Be alert and relaxed and take your time. • Failure to perceive the patient as a human being
• Keep the conversation as natural as possible.
• Failure to listen
• Maintain eye contact if appropriate.
• Inappropriate comments and questions
• Use appropriate facial expressions and body gestures.
• Using clichés
• Think before responding to the patient.
• Using closed questions
• Do not pretend to listen.
• Using questions containing the words “why” and “how”
• Listen for themes in the patient’s comments.
• Using questions that probe for information
• Use silence, therapeutic touch, and humor appropriately.

Interviewing Techniques Blocks to Communication (continued)
• Open-ended questions or comments • Using leading questions
• Closed questions or comments • Using comments that give advice
• Validating questions or comments • Using judgmental comments
• Clarifying questions or comments • Changing the subject
• Reflective questions or comments • Giving false assurance
• Sequencing questions or comments • Using gossip and rumors
• Directing questions or comments

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 7
Type of Questions Used in Interviews When to Verify Data
• Closed questions — elicit specific information • When there is a discrepancy between what the person is
saying and what the nurse is observing
• Open-ended questions — allow the patient to verbalize
freely • When the data lack objectivity
• Reflective questions — encourage patient to elaborate on
thoughts and feelings
• Direct questions — validate or clarify information

Sources of Data
• Patient
• Family and significant others
• Patient record
• Other healthcare professionals
• Nursing and other healthcare literature

Problems Related to Data Collection Validating Inferences
• Inappropriate organization of the database • Performing a physical examination using proper
equipment and procedure
• Omission of pertinent data
• Using clarifying statements
• Inclusion of irrelevant or duplicate data, erroneous or
misinterpreted data • Sharing inferences with other team members
• Failure to establish rapport and partnership • Checking findings with research reports
• Recording an interpretation of data rather than observed
• Failure to update the database

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 8
Overview of the Five Steps of the Nursing Process:

Documentation of Data
• Enter initial database into computer or record in ink on
designated forms the same day patient is admitted.
• Summarize objective and subjective data in concise,
comprehensive, and easily retrievable manner.
• Use good grammar and standard medical abbreviations.
• Whenever possible, use patient’s own words.
• Avoid non-specific terms subject to individual
interpretation or definition.

Overview of the Five Steps of the Nursing Process:
• It is a process which results to Nursing Diagnosis.
• It is used to identify health care needs and prepare a Nursing Diagnosis.
• Nursing Diagnosis is a statement of a client’s potential or actual health problem
Objective Data vs. Subjective Data •
resulting from analysis of data.
Nursing Diagnosis uses PES format:
P – roblem
E – tiology
• Objective data S – igns and Symptoms
• Activities:
– Observable and measurable data that can be seen, 1. Data Clustering
heard, or felt by someone other than the person 2. Comparing data against standards
experiencing them 3. Data analysis
4. Identify gaps and inconsistencies

– E.g., elevated temperature, skin moisture, vomiting 5. Determine health problems
6. Formulation of Nursing Diagnosis
• Types of Nursing Diagnosis:
• Subjective data 1. Actual Nursing Diagnosis – problem is present
2. Potential Nursing Diagnosis – problem may arise
– Information perceived only by the affected person 3. Possible Nursing Diagnosis – problem may be present
4. Wellness Nursing Diagnosis – transition from a specific level of wellness to a
– E.g., pain experience, feeling dizzy, feeling anxious higher level of wellness

Prioritizing nursing diagnosis is based on what problem endagers person’s life.

Purposes of the Diagnosing Step
Characteristics of Data
• Complete • Identify how an individual, group, or community
responds to actual or potential health and life processes.
• Factual and accurate
• Identify factors that contribute to or cause health
• Relevant problems (etiologies).
• Identify resources or strengths the individual, group or
community can draw on to prevent or resolve problems.

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 9
Purposes of the Diagnosing Step

Purposes of the Diagnosing Step
Types of Diagnoses
• Nursing diagnosis
– Describes patient problems nurses can treat
• Medical diagnosis
– Describes problems for which the physician directs
the primary treatment
• Collaborative problems
– Managed by using physician-prescribed and nursing-
prescribed interventions

Nursing Concerns and Responsibilities
(Alfaro, 2004)
• Monitoring for changes in health status
• Promoting safety and preventing harm
• Identifying and meeting learning needs
• Promoting comfort and managing pain
• Promoting health and well-being
• Addressing problems that limit independence
• Determining human responses

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 10
Four Steps of Data Interpretation
and Analysis
• Recognizing significant data
– Comparing data to standards
• Recognizing patterns or clusters
• Identifying strengths and problems
• Reaching conclusions

Overview of the Five Steps of the Nursing Process:
• Identifying beforehand the specific actions to be done before
implementation of nursing interventions.
• It is used to determine the goals of care and the course of actions to be
Reaching Conclusions undertaken during the implementation phase.
• Activities:
• No problem 1. Priority setting
2. Setting goals and objectives: Goals may be short-term or long term;
• Possible problem the characteristics of a well-started behavioral objectives are as
• Actual or potential nursing diagnosis S – mart
• Clinical problem other than nursing diagnosis M – easurable
A – ttainable
R – ealistic
T – ime-framed
3. Identify alternative nursing care
4. Select nursing measure
5. Formulation of Nursing Care Plan (NCP)
The Nursing Care Plan is made mainly as guide to individualize care.

Goal of Outcome Identification
Formulation of Nursing Diagnoses and Planning Step
• Problem — identifies what is unhealthy about patient • Establish priorities.
• Etiology — identifies factors maintaining the unhealthy • Identify and write expected patient outcomes.
• Select evidence-based nursing interventions.
• Defining characteristics — identifies the subjective and
objective data that signal the existence of a problem • Communicate the plan of care.

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 11
A Formal Plan of Care Allows Three Elements of
the Nurse To: Comprehensive Planning
• Individualize care that maximizes outcome achievement • Initial
• Set priorities • Ongoing
• Facilitate communication among nursing personnel and • Discharge
• Promote continuity of high-quality, cost effective care
• Coordinate care
• Evaluate patient response
• Create a record used for evaluation, research,
reimbursement and legal reasons
• Promote nurse’s professional development

Initial Planning
• Developed by the nurse who performs the nursing history
and physical assessment
• Addresses each problem listed in the prioritized nursing
• Identifies appropriate patient goals and related nursing

Ongoing Planning
• Carried out by any nurse who interacts with patient
• Keeps the plan up to date
• States nursing diagnoses more clearly
• Develops new diagnoses,
• Makes outcomes more realistic and develops new
outcomes as needed
• Identifies nursing interventions to accomplish patient

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 12
Discharge Planning Long-Term vs. Short-Term Outcomes
• Carried out by the nurse who worked most closely with • Long-term — requires a longer period to be achieved and
patient may be used as discharge goals
• Begins when the patient is admitted for treatment • Short-term — may be accomplished in a specified period
of time
• Uses teaching and counseling skills effectively to ensure
home-care behaviors are performed competently

Prioritizing Nursing Diagnoses Categories of Outcomes
• High priority — greatest threat to patient well-being • Cognitive — describes increases in patient knowledge or
intellectual behaviors
• Medium priority — non-threatening diagnoses
• Psychomotor — describes patient’s achievement of new
• Low priority — diagnoses not specifically related to skills
current health problem
• Affective — describes changes in patient values, beliefs,
and attitudes

Maslow’s Hierarchy of Human Needs Parts of a Measurable Outcome
• Physiologic needs • Subject
• Safety needs • Verb
• Love and belonging needs • Conditions
• Self-esteem needs • Performance criteria
• Self-actualization needs • Target time

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 13
Common Errors in Writing
Patient Outcomes Structured Care Methodologies
• Expressing patient outcome as nursing intervention • Procedure — set of how to action steps
• Using verbs that are not observable or measurable • Standard of care — description of acceptable level of
patient care
• Including more than one patient behavior or
manifestation in short-term outcomes • Algorithm — set of steps used to make a decision
• Writing vague outcomes • Clinical practice guideline — statement outlining
appropriate practice for clinical condition or procedure

Types of Nursing Interventions Types of Institutional Plans of Care
• Nurse-initiated — actions performed by a nurse without a • Kardex plans of care
physician’s order
• Computerized plans of care
• Physician-initiated — actions initiated by a physician in
response to a medical diagnosis but carried out by a • Case management plans of care
nurse under doctor’s orders – Clinical pathways, care maps
• Collaborative — treatments carried out by a nurse • Student plans of care
initiated by other providers
• Concept map care plan

Actions Performed in Nurse-Initiated Problems Related to Outcome
Interventions (Alfaro, 2002) Identification and Planning
• Monitor health status • Failure to involve patient
• Reduce risks • Insufficient data collection

• Resolve, prevent, or manage a problem • Nursing diagnoses developed from inaccurate or
insufficient data
• Facilitate independence or assist with ADLs
• Outcomes stated too broadly
• Promote optimum sense of physical, psychological, and • Outcomes derived from poorly developed nursing
spiritual well-being diagnoses
• Failure to write nursing order clearly
• Nursing orders that do not solve problems
• Failure to update the plan of care

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 14
Overview of the Five Steps of the Nursing Process:

Outcomes for “Caregiver
Home Readiness”
• Willing to assume caregiver role
• Knowledge about caregiver role
• Demonstration of positive regard for care recipient
• Participation in home care decision
On-going data collection directs revision of plan of care and interventions. • Confidence in ability to manage care at home
• Knowledge of where to obtain needed equipment

Overview of the Five Steps of the Nursing Process:

• Putting the Nursing Care Plan into action.
• It is used to carry out the NCP and meet client’s health goals. Types of Nursing Interventions
• Requirements for implementation:
1. Therapeutic use of self (TUOS)
• Independent nursing actions
2. Knowledge
3. Technical skills – Nurse-initiated interventions
4. Communication skills • Protocols
• Nurses implement independent (nurse-prescribed), interdependent
(collaborative), and dependent (physician’s-prescribed) nursing actions. • Standing orders
On-going data collection directs revision of plan of care and interventions. • Dependent and collaborative nursing actions
– Physician-initiated interventions
– Collaborative interventions

Advantages of Nursing
Interventions Classifications Implementing the Care Plan
• Standardizing nomenclature • Organize resources
• Expanding nursing knowledge • Anticipate unexpected outcomes/situations
• Developing information systems • Promote self-care: teaching, counseling, advocacy
• Teaching decision making • Assist patients to meet health outcomes
• Ensuring appropriate reimbursement
• Allocating nursing resources
• Communicating nursing to non-nurses
• Linking nursing content

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 15
Aims of Teaching and Counseling Teaching Acronym
• Maintaining and promoting health • T – une into the patient
• Preventing illness • E – dit patient information
• Restoring health • A – ct on every teaching moment
• Facilitating coping • C – larify often
• H – onor the patient as partners in the education process

Teaching Outcomes Factors Affecting Patient Learning
• High-level wellness and related self-care practices • Age and developmental level
• Disease prevention or early detection • Family support networks and financial resources
• Quick recovery from trauma or illness • Language deficits
• Enhanced ability to adjust to developmental life changes • Literacy level

Focus of Patient Education Critical Developmental Areas
• Preparation for receiving care • Physical maturation and abilities
• Preparation before discharge from health care facility • Psychosocial development
• Documentation of patient education activity • Cognitive capacity
• Emotional maturity
• Moral and spiritual development

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 16
Teaching Plans for Older Adults Three Learning Domains
• Allow extra time • Cognitive — storing and recalling of new knowledge in
the brain
• Plan short teaching sessions
• Psychomotor — learning a physical skill
• Accommodate for sensory deficits
• Affective — changing attitudes, values, and feelings
• Reduce environmental distractions

Cope Model Key Points to Effective Communication
• C – reativity • Be sincere and honest.
• O – ptimism • Avoid too much detail and stick to the basics.
• P – lanning • Ask for questions.
• E – xpert information • Be a cheerleader for the patient.
• Use simple vocabulary.
• Vary the tone of voice.
• Keep content clear.
• Listen and do not interrupt.

Providing Culturally Competent
Patient Education Sources of Information
• Develop an understanding of the patient’s culture. • Primary — patient
• Work with multicultural team. • Secondary — medical records, patient family
• Be aware of personal assumptions, biases, and
• Understand the core cultural values of the patient or
• Develop written material in native language of the
• Use testimonials of persons with same cultural
background as the patient.

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 17
Teaching Strategies
Assessment Parameters • Lecture
• Discussion
• Readiness to learn
• Panel discussion
• Ability to learn
• Demonstration
• Learning strengths
• Discovery
• Role playing
• Audiovisual materials
• Printed materials
• Programmed instruction
• Web-based instruction

Considerations for Successful
Promoting Compliance Patient Teaching
• Be certain that instructions are understandable and • Forming contractual agreements
support patient goals.
• Considering time constraints
• Include the patient and family as partners in process.
• Scheduling
• Utilize interactive teaching strategies.
• Group versus individual teaching
• Develop interpersonal relationships with patients and
their families. • Formal versus informal teaching
• Manipulating the physical environment

Sample Teaching Strategies Obtaining Feedback About Learning
• Cognitive domain — lecture, panel, discovery, written • Reinforcing and celebrating learning
• Evaluating teaching
• Affective domain — role modeling, discussion,
audiovisual materials • Revising the plan

• Psychomotor domain — demonstration, discovery,
printed materials

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 18
Documentation of the Variables Influencing
Teaching-Learning Process Outcome Achievement
• Summary of the learning need • Patient variables
• The plan – Developmental stage
• The implementation of the plan – Psychosocial background
• Evaluation results • Nurse variables
– Resources
– Current standards of care
– Research findings
– Ethical and legal guides to practice

Guidelines to Patient Counseling Common Reasons for Noncompliance
• Make everyone feel comfortable in the situation and • Lack of family support
• Lack of understanding about the benefits
• Counseling may be formal or informal.
• Low value attached to outcomes
• Use interpersonal skills of warmth friendliness, openness,
and empathy. • Adverse physical or emotional effects of treatment

• Caring is fundamental in the counseling role. • Inability to afford treatment

Factors to Consider When
Types of Counseling Delegating Nursing Care
• Short-term • Patient condition
• Situational crisis • Complexity of the action
• Long-term • Potential for harm
• Developmental crisis • Degree of problem-solving and innovation necessary
• Motivational • Level of interaction required with patient
• Capabilities of UAP
• Availability of professional staff to accomplish workload

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 19
Overview of the Five Steps of the Nursing Process:

Nursing Care That Should Not • Measuring the client’s health achievements based on the goals specified.

Be Delegated to a UAP • It is used to determine the extent of which goals of nursing care have been
• Activities:
• Initial and ongoing nursing assessment 1. Data collection about the client’s response

• Determination of nursing diagnoses, plans, evaluations 2. Compare data to outcome criteria
3. Analyze the result
• Supervision and education of nursing personnel 4. Modify the Nursing Care Plan as necessary

• A nursing intervention requiring professional nursing To encourage further goal achievement, it is important for the nurse to
knowledge, judgment and/or skill evaluate client’s goal achievment as early as possible.

Five Rights of Delegation Evaluating Step
• Right task • Allows achievement of outcomes
• Right circumstances • Directs nurse-patient interactions
• Right person • Measures patient outcome achievement
• Right direction/communication • Identifies factors to achieve outcomes
• Right supervision • Modifies the plan of care, if necessary

Overview of the Five Steps of the Nursing Process:

Action Based on Outcome Achievement
• Terminate plan of care
• Modify plan of care
• Continue plan of care

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 20
Four Types of Outcomes
• Cognitive — increase in patient knowledge
• Psychomotor — patient’s achievement of new skills
• Affective — changes in patient values belief, and
• Physiologic — physical changes in the patient

Five Classic Elements of Evaluation Evaluating Outcomes
• Identifying evaluative criteria and standards • Cognitive — asking patient to repeat information or apply
new knowledge
• Collecting data
• Psychomotor — asking patient to demonstrate new skill
• Interpreting and summarizing findings
• Affective — observing patient behavior and conversation
• Documenting judgment
• Physiologic — using physical assessment skill to collect
• Terminating, continuing, or modifying the plan and compare data

Evaluative Criteria vs. Standards Variables Affecting Outcome Achievement
• Criteria — measurable qualities, attributes, or • Patient
characteristics that specify skills, knowledge, or health
status – E.g., a patient gives up and refuses treatment

– Describe acceptable levels of performance by stating • Nurse
expected behaviors of nurse or patient – E.g., a nurse is suffering from burn-out
• Standards — levels of performance accepted and • Healthcare system
expected by the nursing staff
– E.g., inadequate staffing
– Established by authority, custom, or consent

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 21
Four Steps Crucial to
Evaluative Statements Improving Performance
• Decide how well outcome was met (met, partially met, or • Discover a problem.
not met)
• Plan a strategy using indicators.
• List patient data or behaviors that support this decision
• Implement a change.
• Assess the change and/or plan a new strategy if
outcomes are not met.

Improving Professional Performance

• Peer review
• Quality assurance programs
• Structure evaluations
• Process evaluations
• Outcome evaluations
• Quality improvement
• Nursing audit
• Concurrent and retrospective evaluations

Revisions in the Plan of Care Determining Adequacy of Evaluation Step
• Delete or modify the nursing diagnosis. • Evaluate patient achievement of desired outcomes.
• Make the outcome statement more realistic. • Review how the process is used.
• Adjust time criteria in outcome statement. • Revise the plan of care if necessary.
• Change nursing interventions. • Participate in quality-assurance programs.

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 22
Determining Adequacy of Evaluation Step Determining Adequacy of Evaluation Step
• Evaluate patient achievement of desired outcomes. • Evaluate patient achievement of desired outcomes.
• Review how the process is used. • Review how the process is used.
• Revise the plan of care if necessary. • Revise the plan of care if necessary.
• Participate in quality-assurance programs. • Participate in quality-assurance programs.

Major Premises of Quality Improvement
(Schroeder, 1994)
• Focus on organizational mission
• Continuous improvement
• Customer orientation
Nursing Skills
• Leadership commitment
• Empowerment
• Collaboration/crossing boundaries
• Focus on process
• Focus on data and statistical thinking

Questions to Insure a Firm Four Blended Skills
Commitment to Evaluation

• What are the patient’s outcomes? • Cognitive skills — make sense of the situation and grasp
what is necessary to achieve goals
• What are nursing values?
• Technical skills — manipulate equipment skillfully to
• How can these values be formalized in standards and produce desired outcome
evaluative criteria?
• Interpersonal skills — establish and maintain caring
• What data exist to determine whether criteria are met? relationships that facilitate achievement of goals
• How can these data best be collected, analyzed, and • Ethical/legal skills — personal moral code and
interpreted? professional role responsibilities
• To what courses of actions do the findings lead?

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 23
Cognitively Skilled Nurses
Ethically and Legally Skilled Nurses
• Offer scientific rationale for patient plan of care
• Are trusted to act in ways that advance interests of
• Select nursing interventions most likely to yield desired patients
• Are accountable for the practice
• Use critical thinking to solve problems creatively
• Act as effective patient advocates
• Mediate ethical conflict among patient, significant others,
and healthcare team

Considerations When Posed with a
Technically Skilled Nurses Thinking Challenge
• Use technical equipment with competence and ease to • Purpose of thinking
achieve goals with minimal distress to patients
• Adequacy of knowledge
• Creatively adapt equipment and technical procedures to
needs of patients in diverse circumstances • Potential problems
• Helpful resources
• Critique of judgment/decision

Interpersonally Skilled Nurses
Characteristics of Interpersonal Caring
• Use interactions with patients and significant others and • Promotion of dignity and respect of patients
colleagues to affirm their worth
• Centrality of the caring relationship
• Elicit personal strengths and abilities of patients to
achieve health goals • Mutual enrichment of both participants in the nurse-
patient relationship
• Provide the healthcare team with knowledge about
patient goals and expectations
• Work collaborative with healthcare team as respected
and credible colleagues

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 24
Steps in Concept Map Care Planning
Developing Ethical/Legal Skills
• Develop a basic skeleton diagram.
• Developing accountability
• Analyze and categorize data.
• Reporting incompetent, unethical, or illegal practice
• Analyze nursing diagnoses relationships.
• Identify goals, outcomes, and interventions.
• Evaluate patient’s responses.

Clinical Reasoning

Critical Thinking and Clinical Reasoning

• Is purposeful, informed, outcome-focused thinking
• Is driven by patient, family, and community needs
• Is based on principles of nursing process and scientific
• Uses both intuition and logic, based on knowledge, skills,
• Requires strategies that make the most of human
• Is constantly reevaluating, self-correcting, and striving to

Joannes Paulus T. Hernandez, B.S.H.B.,
B.S.N., R.N. 25