Nursing Care Plan: An Evidence-Based Tool For Learning and Providing High Quality Care

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Nursing Care Plan: An Evidence-Based Tool for Learning and Providing High Quality
Care
Book · March 2013
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TABLE OF CONTENTS
Page
Table of Contents
Chapter 1 I NTRODUCTI ON 1
Statement of the Problem 3
Hypotheses 4
Conceptual Framework 4
Models that Guided this Study 7
Roy’s Adaptation Model 7
Vygotsky’s Sociocultural Theory of Development 8
Commission on Higher Education Memorandum 14, Series 8
of 2009
Scope and Limitation 10
Significance of the Study 11
Definition of Terms 12
Chapter 2 REVI EW OF RELATED LI TERATURE 17

Related Literature 17
The Nursing Process: Globalization of a Nursing Concept 17
Nursing Care Plan 19
Clinical Experience 21
Framework of the Nursing Education in the Philippines 22
Standards of Nursing Practice 24
Related Studies 24
Synthesis 28
Chapter 3 M ETH ODOLOGY 31

Research Design 31
Participants of the Study 31
Sampling Design 32
Research Instrument 33
Validity 34
Reliability 35
Statistical Tool and Treatment of the Data 35
Data Gathering Procedure 35
Chapter 4 PRESENTATI ON, ANALYSI S AND 38

I NTERPRETATI ON OF DATA
Nursing Students’ Understanding of the Concept of NCP 38
Analysis of the Contents of the Components of NCP as 45
Formulated by the Nursing Students
Nursing History and Physical Examination 45
Assessment 47
Nursing Diagnosis 49
Rationale 53
Planning / Desired Outcomes 55
Implementation / Interventions 59
Justifications 61
Evaluation 61
Significant Interaction Between the Effects of Gender and 62
NAT/CSAT Scores Grouping on Mean Scores Using the
School’s NCP Model
Perceived Difficulties Encountered by the Nursing Students 64
in Formulating Nursing Care Plan
Nursing Care Plan Components: How Taught, Applied, 71
Corrected and Evaluated in the Classroom and Clinical
Area
How the Proposed Enhanced Model Addressed Issues and 73
Concerns Encountered with the School’s NCP Model
Significant Interaction Between the Effects of Gender and 80
NAT/CSAT Scores Grouping on Mean Scores Using the
Enhanced NCP Model
Significant Difference in NCP Mean Scores When Using 81
the School’s Model and the Enhanced Model
Chapter 5 SUM M ARY OF FI NDI NGS, CONCLUSI ONS AND 82

RECOM M ENDATI ONS
Summary of Findings 82
Conclusion 84
Recommendations 84
REFERENCES 87
APPENDI CES
A Sample Approval of Dissertation Proposal 93
B Sample Letter to the Dean of the College of Nursing 94
C Sample Letter to the Chief of Hospital 95
D Sample Letter to the Chief Nurse 96
E Sample Informed Consent Form 97
F Review of Metaparadigm of Nursing with the Integration of 100
Roy’s Adaptation Model
G Nursing Care Plan Enhancements 101
H Enhanced NCP Model 104
I School’s NCP Model 107
J Nursing Care Plan Evaluation Criteria 108
K Nursing Care Plan Scoring Rubric 111
L Nursing Care Plan Scoring Guide 112
M Interview Guide 113
CURRI CULUM VI TAE 114
LI ST OF TABLES
Number Page
1 Profile of the Participants 32
2 Analysis of Nursing History and Physical Examination 46
Components
3 Analysis of Assessment Components 48
4 Analysis of Nursing Diagnosis Components 50
5 Analysis of Rationale Components 54
6 Analysis of Planning Criteria 56
7 Analysis of Implementation/Intervention Components 60
8 Results of 2-Way ANOVA, NAT/CSAT and Gender Interaction 62
When Using School’s NCP Model
9 Summary of NCP Components: Taught and Applied 71
10 Summary of NCP Components: Corrected and Evaluated 72
11 Comparison of Assessments in Session 1 and Session 3 75
12 Comparison of Nursing Diagnosis in Session 1 and Session 3 75
13 Comparison of Interventions in Session 1 and Session 3 76
LI ST OF FI GURES
Number Page
1 Schematic Diagram of the Study 10
2 Flow of the Research Process 37
3 NCP Average Grade Summary 74
4 Nursing Care Plan Scores Per Component Per Session 79
5 Metaparadigm of Nursing (with the Integration of Roy’s 100
Adaptation Model)
Chapter 1
I NTRODUCTI ON
“Our lives begin to end the day we become silent about things that matter.”
–M ar tin Luther King Jr .
“Quality challenges facing nursing education are always changing...”

(L. E.Masselink, personal communication, April 4, 2011).
Indeed change has implications in every dimension of man’s existence

especially in healthcare and nursing. The increasing complexities in health-care
provision, the increasing number of health professionals at different levels, and the
need to assure more equitable access to health care are few of the reasons cited by the
World Health Organization (WHO) for the need to establish, develop, and implement
global standards for nursing and midwifery education (WHO, 2009).
The knowledge and competencies to meet these increasing complexities in
health-care provision and the variety of care needs may be daunting for the nursing
students. The nursing curriculum is designed to prepare and to allow for the
accumulation of knowledge and practice experiences in a span of four years.
Nursing education is sometimes perceived to be preparing students for their
nursing board examinations. Bleich (2009) pointed out that the licensure examination
is a minimum standard - meaning, it tests only for minimum safe competency (cited
in Stokowski, 2011). Graduating and passing the nurse licensure examination is only
the beginning hence, continuing learning is needed (Mallik, Hall & Howard, 2009).
The same paradigm is observed in the Philippine Nurse Licensure Examination
(NLE). The NLE also tests the competencies of the beginning nurse practitioner to
care for the clientele across age groups. The competencies are assessed through
application, interpretation, analysis, decision-making and problem solving based on
clinical situations that are presented. The tests cover the following: patient care
1
competencies that include safe and quality nursing care, communication,
collaboration and teamwork, and health education that comprise 65 percent of the test
items; empowering that include legal responsibility, ethico-moral responsibility and
personal and professional development that comprise 15 percent of the test items;
enhancing that includes record management and management of resources and
environment that comprise ten percent of the test items; and enabling that includes
quality improvement and research that comprise ten percent of the items. These
patient care competencies that are aimed to be developed among the nursing
graduates are anchored in the nursing process as the framework (Sto. Tomas, PRC –
BON, 2009).
Based on the beginning competencies assessed in the licensure examinations,
the training and experiences gained by nursing students in the clinical area would be
of very great value. Making meaningful use of the practice nursing care plans that the
students formulated in their related learning experiences would be a very valuable
tool that can contribute to the improvement of their patient care-related
competencies.
The nursing care plan aims to teach students the processes involved in
providing safe and quality care. It is presented in a step by step model that progress
from assessment to evaluation. It also includes a provision for scientific rationale for
each nursing intervention selected. Hence, the nursing care plan is a complete
teaching and learning tool based on evidences—evidences showing the
manifestations of clients, evidences explaining why a particular condition is
happening, and evidences on what particular course of therapeutic management
match the needs of the patient among others.
It is suggested that writing care plans enables the clinical instructors to review
the planned care-related activities of students during their clinical training. During
this review, the instructor is able to appraise if the nursing student provided complete
assessment data to support the nursing diagnosis arrived at and the interventions
identified to help solve the health problems of the patient (Ralph and Taylor, 2008).
2
This study is anchored on the belief that it is in the basic nursing education
program that foundations are laid out, developed and strengthened. The researcher
believes that it is very essential and important to equip and guide the nursing students
with updated knowledge, skills and attitudes needed in formulating and
implementing their nursing care plan. This will help develop and strengthen their
competencies in application, interpretation, analysis, decision-making and problem
solving needed in providing competent, safe, and quality care. Improving the
instructional strategies and providing focus and attention to the learning needs of the
nursing students will contribute to better learning, improved skills, and promotion of
positive attitudes toward learning and patient care.
The foregoing presentation suggests that there is a pressing need for constant
updating and reviewing of learning guides both theoretically and clinically.
Consequently, meaningful learning experiences need to be provided in order to equip
and guide future nurses with basic competencies. The central focus of this inquiry is
the nursing care plan based on the nursing students’ clinical experiences, which shall
depict what they have learned and applied in terms of richness, breadth and depth in
rendering quality nursing care having completed three academic years.
Statement of the Problem

The primary purpose of this study was to examine the Nursing Care Plan based
from Level 3 nursing students’ clinical experiences.
Specifically, it sought to answer the following questions:
1. What are the nursing students’ understandings of the concept of nursing
care plan (NCP)?
2. What are the contents in each component of the written NCP formulated by
the nursing students using when the school’s NCP model?
3. Is there a significant interaction between the effects of gender and
NAT/CSAT Scores grouping on the written NCP mean scores when using
the school’s NCP model and rated using the NCP Scoring Criteria?
3
4. What are the perceived difficulties encountered by the nursing students in
the formulation and implementation of the nursing care plan?
5. How were the nursing care plan concepts taught, applied, corrected and
evaluated in the classroom and the clinical area?
6. How does the proposed model address the issues and concerns that the
students encountered when using the school’s nursing care plan model?
7. Is there a significant interaction between the effects of gender and
the enhanced NCP model and rated using the NCP Scoring Criteria?
8. Is there a significant difference in the nursing students’ written NCP Scores
when using the school’s model and the enhanced model?
H ypotheses
Based on the problems identified, the following hypotheses were advanced:
1. There is no significant interaction between the effects of gender and
the school’s NCP model and rated using the NCP Scoring Criteria.
2. There is no significant interaction between the effects of gender and
the enhanced NCP model and rated using the NCP Scoring Criteria.
3. There is no significant difference in the nursing students’ written NCP
Scores when using the school’s model and the enhanced model?
Conceptual Framework
This study is inspired by Tanner’s (2006) advocacies and challenge to nurse
educators to develop and test new models in providing clinical education and the
utilization of nursing care plan to support the attainment of specific clinical learning
outcomes.
The nature of the problems advanced in this study required evaluation of the
nursing students’ clinical experience in using the school’s NCP model. After
4
assessing the students’ understanding of the concept of NCP, contents in each
component of their NCPs, perceived difficulties in formulating and implementing
their NCPs, how NCP concepts were taught, applied, corrected and evaluated in the
classroom and clinical area, proposed enhancements designed to improve the
teaching and learning values of NCPs in their clinical experience were introduced.
As a whole, the objectives of this study were to evaluate and seek
enhancements. These objectives drew support from Stufflebeam’s (2007) advocacies
that pursuing ongoing improvements demonstrate prima facie evidence of being
accountable. He further advanced that being accountable to a certain extent means
that one is engaging in continuing improvements. This is the ultimate goal of the
researcher in this study.
In order to address the problems advanced in this study, Stufflebeam’s (2007)
Context, Input, Process, and Product (CIPP) Framework was used in order to guide
the conduct of this study.
The CIPP Framework is an acronym, represented by the following terms and
conceptually defined (Stufflebeam, 2007) and applied in this study:
Context evaluation refers to defining and assessing of relevant needs and
priorities as bases for judging goals and outcomes.
In this study, nursing students who have completed their third year and
characterized by their NAT Scores, CSAT Scores, and gender were assessed
on their understanding of the concept of nursing care plan (NCP), the contents
in each component of their written NCP formulated using the school’s NCP
model and their perceived difficulties in formulating NCP. One-on-one
interviews and focus group discussions were utilized in generating information
from the participants.
I nput evaluation refers to the assessment of alternative approaches to meeting
needs as a means of planning programs and allocating resources.
This study was divided into five phases. The first phase involved
securing permissions and approvals to conduct this study. Phase two involved
the application of the students’ knowledge and understanding of the school’s
5
NCP model through actual formulation of NCP based on an assessment of
patients who were hospitalized in two separate sessions. Phase 3 involved
focus group discussion on their perceived difficulties. After evaluating the
transcripts, a separate schedule was made to review the concepts of nursing,
integration of Roy’s Adaptation Model, and introduction of an enhanced NCP
Model using Vygotsky’s Socio-cultural Development Theory as the medium in
imparting new knowledge. The fourth involved the utilization of the enhanced
model guided by the nursing concepts and Roy’s Adaptation model in
formulating nursing care plans in another two separate sessions. The fifth
phase involved interviewing key informants: nursing alumnae and practicing
staff nurses who graduated from the school and clinical instructors who were
still actively teaching at the same school.
Process evaluation refers to the documentation and assessment of the
programs that were implemented.
In this study, the nursing care plans formulated by the nursing students
using the school’s model and later on using the enhanced model were
evaluated and scored using a nursing care plan evaluation criteria based on
completeness, appropriateness, relevance, use of evidence, and relatedness of
information in each component. The scores were then interpreted using the
scoring matrix.
Product evaluation refers to the assessment of all outcomes, comparing
outcomes to assessed needs, interpreting outcomes against program implementation
or contrasting outcomes with other programs.
In this study, the quality of the NCP outputs was evaluated using NCP
evaluation criteria and NCP scoring rubric. The scores when using the school’s
model and the enhanced model were interpreted. The results were validated
using interviews from key informants comprised of alumna and clinical
instructors.
6
M odels that guided this study
Roy’s Adaptation M odel
Nursing as a profession is a social function conducted in the context of nurse-
patient interaction. In this study, Sister Callista Roy’s Adaptation Model provided the
conceptual basis of the bio-psycho-socio-cultural-spiritual dimensions of human
beings. Roy’s Adaptation Model describes the meta-paradigm concepts of human
being (as an individual, as a family, as a community, and as a population group),
environment, health and nursing. The model portrays human beings as endowed with
internal and external characteristics that are influenced by his/her interactions with
the environment. Roy explains that in these interactions with the environment,
various stimuli affect the way human beings react. These stimuli prompt the “coping
processes” to allow the human being to mobilize his/her adaptive modes in order to
continue functioning. The coping mechanisms according to Roy include innate
processes and acquired processes. Further, Roy categorized coping processes into
regulator subsystems and cognator subsystems. Regulator subsystems involve
responses of a person through the mobilization bio-physiological processes. The
cognator subsystems involve cognitive-emotional channels consisting of perceptual
and information processing, learning, judgment, and emotion. The outcomes of the
coping processes enable the person to respond to the stimuli that are demonstrated
either as adaptive responses that lead to health and well-being or ineffective
responses that lead to ill health. Nursing, according to Roy & Andrews (1999) comes
in with the goal of promoting adaptation for individuals and groups in order to
contribute to health, quality of life, and in dying with dignity by assessing behavior
and factors that influence adaptive abilities and by intervening to expand those
abilities and to enhance environmental interactions (cited in Fawcett, 2005).
The model is derived from interrelated premises and concepts that relate to
reality. The central focus of Roy’s Adaptation Model is on the concept of adaptation
of a person. Roy’s concepts of person, environment, health and person are presented
to have an interrelation to the central concept of adaptation of a person (Phillips,
2010). Roy posits that the person continually experience environmental stimuli. The
7
person responds by coping to the stimuli that either leads to an effective adaptation or
to an ineffective response. An effective adaptation promotes integrity and helps the
person to achieve the goals of adaptation--to achieve survival, growth, reproduction,
mastery, and person and environmental transformations. Ineffective responses to the
environmental stimuli lead to failure to achieve or threaten the goals of adaptation.
The role of the nurse is to assist in the person’s effort in adaptation by managing the
environment.
Vygotsky’s Sociocultural Theory of Development

In this study, Vygotsky’s Sociocultural Theory of Development was used by
the researcher in guiding the nursing students. Learning starts when the nursing
instructor and nursing student exchange ideas, concepts relating to the condition and
care of patients. He believes that learning occurs within the context of a social
situation, the use of language and an embracing culture. As one of the foundations of
constructivism, it asserts three major themes. First, social interaction plays a
fundamental role in the process of cognitive development on the social level and later
on the individual level, meaning between people and then inside the person. Second,
this theory focused on the connections between people and the socio-cultural context
in which they act and interact in shared experiences. Third, humans use tools
(language) that develop from a culture, such as speech and writing, to mediate their
social environments. Vygotsky believed that internalization of these tools lead to the
development of higher thinking skills (cited in Eggen & Kauchak, 2010).
Many schools have traditionally held a transmission model wherein a teacher
or lecturer “transmits” information to students. In Vygotsky’s theory, learning is
promoted when students play active roles—that is, learning becomes a reciprocal
experience between students and teacher.
Commission on H igher Education (CHED) M emorandum 14, Series of 2009

The mandate for ensuring the provision of relevant and quality health services
that is locally and globally competitive is embodied in the Commision of Higher
8
Education’s Memorandum 14 (CHED, 2009). The BSN program emphasized that the
major aims of preparing beginning nurse practitioners should be the development of
professional competencies and the continued assumption of the responsibility for
professional development utilizing research in the practice of the profession.
The program further aims in developing nurses who will demonstrate
competencies in the following Key Areas of Responsibility: Safe and quality nursing
care; management of resources and environment; health education; legal
responsibility; ethico-moral responsibility; personal and professional development;
quality improvement; research; record management; communication; and
collaboration and teamwork (CHED, 2009).
CHED (2009) further recommends that the nursing process be utilized as the
framework with the integration of holistic care of client across the life span for the
promotion and maintenance of health in the related learning experiences of nursing
students.
The schematic diagram showing the concepts underpinning this study and
integrated into the CIPP framework is presented in Figure 1. The integration of the
elements of the instructional and learning processes—social interaction, culture and
language—according to Vygotsky’s Socio-cultural Theory of Development enhances
learning and development. The concepts of Roy’s Adaptation Model—human
being, environment, health, nursing, coping processes and adaptive modes—are
integrated into the instructional enhancements in formulating nursing care plans by
the nursing students in order to come up with enriched learning, enhanced nursing
care plans and ultimately trains them to provide improved, competent, safe and
quality nursing care.
The foregoing presentation of the theories and concepts guided the researcher
in studying the nursing care plan based on the nursing students’ clinical experience.
9
Scope and Limitation
This study involved twelve (12) third year nursing students enrolled in the
second semester of AY 2010-2011. Along the course of the implementation of this
study, two nursing students decided to discontinue their participation. Two students
with similar characteristics with those who discontinued were recruited, provided
10
orientation and provided tasks to catch up with the other participants were carried out
in order to complete the rooster of participants required for this study.
This study focused in describing and analyzing the nursing care plan based
from the nursing students’ clinical experience. The study was limited in describing
and analyzing the students’ understanding of the concept of the nursing care plan, the
analysis of the components of the nursing care plan guided by an evaluation tool, and
the difficulties encountered in formulating nursing care plan. Evaluation as a
component of the nursing care plan was not carried out since the purpose of the study
is limited to the formulation of a written nursing care plan from assessment to the
justification of interventions only.
Significance of the Study

The results of this study may be of value and may benefit the following:
The Academic Nursing Administrators may be able to review the existing
NCP model that has been used and adopt a model that would integrate the bio-
psycho-socio-cultural-spiritual characteristics of a client’s being into a meaningful
and workable nursing care plan to be used consistently across all year levels.
The Nursing curriculum advocates may be able to review and adopt a
standardized and workable competency-based evaluation criteria designed to
objectively appraise the completeness, appropriateness, relevance, evidence-based
and relatedness (CARER) of the nursing care plan formulated by the student.
The Nursing faculty may be able to adopt strategies that will consistently
provide the necessary guidance, coaching, and ensuring that the students utilize the
components of the nursing care plan appropriately as a critical thinking and decision
making tool in order to provide a workable and safe nursing care to the clients.
The Nursing students may learn to consistently and properly use and apply
the various components of the nursing process as the framework in formulating a
nursing care plan in order to enhance critical thinking and decision making skills and
in order to provide safe and quality care to the clients.
11
The future researchers might be able to replicate or refer to the results of this
study in order to uncover areas that still need to be enhanced.
Definition of Terms
The following terms were conceptually and operationally defined as the point
of reference made in describing and analyzing the nursing care plan formulated by
the nursing students. In this study, the points of reference were their clinical
experiences.
Clinical experience is conceptually defined as that part of clinical nursing
education that enables students to move from theoretical learning about nursing -
based on textbook and classroom explanations of human responses to illness and its
treatment - to practical learning in making the observations and performing the
interventions necessary to manage learning in making the observations and
performing the interventions necessary to manage those responses in real-life
situations. Theory becomes a reality as students begin to make connections between
the generic “usual” case presented in the classroom and the specific “actual” case
with which they are involved (O’Connor, 2006).
It is operationally defined in this study as that part of the nursing education
program wherein the nursing students enter the hospital or any setting outside the
classroom to engage with patients, (individual, family, groups, communities) and be
able to apply their theoretical knowledge in assessing, diagnosing, justifying,
planning, implementing and evaluating nursing care and in solving the health or
other non-health related problems that can be solved and managed within their
capabilities.
Formulating Nursing Care Plan is conceptually defined as the act of writing
an organized nursing care plan in accordance with a specified model.
It is operationally defined in this study as creating a written nursing care plan
using the standard model and an enhanced model.
Nursing Care Plan (NCP) is conceptually defined as an instructional tool that
include assessment data that are organized, identification of nursing diagnoses, client
12
goals, outcome criteria, nursing interventions, scientific rationale and evaluation
(Craven & Hirnle, 2007; Carpenito-Moyet, 2007; Alfaro-LeFevre 2009; Alfaro-
LeFevre, 2002).
In this study, it is viewed as the written document used as a guide by students
in providing care to their assigned patient. The following are the components of the
written Nursing Care Plan and are operationally defined as used in this study:
a) Assessment refers to the act of collecting, analyzing and interpreting
information. The students indicate the specific and measurable descriptors
of the signs and symptoms they identified during the interview and physical
examination performed and are clustered to support the patient’s health-
related problems.
b) Nursing Diagnosis refers to the clinical judgment arrived at by the nursing
students based on the information that they gathered. The problem
identified is labeled using the NANDA statement, supported by the etiology
and the corresponding signs and symptoms with specific and measurable
descriptors that are demonstrated by the patient in relation to the identified
problem.
c) Rationale refers to the explanation of how the health problem developed. It
is the application of both scientific explanations and observations based on
the bio-psycho-socio-cultural-spiritual variables that lead to the
development of the signs and symptoms and the processes involved in the
health problem. The coping processes and the adaptations are integrated in
order to reflect the students’ interpretation and analysis of how the patient’s
condition developed. This is then made as the basis in planning what to do
in order to help and facilitate the promotion of healing, prevention of
complications, facilitating rehabilitation and restoration of function. In
wellness state, the nursing students develop plans aimed at promoting
health and preventing illness.
d) Planning of goals of care/outcomes refers to setting of goals of care and
desired outcomes that are individualized and prioritized and with specific,
13
measurable, attainable, realistic and time-bounded descriptions. The goals
of care are represented by stating a time frame, the improved state of the
problem and the desired outcomes that are stated as the improved state of
the signs and symptoms manifested by the patient.
e) I mplementation refers to both collaborative and independent interventions
aimed at improving or resolving the health manifestations of the patient: (a)
collaborative interventions refer to the prescriptions made by the attending
physicians, therapists, laboratory technicians, dieticians and other members
of the health team who provide care directly or indirectly to the patient and
family; and (b) independent interventions refer to the nurse-initiated
activities that are aimed to complement the collaborative interventions and
other ethically, morally and legally acceptable actions needed in order to
facilitate the attainment of the goals of care that has been set. The
interventions are categorized using the AMETHODIST Model:
Assessment-related; Medications-related; Exercise-, sleep-, rest-,
environment modification-related; Treatment-, diagnostic procedures-,
safety- and comfort-related; Hygiene- and self-care activities-related;
Outpatient-, referral-, or discharge planning-related; Diet-related; Inspiring-
, motivating-, and/or psycho-emotional support-related; Spirituality-,
Sexuality-related; and Teaching- or health education-related.
f) Justification refers to the scientific basis or evidences explaining the
appropriateness, relevance, effectiveness and relatedness of each of the
interventions provided to the patient.
g) Evaluation of the care plan refers to the accounting of health status of the
patient after interventions were carried out in a span of time based on the
goals of care and desired outcomes that were planned.
Nursing Care Plan (NCP) Evaluation Criteria is operationally defined in
this study as the rating tool used to appraise the application or non-application of
criteria based on the characteristics described in each of the component of the NCP.
The application of a criterion was assigned a score of one (1) and the non-application
14
was assigned a score of zero (0). The NCP Evaluation Criteria are based on
prescribed characteristics that describe the contents in each component of the NCP
such as completeness, appropriateness, relevance, evidence-based, and relatedness
(CARER Model):
(a) Completeness is operationally defined in this study as the collection and
provision of all pertinent information needed in every component of the
NCP. It also refers to the application of all steps involved in a process or
model in each of the component of the NCP.
(b) Appropriateness is operationally defined in this study as the preciseness,
accuracy or correctness of the information provided by the students in
each of the component of the NCP in relation to the patient’s health
problem.
(c) Relevance is operationally defined in this study as the importance and
significance of all information provided in each of the component of the
NCP and in relation to the patient’s health problem.
(d) Evidence use is operationally defined in this study as the integration of
substantial, significant and meaningful proofs provided in each
component of the NCP that are used to support the judgments and
decisions on the best possible solution to the patient’s health problem. It
also refers to nursing actions that are based on scientific principles and
updated accepted practices that are ethically, morally, and legally
appropriate, relevant, and related.
(e) Relatedness is defined in this study as the connectedness of the
information provided in each of the component of the NCP with the other
components of the NCP in relation to the health problem of the patient.
The relatedness is demonstrated in the utilization and application of
information and concepts of biological/physiological, psychological,
socio-cultural, or spiritual processes or experiences that are going on in
the patient that are gathered by the nursing student to support the
formulation of her nursing diagnosis, rationale, plans, interventions,
15
justifications and evaluation. It also means the connectedness of concepts
in explaining the flow of events that are going on in the patient’s
situation.
Nursing Care Plan (NCP) Scoring Guide is operationally defined in this
study as the reference guide for the conversion of the rubric scores into grades. The
rubric scores attained in each component of the NCP were summed up as a whole
and cross-referred to the NCP scoring guide in order to determine the NCP grade
equivalent.
Nursing Care Plan (NCP) Scoring Rubric is operationally defined in this
study as the guide in scoring each component of the NCP based on the extent of
application or non-application of the established criteria. Scores were interpreted in
terms of the extent of application of the criteria as to: (a) very sufficient is scored 3;
(b) sufficient is scored 2; (c) deficient is scored 1; and (d) very deficient is scored 0.
Nursing Students in this study refers to the third year students in the College
of Nursing enrolled during the second semester of AY 2010–2011.
16
Chapter 2
REVI EW OF RELATED LI TERATURE
Related Literature
The Nursing Process: Globalization of a Nursing Concept
The nursing process is characterized as a global concept that is being taught,
discussed and implemented worldwide. Global organizations, such as the World
Health Organization (WHO) and the International Council for Nurses (ICN)
acknowledge the use of the nursing process as a central concept in nursing. Various
national governments and nursing organizations based their legal prescription of
quality nursing on the nursing process, for example, Sweden, Germany, UK, South
Africa, State Practice Acts in the USA, the American Nursing Association (ANA),
Czech Republic (Uys & Habermann, 2005). Canada, Australia, New Zealand, India,
among others and the Philippines recognize the nursing process as well as the
framework in providing safe, competent and quality care.
Uys & Habermann (2005) point out that the nursing process is grounded in a
problem-solving cycle, which usually includes at least the following phases: (a)
collecting information and assessing the patient; (b) planning the care and defining
the relevant objectives for nursing care; (c) implementing actual interventions; and
(d) evaluating the results. They mention that other regions use five or six cycles by
further differentiating formulating nursing diagnosis, setting objectives and planning
to guide the planning and actual nurses’ actions in more detail.
Taylor & Game (2005) insinuated that the major impact of the nursing process
is that it now underpins nursing practice within clinical environment and it also
underpins the teaching of nursing to neophyte groups. They underscored that in
Australia, each nursing program needs to adhere to the ANCI standards for
competency that include a working application and knowledge of the nursing
process.
17
They mentioned that efforts to use the nursing process as a holistic approach
was upset because nurses tended initially to concentrate on the medical diagnosis and
treatment of the patient, and tried to reflect all of the nursing care in terms of the
medical management. With the introduction of NANDA, nurses had specific nursing
diagnostic groups and nursing diagnoses within those groups so they were then able
to embrace fully the holistic nature of nursing assessment. Another predicament in
Australia is that the nursing care plan is running the risk of being reduced into a
checklist causing concerns that the nursing process will be relegated back to task
orientation (Taylor & Game 2005)
The nursing process in the Caribbean is defined as a systematic, logically
structured, problem-solving method for nurses, a tool that helps to plan care: ‘it is a
tool that is effective and easy to use’; and ‘it assists the nurse to organize the patient
position on the health-illness continuum, and to make nursing interventions’. It is
also indicated as the knowledge base for all nurses and ‘allows for standardization of
care’, a dynamic process and a ‘good management tool’. The Caribbean Standards of
Nursing Care stipulates in one of its philosophical statements that ‘Client care is
individualized through the Nursing Process’ (Hewitt, 2005).
In the Czech Republic, the organization of nursing practice and nursing
management is described in terms of the nursing process. The nursing process is
described as an essential methodological framework for the implementation of the
nursing objectives. The Ministry of Health (1998) supports the use of nursing process
as a systematic and specific method of individualized approach to the nursing of
every patient/client in the hospital or community setting, which is implemented
through: (a) assessment of the patient; (b) definition of the nursing problems
(diagnoses); (c) planning the individualized nursing care; (d) implementing the
proposed care; and (e) evaluating the effect of the care rendered. Research is a
component in nursing education. Yet, there is no record of any research project on
the nursing process (Mellanova, 2005).
As a whole, the nursing process is depicted as a mature model designed by
nurses and to be used by nurses in providing safe and quality patient care.
18
Nursing Care Plan
Chappy and Stewart (2004) state that curriculum practices in nursing include
requiring students to write care plans as part of their clinical experiences in 98
percent of the nursing programs that they surveyed (cited in Tanner, 2006).
The nursing process is a conceptual framework that enables the student or the
practicing nurse to think systematically and process pertinent information about the
patient. Collecting objective and subjective data about the patient, formulating a
nursing diagnosis based on the data, planning the care and expected outcomes,
implementing the care, evaluating the care, and revising the care based on the results
of the evaluation comprise the nursing process. These components comprise the
contents of the written student nursing care plan (Huckabay, 2009)
Field (1987) advocated that in order to be successful, nurses need knowledge
and skills in the cognitive process of problem-solving, commonly referred to as the
nursing process, an understanding of the parameters of the care situation (that is the
nurse and client setting), and the theoretical knowledge base needed in order to solve
the problem” (cited in Kelly, 2005).
The organization of the nursing process guides the production of nursing care
plan and the documentation of care in all fields of nursing. The nursing care plan
represents the concrete form which makes explicit the process orientation in nursing.
Mason (1999) articulated that the nursing care plan is supposed to enhance
systematic care and to operate additionally as a vehicle for communication, fostering
continuity and visibility of care (cited in Kelly, 2005).
The importance of learning and mastering how to formulate nursing care plan
among nursing students is supported by practical and legal requirements from the
nursing profession. Smith and Dougherty (2001) explain that the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) requires that the clinical
record include evidence of client assessments, nursing diagnosis and/or client needs,
nursing interventions, client outcomes, and evidence of a current nursing care plan.
This requirement stems from the demands from stakeholders and to support health
reimbursements (cited in Kozier, Erb, Berman & Snyder, 2004).
19
The nursing care plan aims to teach nursing students the care planning process.
It is presented in a step by step process that progresses from assessment to evaluation
that also include spaces for scientific rationale for each nursing intervention selected.
Writing care plans enable the clinical instructors to review the planned care activities
of the nursing students. It is during this review that the instructor is able to appraise if
the nursing student provided complete assessment data to support the nursing
diagnosis arrived at and the interventions identified to help solve the health problems
of the patient. More importantly, it shows how to apply classroom and textbook
knowledge to practice (Ralph & Taylor, 2008).
Ralph and Taylor suggested and emphasized that nursing students need to do
complete, appropriate and careful nursing assessment in order to make full use of the
broad base of information covered in books. The assessment findings should be used
to select an accurate diagnostic statement and an appropriate nursing care plan. They
posited that in this manner, the nursing students can ensure that their patients receive
comprehensive, individualized, and consistent nursing care.
According to Wilkinson (2007) most nurses use the term plan of care or care
plan when referring to the outcomes and nursing orders for a single problem or
nursing diagnosis and/or when referring to the total plan of care for a patient.
The educational purpose of nursing care plans include: (a) as strategy in
nursing education that requires the student to apply the nursing process in order to
direct the student to learn critical thinking with analysis of assessment data; (b)
determining priority and non-priority nursing diagnoses/collaborative problems (c)
validation of nursing diagnoses and collaborative problems; (d) establishing realistic
goals of care based from assessment data; (e) formulating interventions aimed at
facilitating resolution of nursing diagnoses or collaborative problems; and (f)
evaluating the effectiveness of the plan after the implementation of care (Carpenito-
Moyet, 2010).
As a whole, the nursing care plan is used not only as a tool for teaching but
also as a tool to guide nurse practitioners in designing safe and quality care that
address patients’ needs.
20
Clinical Experience
Nursing is considered as a practice-based profession since it is involved in the
actual delivery of health care. This is one of the primary reasons why the completion
of a university academic course alone leading to the degree of nursing is not
sufficient for professional registration. Clinical components or related learning
experiences are needed in preparing nurses of the future. Nursing students must also
learn to nurse patients or clients in the real world of health care. A substantial part of
any nursing course needs to be spent learning to nurse in a wide variety of healthcare
contexts. The healthcare encounters in various health care settings provide rich
learning experiences as they apply and practice what they learned from the classroom
into the actual scenario. Making learning clear is dependent on the interpretation of
experience and events made by the learner alone and/or with their practice
mentor/supervisor. Knowledge gained in this way is very personal and often depends
on the reflective skills of the student and the reflective and learning facilitation skills
of the practice mentor/supervisor (Mallik, Hall, & Howard, 2009).
The goal of clinical learning experience is the development of clinical nursing
competence. According to DeBack and Mentkowski (1986), clinical nursing
competence is effective clinical nursing performance or behavior, consisting of
several integrated components - knowledge, skills, affect, motivation, and self-
perception. Clinical nursing competence is developed through instruction in the
nursing curricula therefore it is an outcome of an educational process (cited in Lee-
Hsieh, Kao, Kuo, & Tseng, 2003).
Tanner (2006) advocates that there is a need to develop and test new models of
clinical education in order to meet the challenges and intricacies in today’s demands
for competent, safe, and quality health care. She suggests that clinical nursing
education should include:
a) Focus on outcomes-oriented and competency-based learning experiences.
b) Utilization of varied learning activities designed to match learner, teacher
and situations. Teaching-learning strategies should include research-based activities,
21
total patient care, and preparation of a nursing care plan in order to support the
attainment of specific learning outcomes.
c) Integrating evidence-based teaching methodologies that include
preparations to be made by students in anticipation of the clinical learning
experience, faculty-student support system through questioning, guiding, coaching,
debriefing, reflecting, providing feedbacks, and various assessment approaches in
order to determine the extent of learning.
d) Recognizing and incorporating the growing body of evidences on
apprenticeship, preceptorship, situated learning, deliberate practice and development
of expertise in practice.
e) Integrating simulation in order to complement the hands-on clinical
experiences.
f) Recognizing the need for flexibility in adopting faculty-to-student ratio and
student time on task matching with the nature of learning activity.
The foregoing presentation gave emphasis for the need for nurse educators to
innovate in order to provide the best possible clinical training not only to nursing
students but also to nurse practitioners. It also provided a strong basis for testing an
innovative model in teaching nursing students on how to formulate nursing care
plans that integrate theory into practice.
Framework of the Nursing Education in the Philippines

Article 1 Section 1 defines the framework that sets the direction of nursing
education. The major components of the framework focus on the following: (1)
consideration of the person as a unique bio-psycho-socio-cultural and spiritual being
who is in constant interaction with the environment; (2) these interactions affect
individuals, families, population groups and societal health status; (3) caring roles
assumed by nurses in the promotion and restoration of health, prevention of diseases,
alleviation of suffering and when recovery is not possible, in assisting patients
towards a peaceful death; (4) need for nurse to collaborate with other members of the
health team and other sectors to achieve quality health care; (5) the various clients
22
served by nurses by providing holistic healthcare represented by individuals,
families, population groups, communities and society as a whole; (6) core values
vital to the development of a professional nurse and emphasized in the BSN program
that are anchored in Love of God, caring as the core of nursing, compassion,
competence, confidence, conscience, commitment (to a culture of excellence,
discipline, integrity and professionalism), love of people, and love of country.
The course objectives suggested by CHED for the related learning experience
are consistent with the global objectives to prepare nurses who will provide safe,
competent and quality care. The objectives provide direction where the related
learning experiences should focus. High on the priority is related to nursing care that
emphasizes the utilization of the nursing process as the framework in formulating
nursing care plan. These objectives include (CHED Memo 14, 2009):
1. Utilizing the nursing process in the holistic care of client for the promotion and
maintenance of health
a. Assessing with the client his/her health status and risk factors affecting
health
b. Identifying actual wellness/at risk nursing diagnosis
c. Planning with client appropriate interventions for the promotion and
maintenance of health
d. Implementing with client appropriate interventions for the promotion
and maintenance of health
e. Evaluating with client outcomes of a healthy status
2. Ensuring a well-organized recording and reporting system
3. Observing bioethical principles and the core values (love of God, caring, love
country and of people)
4. Relating effectively with clients, members of the health team and others in
work situations related to nursing and health; and,
5. Observing bioethical concepts/principles and core values and nursing
standards in the care of clients
23
Standards of Nursing Practice
The goal of every governing body and practice discipline is to ensure that
competency standards are put in place and observed to ensure safe and quality
practice.
The Board of Nursing (BON) enhanced the competency standards for Filipino
nurses in May 2009 in order to respond to the escalating sophisticated demands for
competent, safe, quality care among Filipino nurse practitioners not only in the
Philippines but internationally as well (BON, 2009).
The Association of Nursing Service Administrators of the Philippines, Inc.
(2008) published the Manual on Standards of Nursing Services. The manual serves
as guide as well as a cross-reference to corresponding requirements set forth in the
Philippines by ANSAP and the international accrediting body like the Joint
Commission International (ANSAP, 2008).
Relevant to this study is the first part of the manual that pertains to Clinical
Services. Utilizing nursing process, ANSAP (2008) identified five standards to wit:
I. Standards on Assessment of Care.
II. Standards on Care of Patient.
III. Standards on Patient and Family Education
IV. Standards on Access and Continuity of Care.
V. Standards on Nursing Documentation.
As a whole, this study is informed and guided by the standards promulgated by
stakeholders in nursing—Commission on Higher Education, Board of Nursing, and
the Association of Nursing Service Administrators of the Philippines.
Related Studies
McEwen and Brown (2002) surveyed 150 Associate Degree in Nursing
programs, 125 BSN programs and 25 diploma programs using stratified random
sampling from 1,249 NLNAC accredited nursing programs to determine: what
conceptual frameworks are used to guide the curricula of undergraduate nursing
programs; what tools, concepts, and processes are emphasized in the curriculum;
24
relative weight given to the four components of the nursing meta-paradigm (person,
environment, health and nursing) in the curriculum; and differences in the
components of the conceptual framework and how it is used in the curriculum.
The study revealed that the nursing process is the most commonly used
component for conceptual frameworks for nursing curricula, reportedly used by 55
percent of the programs. Simple-to-complex organization, a bio/psycho/social model,
and nursing theorists were used by at least one third of all programs (McEwen &
Brown, 2002).
The study shows that 33 percent employ nursing theorists as one of the
component of the conceptual framework of the nursing programs. Orem and Roy
were reported as the most frequently cited theorists. Other theorists that formed part
of the conceptual framework include Parse, Levine, King, Newman, and Henderson,
Boykin (caring), Chater, and Sister Simone Roach (McEwen & Brown, 2002).
In using the meta-paradigm concepts, the BSN programs devoted higher
percentage of time to environment than both ADN and diploma programs; BSN
programs devoted more time to health than ADN programs. Both ADN and diploma
programs devoted significantly more time to nursing than BSN programs (McEwen
& Brown, 2002).
On tools, concepts and processes emphasized in the curriculum, critical
thinking was the most commonly reported with 74 percent of the programs;
therapeutic nursing interventions (64 percent), problem solving (52 percent) and
communication (49 percent). Statistical analysis indicated that BSN programs were
more likely to stress critical thinking and ADN and diploma programs were more
likely to stress problem solving (McEwen & Brown, 2002).
On the emphasis of content and process, the report states that there was a
balance in the emphasis. The diploma programs were most likely to emphasize
content while BSN programs were least likely (McEwen & Brown, 2002).
According to Rentschler and Spegman (1996), the implication presented by the
issue of emphasis in content versus process is the exposure of inconsistencies
between the beliefs and practices of nurse educators. Myers et al. (1991) argue that
25
although process skills are highly valued, faculty are more comfortable with content-
focused than process-focused teaching. They pointed out that faculty have difficulty
giving up the content they value. According to Myers et al. (1991), content-focus
emphasizes the need for information before understanding and applying it in nursing
practice. A process focus emphasis on the other hand is of value in developing
critical thinking abilities for safe, appropriate decision making and recognition of
multiple perspectives. In this study, a balanced combination of content and process
was reported by more than 70 percent of the programs which appears appropriate
because content and process cannot be separated (cited in McEwen & Brown, 2002).
Palese, De Silvestre, Valoppi, and Tomietto (2009) evaluated nursing care
plans written between 1996 and 2006 by 3,784 students who had completed a
baccalaureate course in nursing process at a university in northern Italy. The study
aimed to find out the number of problems identified by the students on the care plan,
including the nursing diagnoses (actual and risks) and collaborative
problems/potential complications whether the problem given priority by the patient is
also identified by the student as a nursing diagnosis or whether this is listed as a
collaborative problem; the number of objectives recorded for the primary problem
identified in the care plan; the number and typology of interventions planned for the
primary problem identified in the care plan and whether the students recorded an
evaluation of the level of achievement of the objectives listed in the care plan.
The findings indicated that for each care plan, the students reported an average
of 6.3 problems. Fewer than 10 problems were reported in 3,405 (90.3%) of the care
plans. Of the total problems, 5.1 related to nursing diagnoses (actual or risk), and 1.2
were identified as collaborative problems or potential complications. The students'
care plans identified 1.9 diagnoses for each collaborative problem or potential
complication. First-year students gave nursing diagnoses priority more frequently
than students did in their second year (OR 1.09; CI 95% 1.02-1.16; p = .01); students
in their second year more frequently gave priority to nursing diagnoses than did
third-year students (OR 1.11; CI 95% 1.05-1.17; p = .00). Third-year students,
however, were less likely to name nursing diagnoses as a priority (OR 0.71; CI 95%
26
0.68-0.75; p = .00); they chose potential complications or collaborative problems
instead. The students developed an average of 1.3 objectives (±077; range 0-9;
median 1) for the diagnosis given priority. The students planned an average of 3.8
interventions (range 0-124; ±2.23; median 3). In 1,947 care plans (51.5%), no results
of evaluation were reported (cited in Palese et al., 2009).
Palese et al. (2009) concluded that students enrolled in the baccalaureate
nursing course at this university use the NANDA-I Taxonomy in their care plans and
use a wide variety of diagnostic labels, more than the number documented in
literature. Students tend to exhibit deficiencies in two fundamental aspects of nursing
care planning. The objectives do not always include evaluation criteria, and the
evaluation itself may be lacking. While students are able to include technical
interventions (e.g., feeding and mobility), they seem to have difficulty explaining
sustained interpersonal relationships with patients. Some parts of the nursing care
plan (such as problems, nursing diagnoses, and collaborative problems) appear to
vary with the patients' reason for being hospitalized. These findings indicate the need
to help students examine a wide range of patients' case histories to learn the different
components of the nursing process, clinical judgment, and recognition of the patients'
problems. Students develop progressively in their ability to write a care plan using
the NANDA-I Taxonomy. The results of this study suggest that this is a lengthy
learning process requiring at least 3 years. For this reason, Palese et al. suggest that it
is important to introduce experience with patients in the first year of study in which
students prepare individualized care plans so that they can progressively improve
their knowledge, critical thinking abilities, and the quality of care plans they develop.
In fact, at the end of the baccalaureate study, students appear to have a more holistic
approach to patients, including more variety of nursing diagnoses (e.g., anxiety) than
simply problems based on physical needs (e.g., mobility impairment), and are able to
use more accurate terminology in writing the nursing diagnoses. Third-year students
develop a more comprehensive approach to the patients, including collaborative
problems and potential complications, thereby demonstrating improved ability to
recognize the risk of some complications and to plan collaborative interventions. At
27
the completion of the baccalaureate degree, students demonstrate improved ability in
evaluating objectives and reporting the results of nursing interventions. This
improvement is related to the ability to include formal criteria in the objectives
developed in the care plan (Palese, 2009).
Synthesis
The expectations from health care consumers, stakeholders, governing bodies,
interest groups, nurse educators and practitioners fueled the need to equip nursing
students and nurse practitioners with competencies aimed at providing safe,
competent and high quality care at all times.
In this study, the nursing process as a globally accepted framework in
formulating nursing care plan was demonstrated and substantiated. The nursing
students in this study made use of the components of the nursing process in
formulating their nursing care plans based on their clinical experiences. It suggested
that when efforts are exerted in order to improve learning and mastery, improvements
in the way patient care becomes evident. These improvements were demonstrated
when enhancements were introduced.
In this study, the competencies required from nursing students in terms of
thinking, feeling and doing patient care-related matters anchored on completeness,
appropriateness, relevance, evidence use and relatedness (CARER) in the application
and utilization of the nursing process were demonstrated. This study also
demonstrated that nursing students benefit best in using the nursing process as the
framework in developing and formulating their nursing care plans.
In this study, the educational purpose of nursing care plans as advocated by
Carpenito-Moyet (2010), CHED (2009), and BON (2009) were given focus in the
clinical learning activities.
This study showed the utilization of the nursing care plan as: (a) a strategy in
nursing education that requires the student to apply the nursing process in order to
direct the student to learn critical thinking with analysis of assessment data; (b)
determining priority and non-priority nursing diagnoses/collaborative problems (c)
28
validation of nursing diagnoses and collaborative problems; (d) establishing realistic
goals of care based from assessment data; and (e) formulating interventions aimed at
facilitating resolution of nursing diagnoses or collaborative problems as suggested by
Carpenito-Moyet (2010). Evaluations of the outcomes of the nursing care plans were
not done in this study since the purpose is to find out how nursing students formulate
their nursing care plans up to the component of justification of interventions that
were implemented.
In this study, the application of the theory of Vygotsky is demonstrated.
Learning took place during social interaction, that is, during the lecture-discussions
and exchange of ideas in relation to the presentation of important concepts relevant to
the improvement of their written nursing care plan. Language is used for shared
understanding, especially when the students expressed their understanding of what
the concept of nursing care plan is. Learning took place and was depicted based in
shared meanings within the culture and context of nursing care.
In this study, various teaching strategies were deliberately selected and used
according to the intricacies involved in every learning activity, especially with the
introduction of enhancements. This allowed the facilitation and enhancement of
learning. The nature of nursing entails the integration of cognitive, affective and
psychomotor skills in all aspects of the teaching-, learning-, and application-related
activities. Setting up congruence in thinking, feeling, and doing facilitate the
attainment of the desired learning outcomes which are anchored primarily in
developing competent, safe and quality nursing care providers.
This study demonstrated the integration of Roy’s Adaptation Theory. The
nursing students were able to come up with better understanding of how human
beings think, feel and behave in relation to his interactions with his environment. The
realization by the nursing students of the importance of assessing to provide basis on
how to facilitate the resolution of the health-related problems was reflected in the
improvement in their nursing care plans after the enhancements. The principle that
human beings have biological, psychological, socio-cultural, and spiritual
29
dimensions guided the nursing students in thinking what interventions fit the need of
the patient especially after the enhancements were introduced.
In this study, the findings of Palese et al. showed that the nursing students need
to expand the way they formulated their nursing care plans. The current study
illustrated the limitations in the way the nursing students formulated their nursing
care plans especially in the number of problems identified and the goals of care
planned.
In this study, the nursing students were able to improve the quality of their
nursing care plans in terms of completeness, appropriateness, relevance, use of
evidence, and relatedness after the enhancements were introduced.
In this study, the difficulties encountered by the new RNs in del Bueno’s study
were also demonstrated. The difficulties expressed were in the areas of assessment
and prioritization of nursing diagnosis. With the use of the enhancements in their
nursing care plan, these difficulties were addressed.
In this study, the suggestions made by Tanner on how to improve clinical
teaching were integrated. This was demonstrated by the introduction of innovative
ways of teaching students how to gather information, interpret and analyze, make
guided decisions based on completeness, appropriateness, relevance, use of evidence
and relatedness (CARER) that were reflected in their improved nursing care plans.
The greatest challenge directed towards teachers is to determine complete,
appropriate, relevant, evidence-based, and related (CARER) learning activities and
learning outcomes.
The current study is a response to this overwhelming challenge to come up
with a novel teaching tool aimed at producing competent, safe and quality nursing
care provider.
30
Chapter 3
M ETH ODOLOGY
This chapter presents the research design used in this study, the participants,
the sampling design, the research instrument, data-gathering procedure and treatment
of the data.
Research Design
The research design used in this study is descriptive analysis. Qualitative data
were generated utilizing face to face interview, document review, focus group
discussion, and key informants interview. The nursing care plan based from the
nursing students’ clinical experiences were described and analyzed. Quantitative data
were generated utilizing the nursing care plan evaluation criteria, scored and
analyzed utilizing statistical tools.
The combination of data collection procedures and sources of information
provided triangulation that added to the depth, rigor, and trustworthiness of this
study.
Participants of the Study

There were three (3) sets of participants in this study.
The first set, the main participants were comprised of twelve (12) Level 3
student nurses (six males and six females) who were enrolled during the second
semester of Academic Year 2010-2011. They provided first hand information in how
they formulated their Nursing Care Plans based on their clinical experiences.
Included as informants were four patients admitted in the medical ward of a
Regional Hospital. They provided actual and essential health-related information to
be used by the participants in the formulation of their nursing care plans. Ethical
considerations were strictly observed throughout the study. Written permissions and
informed consents were sought prior to the implementation and to each of the
participants and patients.
31
Key informants/participants included three (3) nursing alumni and three (3)
clinical instructors that provided additional sources of information that were relevant
and significant to the current study.
Sampling Design
Patton (2002) recommends that the participants in a study should be chosen
with the principle in mind that they are able to provide the necessary rich information
and insights that offer useful manifestations for the understanding of the problems
being studied. On the basis of the suggested sample sizes by the various experts, the
researcher selected three sets of participants that will ensure that substantial
information may be drawn out in terms of depth, relevance and significance.
Table 1
Profile of the Participants (n =12)
NAT
Group Gender N CSAT (Average)
(Average)
Male 2 95.00 97.50
Female 2 93.50 99.00
Group 1
Average 94.25 98.25
Male 2 60.99 80.50
Female 2 73.67 78.33
Group 2
Average 66.84 79.42
Male 2 39.50 57.50
Female 2 45.50 51.00
Group 3
Average 42.50 54.25
In this study, the third year nursing students were chosen to represent the
current enrollees of the College of Nursing. The rationale was that they already have
at least two full semesters of clinical experience and have formulated nursing care
32
plans in their previous clinical learning experiences. The participant characteristics
included the college scholastic aptitude test (CSAT) scores, nursing aptitude test
(NAT) scores and gender in order to provide additional differentiation. Table 1
depicts the profile of the participants.
With the personal assistance of the Level 3 Chairperson and Level 3
instructors, participants were randomly recruited from different classes so that the
defined characteristics can be satisfied. The rationale, objectives and mechanics of
the study were presented during the orientation of the participants.
Research I nstrument
The researcher utilized a variety of instruments to address the objectives of this
study. The variety of sources of information and methods of gathering information
provides triangulation that adds trustworthiness and rigor to this study.
Research problem number 1 was addressed by using an interview guide
(Appendix M) to answer “What is your understanding of the concept of Nursing Care
Plan?” The answer can either be in essay, statement or in phrases.
Research problem numbers 2, 3, and 6 looked into the contents in each of the
components of the written care plan formulated by the nursing students. The
researcher utilized:
a) Nursing Care Plan Evaluation Criteria
The NCP Evaluation Criteria is a criterion-based tool that assesses the contents
of the NCP (Appendix J). The criteria were derived from the indicators of nursing
care, particularly the application and utilization of the nursing process described by
CHED Memo 14, 2009, National Core Competency Standards for Filipino Nurses
(2009) and the ANSAP Standards of Nursing Practice – Clinical Services (2008).
b) Nursing Care Plan Scoring Rubric
The Nursing Care Plan Scoring Rubric is derived from the NCP Evaluation
Criteria (Appendix K). The number of attained criteria in each component of the
nursing care plan was scored according to the completeness, appropriateness,
relevance, use of evidence, relatedness, and quantity of parameters attained. The
33
aggregate raw scores were summed up and cross-referred to the NCP Scoring Guide
(Appendix L) for its equivalent grade and interpretation as follows:
Rubric Scores I nterpretation

3 Very Sufficient
2 Sufficient
1 Deficient
0 Very Deficient
Research problem number 4, to determine the perceived difficulties

encountered by the nursing students in the formulation and implementation of the
nursing care plan, a semi-structured interview guide (Appendix M) was utilized
during the focus group discussion.
The difficulties expressed by the nursing students were validated using semi-
structured face-to-face interview guide with nursing alumni, staff nurse, and clinical
instructors as key informants.
Research problem number 5, utilized a survey guide (Appendix M) that deals
on how were the nursing care plan concepts taught, applied, corrected and evaluated
in the classroom and the clinical area.
Validity of the Research I nstrument

The instruments, interview guides, and survey guide underwent validations by
five (5) Nursing Administrators who have extensive experience in clinical nursing,
academe and as administrators. The panel of instrument evaluators is comprised of
three (3) PhD Degree holders and two (2) Master in Nursing Degree holders with an
average experience of twenty-six (26) years as clinicians, administrators, and
academicians. The instruments were rated, found sufficient and approved for use in
the current study.
The current study adopted the NCP Evaluation Criteria, NCP Scoring Rubric
and NCP Scoring Guide used by the researcher in his previous study. The NCP
34
Evaluation Criteria were comprised of parameters that describe its application or
non-application. Application of a parameter is scored one (1) and non-application of
a parameter is scored zero (0).
Reliability of the Research I nstrument

The NCP Evaluation Criteria and NCP Scoring Rubric were pre-tested and
subjected to inter-item correlation coefficient test using 0.05 level of significance.
The inter-item correlation coefficient for the overall NCP Evaluation Criteria
and the NCP Scoring Rubric yielded a Cronbach’s alpha of .921 and .939
respectively. The test results suggested a very high inter-item correlation coefficient;
hence, the instruments were used for the purpose of providing an objective evaluation
and analysis of the contents of the nursing care plan.
Statistical Tool and Treatment of the Data

In research problems 3 and 7, Two-way Analysis of Variance (2-Way
ANOVA) was used to determine the significant interaction between the effects of
gender and NAT/CSAT Scores grouping on the written NCP scores when using the
school’s model (Problem #3) and the enhanced model (Problem #7).
In research problem 8, dependent t Test was used to determine significant
difference in nursing students’ written NCP scores when using the school’s model
and the enhanced model.
All data were processed using SPSS v.17.
Data Gathering Procedure

The following phases (Figure 2) were followed to gather data:
Phase 1: After the approval and ethical consideration of the research proposal
by the Members of the Review Board were granted, letters and requests for
permissions were sought and granted by the Dean and Level 3 Chairperson of the
College of Nursing; the Chief of Hospital, Chief Nurse, and Nurse Supervisors of the
Medical Ward of a Regional Hospital. Recruitment, informed consent and orientation
35
of nursing student participants, patient informers, and key informants were
undertaken. Research instruments validation and reliability tests were carried out.
Phase 2: There were two (2) sessions done separately at different time frames.
With an actual admitted patient, nursing students assessed the patients at the same
time. After gathering the necessary information, they went to the library together and
formulated their nursing care plan. The researcher did NCP analysis based on the
guidelines set. Descriptive and statistical analyses of the NCPs were undertaken.
Phase 3: In a focus group discussion, the researcher drew the difficulties
encountered during the formulation and implementation of the nursing care plan. An
atmosphere of friendliness, openness, trust and confidentiality was maintained.
The researcher in another session conducted a review of the concepts of
nursing, Roy’s Adaptation Model, and introduced an enhanced NCP model in order
to address the issues and concerns presented in a 45-60 minutes lecture discussion.
Phase 4: After addressing the nursing students’ concerns and issues in the
formulation and implementation of the nursing care plan, two (2) sessions were done
separately at different time frames. The enhanced NCP model was utilized in
formulating their NCPs. The written output was subjected to NCP Evaluation and
Analysis.
Phase 5: Key informants face-to-face discussions were carried out involving
nursing alumni, alumni staff nurse, and nursing instructors. The discussions were
captured by a tape recorder and principles of openness, trust, and confidentiality were
observed.
36
37
Chapter 4
PRESENTATI ON, ANALYSI S AND I NTERPRETATI ON OF DATA
On the Nursing Students’ Understanding of the Concept of Nursing Care Plan

Based from the nursing students’ understanding of the concept of nursing care
plan, the responses were clustered as follows:
A. Cluster 1:
“ NCP is basically a tool that will guide nurses in planning the inter ventions
that they will be car rying out for their patient.”
“ NCP is a conceptual map of the nur sing inter ventions that ar e appropriate
for the client.”
“ NCP will ser ve as a guide for the nurse to r ender nur sing procedure. It is a
diar y of the nurse-patient medical r elationship but mainly focuses on the client’ s
r esponses to ther apy” .
“ NCP is a systematic tool used to r ender effective car e to the patient. NCP
could help nurses improve their car e for the patient.”
“ NCP is an outline of information needed to provide quality car e to a patient.
It ser ves as a guide for the nur se in pr ioritizing the needs of the patient.”
“ It is a way to handle your clients with care. It is a systematic way of
providing proper and adequate care to achieve a healthy state.”
“ NCP is a written scheme r egarding how we pr ovide proper management to
our clients. It will guide us in constr ucting appropriate nur sing management to our
clients in r elation to their under lying illness.”
“ It is a tool used by student nurses in guiding and keeping track of patient’ s
health.”
“ NCP is a plan of action for the inter ventions intended to the client’ s case or
condition.”
38
“ NCP is the planning of care that the nurse do in order to assess the patient’ s
condition. The nurse can identify the proper car e that is appropriate or applicable to
the patient. Through the NCP, nurses would have a step by step process or can give a
systematic car e to the patient. Thr ough the NCP, nur ses can have a basis, can have a
baseline in order to compare the pr evious condition of a patient and the pr esent
one.”
“ It is a plan where you obser ve/assess your patient’ s condition,
pr epare/construct planned inter ventions to implement to client’ s needs.”
“ It is when you formulate a care for your client.”
“ A process wherein actual or potential health problems are identified by
fur ther assessing patient’ s condition.”
B. Components of the Nursing Care Plan

“ The assessment phase is the most impor tant par t of the NCP since once a
nurse does not cor r ectly assess the patient, the r emaining parts of the NCP will be
er roneous and the nurse will sur ely not get the desired outcome he/she wants to
achieve. The nur se should also for mulate the nursing diagnosis while utilizing he
assessment as the basis. The desir ed outcomes should then be applicable and
significant to the par t of the patient. All the outcomes should be measurable and
attainable. The nursing interventions should also focus on the condition of the
patient. The nurse should pr ovide the r ationale for each of the inter ventions. The
practice of nursing skills should always have its justifications and be based on
evidences (scientific evidences).”
“It contains the nurse’ s assessment on both physical and mental status of the
client as well as strengths, weakness, risks posted in the client. The nursing diagnosis
in it would be most likely the priority deviated r esponse of the client towar ds his
illness. The nurse formulates goals for the client’ s well-being or to resume the
client’ s autonomy plan for interventions and evaluate them after execution (based
on the client’ s state of autonomy after the car e). Finally, it could be r evised
whenever it is no longer suitable for the client.”
39
“ It involves the use of the nursing method fr om assessing the client,
for mulating a nursing diagnosis, establishing expected goals in car ing for the client,
deter mining the pr oper nur sing inter ventions for the patient’ s condition and the
evaluation of car e rendered. NCP could aid the nur se in conducting an accurate
assessment so the nurse could understand the patient’ s condition, his/her needs,
limitations and str engths. The NCP could help the nurse in setting SM ART goals for
the patient and then evaluate the nur ses’ per for mance/car e given to the patient.”
“ It serves as a guide for the nurse in pr ioritizing the needs of the patient.
Catering these needs through inter ventions that ar e appropr iate in line with these
needs basically depicts the goals set to deliver the best care possible.”
“ Per for ming proper inter ventions to promote optimum health of the client.”
“ It has seven columns, the assessment, the nur sing diagnosis, the r ationale,
the desired outcome, nursing intervention, justification, evaluation. Assessment
consists of only two variables which ar e the objective and subjective variables in the
nursing diagnosis. There ar e two classifications that we consider . These ar e actual
and risk in the nur sing diagnosis, it will help us understand fur ther on what is r eally
the pr edicament of our patients. It will guide us in constructing appropriate nursing
management to our clients in r elation to their underlying illness.”
“Assessing patient’ s physical appear ance, inter viewing patients about how
they ar e cur rently feeling by asking patients, we would be able to know subjective
data about them that we can’ t conclude upon obser vation. It is in NCP that we are
able to evaluate our strategies and intervention that we did in our client, do once
again if those desired goals wer e not met. NCP is somehow a “ challenge” for our
part because we could be able to assess and know if we wer e effective in delivering
care to our patients.”
“ Ther e would be a set of goal after the time given, actions must be met. NCPs
have differ ent nur sing diagnoses and it could either be actual or risk. For the actual
nursing diagnosis, it should be that the client is manifesting it in risk/potential. The
client has the possibility to be in that condition or it is just a plan to pr event the
manifestations that is not yet pr esent.”
40
“ The nurses can identify the proper car e that is appropriate or applicable to
the patient. In nursing car e plan the nurse would have intervention and justify the
care that the patient needs. Through NCP nurses would have a step by step process
or can give a systematic care to the patient. Through NCP the nurse can have a
basis, can have a baseline in order to compar e the previous condition of a patient
and the pr esent one. The nurse also can give an appropriate nur sing diagnosis to the
patient.”
“ Uses ADPI E (assessment, diagnosis, planning, intervention, evaluation)”
“ It is a way of improving patient car e by acquir ing essential data, both
objective and subjective.”
C. Cluster 3
“ NCP is very beneficial to novice nurses since they need to enhance their
skills in physical assessment and planning nur sing inter ventions that are applicable
to the condition of the patient.”
“ Basically based fr om the client’ s r eactions towar d his/her illness. I t could be
revised whenever it is no longer suitable for the client.”
“ NCP could aid the nurse in conducting an accurate assessment so the nurse
could under stand the patient’ s condition, limitations and str engths. NCP could help
the nur se in setting SM ART goals for the patient and then evaluate the nurses’
perfor mance/car e given to the patient. NCP could help nur ses improve their care for
the patient.”
“ To provide quality care to a patient. Cater ing these needs through
inter ventions that are appropriate in line with these needs basically depicts the
goals set to deliver the best car e possible depending on the factors involved such as
time, feasibility, condition of the patient.”
“ Per for ming proper inter ventions to promote optimum health of the client. A
systematic way of providing proper and adequate care to achieve a healthy state.”
41
“ How we pr ovide pr oper management to our clients. It will guide us in
constructing appropriate nursing management to our clients in r elation to their
under lying illness.”
“ NCP is somehow a “ challenge” for our part because we could be able to
assess and know if we are effective in delivering care to our patients.”
“ The plan of car e should be systematic, measur able, appropriate, r ealistic and
time-bounded. It is just a plan to prevent the manifestations that is not yet pr esent.”
“ Through the NCP, nurses would have a step by step pr ocess or can give a
systematic car e to the patient. Thr ough the NCP, the nurse can have a basis, can
have a baseline in or der to compare the previous condition of a patient and the
present one.”
“ It provides a concr ete backgr ound about the patient thus enhancing nursing
approach in terms of knowledge and skills.”
As a whole, the general themes extracted from the various insights provided by
the nursing students’ understanding of the nursing care plan based on their clinical
experiences can be explained in terms of its:
a) Nature
The nursing care plan is described as a systematic tool comprised of written
information outlining assessment findings, prioritized needs, plan of care
and interventions aimed at guiding and directing the nursing students and
nurses in providing quality care to the patient.
b) Components
The nursing care plan is comprised of components namely assessment,
nursing diagnosis, rationale, plans/desired outcomes, implementation /
interventions, justification, and evaluation.
c) Purpose/Goal
The nursing care plan aimed to enhance their knowledge, skills, and
approaches in assessing and planning interventions in order to provide
appropriate, adequate, proper, and effective care to the patients.
42
The understanding made by the participants on what nursing care plan is all
about is supported by the suggestions made by O’Connor (2006) and Carpenito-
Moyet (2007) that nursing care plans provide opportunities for the nursing students
to: (a) be intellectually guided in preparing for their clinical experience; (b) be able to
review relevant theoretical information and procedural guidelines; (c) be able to
prepare in providing care to their assigned patients; and (d) provide them an
opportunity to demonstrate how they understand the problem-solving process used in
assisting clients to maintain or regain a higher level of function (O’Connor, 2006;
Carpenito-Moyet, 2007). The nursing care plan format of the school being used by
the nursing students were similar to the recommended educational format which
contains: (a) assessment data that are organized; (b) interpreting assessment findings
leading to the identification of nursing diagnoses; (c) identification of client goals
and outcome criteria; (d) nursing interventions (e) scientific rationale; and (f)
evaluation.
The American Nurses Association (2003) defines nursing as “the protection,
promotion, and optimization of health and abilities, prevention of illness and injury,
alleviation of suffering through the diagnosis and treatment of human response, and
advocacy in the care of individuals, families, communities, and populations (cited in
Wilkinson, 2007).
The definition portrays nursing as thinking, feeling and doing profession.
Hence, it is very important that nurses develop and strengthen their skills in
providing safe, competent and quality care by continuously updating themselves with
current knowledge, skills and an adapting attitude. A useful educational tool that
purportedly aimed at developing skills in thinking and problem solving is the nursing
care plan.
Nursing education in the Philippines is guided by the National Core
Competency Standards for Filipino Nurses promulgated by the Professional
Regulation Commission – Board of Nursing (PRC-BON). The Key Area of
Responsibility—Safe and Quality Nursing Care—emphasized the utilization of the
nursing process as the framework for nursing. The core competencies expected to be
43
developed among nursing students under Core Competency 7 include: (a) performing
comprehensive and systematic nursing assessment; (b) formulating plan of care in
collaboration with clients and other members of the health team; (c) implementing
planned nursing care to achieve identified outcomes; and (d) evaluating progress
toward expected outcomes (PRC-BON, 2009).
The descriptions provided by the nursing students were in line with the core
competencies drawn out by the educational system. These basic understandings are
important in guiding the students where to focus in their academic and clinical
studies.
Cook, Gilmer, and Bess (2003) described how beginning students defined
nursing. The definitions provided for nursing as a verb were caring, implementing,
assessing, analyzing and analyzing (cited in Emerson, 2007).
These definitions are similar with the understanding described by the
participants in this study. This means that the Filipino nursing students’
understanding of nursing indicated alignment with the global concept of what
nursing and nursing care is.
The need to validate the understanding by the nursing students of the concept
of nursing care plan was supported by the belief of the importance of shared
understanding. Clark & Brennan (1991); Falan (2007); and Mulder, Swaak, &
Kessels (2002) describe shared understanding as having a common knowledge, ideas,
and positions held among a group of people. The Institute of Medicine (2000)
recommends that in order to reduce errors, improve health care, communication, and
obtaining shared understanding, quality and accuracy of health care information is
needed. To have accuracy in the use of words and phrases to represent care means
that the right words are accessible and that they are used at the right time for the right
circumstances based on context (cited in Falan, 2010).
The validation of shared meanings is supported by Vygotsky’s theory that
learning occurs during social interaction (the teaching-learning sessions both in the
classroom and the clinical area) using shared language and shared understanding of
the culture of caring in nursing.
44
On the Analysis of the Contents of the Components of the Nursing Care Plan as
Formulated by the Nursing Students
The contents in each component of the nursing care plans were individually
scrutinized and evaluated using the NCP evaluation criteria (Appendix J and the NCP
Scoring Rubric (Appendix K). The NCP evaluation criteria served as a tool in
providing benchmark parameter from which decisions were based on the quality of
the contents in each of the component of the nursing care plan. It also provided a
grasp on the level of understanding, application, interpretation and analysis and
decision making on the part of the nursing student. This meant that the competencies
in terms of knowledge, skills and attitudes in providing safe and quality patient care
using the nursing care plan can be measured using the NCP evaluation criteria. The
criteria for evaluation and punctuality were not applied in this study. The components
that were evaluated and analyzed were nursing history, physical examination,
assessment, nursing diagnosis, rationale, planning/desired outcomes,
implementation/intervention, and justification. The scoring indicated how well the
contents in each of the components of the NCP measures against the NCP evaluation
criteria that measured completeness, appropriateness, relevance, use of evidence and
relatedness (CARER).
Nursing History and Physical Examination

The nursing history is considered vital because the effectiveness of the
formulation of the nursing diagnosis, outcomes identification and planning,
implementation and evaluation are affected. The information gathered in the nursing
history and physical examination serves as the database, they suggest that history
data must be specific and precise. Generalities need to be avoided. They recommend
that pertinent, concise, detailed information should be gathered (Ralph & Taylor,
2008; Craven & Hirnle, 2007).
Craven & Hirnle (2007) recommend that a clear description of the patient’s
health status and health related problems should be made in order to allow the nurse
45
and patient to plan strategies together to continue healthy patterns, prevent potential
health problems, and alleviate or manage existing health problems.
Table 2 shows the analysis of nursing history and physical examination
components of the nursing care plan.
Table 2
Analysis of Nursing History and Physical Examination Components
NCP Session 1 Rubric I nter- Session 2 Rubric I nter-
Components Yes No Score pretation Yes No Score pretation
n=12 n=12
Nursing History
Criteria
1. Nursing 12 0 1.00 12 0
history is
obtained
2. Information 0 12 - 0 12
is complete
Average Rubric 1.00 Deficient 1.00 Deficient
Score (n=12)
Physical
Examination
Criteria
1. Physical 12 0 1.00 12 0
examination
is done
2. Information 0 12 - 0 12
is complete
Average Rubric 1.00 Deficient 1.00 Deficient
Score (n=12)
All participants did not provide complete written nursing history and physical
examination report. The participants provided brief and incomplete information that
were not completely representative of the patient’s health-illness history. They did
physical examination but they presented incomplete records. The average extent of
application of the Nursing History and Physical Examination components was
deficient.
The participants may not have placed value to the importance of documenting
their assessment findings.
Based on the NCP evaluation criteria, history was taken and physical
examination was done, but rather incomplete.
Completeness may not be possible but with the use of a guide, systematic data
collection can be undertaken. A history guide will allow the nursing student to
46
practice looking for relevant information that should form basis in formulating
effective plans and interventions that can help alleviate or improve the signs and
symptoms manifested by the patient. The nursing student will be able to see the
relatedness and influences of one aspect of a person’s dimension
(biological/physiological, psychological, socio-cultural, spiritual) to another in his
health condition. These assessment findings should form as basis in formulating the
nursing care plan.
The physical examination validates and amplifies the data gathered in the
nursing history. Systematic ways of conducting physical examinations are
recommended to ensure that complete, appropriate and relevant data are gathered.
The body systems method of examination involves systematically assessing the
patient by examining each body system in priority order or in an established
sequence. The head to toe method provides logical, organized framework for
collecting physical examination data. According to Ralph and Taylor (2008),
physical examination findings are crucial to arriving at a nursing diagnosis and
ultimately, in developing sound nursing care plan. Craven and Hirnle (2007) suggest
that the purpose of the health assessment is to establish a database.
The gathering of complete nursing history and conducting complete physical
examination were only done by the students when they have to prepare for their
nursing case presentation. Ordinarily, they do not collect complete history nor
perform complete physical examination.
The researcher posits that not giving attention and importance in gathering
complete nursing history and performing complete physical examination presented a
gap in the training of nursing students.
Assessment
The nursing students have sufficient level of application of the criteria for
assessment as shown in Table 3. However, all participants presented data that lack
measurable descriptions in their first two sessions. The only data that have values
were the laboratory results copied from the medical records of the patients. They
47
need to improve in providing specific and measurable descriptors in the signs and
symptoms that they identified.
The assessment component in the nursing care plan format is the summary of
clustered data derived from the nursing history that are organized. The data reflect a
health problem manifested either as a sign (objective cue) or a symptom (subjective
cue).
These clustered data are the bases for the formulation of the nursing diagnosis.
The quality of the data clustered in the assessment component of the NCP may be
measured in terms of completeness, appropriateness, relevance, basis for evidence of
health problem and relatedness of signs and symptoms. It is in this component that
the nursing student makes a decision on what to prioritize in order to support the
most pressing need or concern of the patient. These clustered data are usually labeled
by the students as subjective cues and objective cues.
Table 3
Analysis of Assessment Components
NCP Components Session 1 Rubric I nter- Session 2 Rubric I nter-
Yes No Score preta- Yes No Score preta-
n=12 tion n=12 tion
Assessment Criteria
1. Data clustered represent
evidence of problems or risks 12 0 1.00 12 0 1.00
for problems
2. Signs observed complement
and validate the symptoms 10 2 0.83 10 2 0.83
verbalized by the client
3. Data describing client’s
symptoms are specific and 0 12 0 0 12 0
have measurable parameter
4. Data describing client’s signs
are specific and have 0 12 0 0 12 0
measurable parameter
5. Signs and symptoms or needs
are adequate to come up with
nursing diagnosis (5 or more
combined for actual or risk 10 2 0.83 10 2 0.83
problems; at least 3 if client
is to be discharged and
improved)
Average Rubric Score 1.75 Suffi- 1.75 Suffi-
(n=12) cient cient
According to Wilkinson (2007), subjective cues represent covert data that are
perceived and can only be verified by the patient. Hence, validation is essential in
48
order to obtain complete, appropriate, relevant, and related information that will
guide the students in arriving at sound clinical judgments. The objective cues
represent the signs that are observed and gathered using palpation, auscultation,
percussion, or inspection. The objective cues or signs need to be related to the
verbalizations made by the patient. As suggested by Ralph and Taylor (2008), data
must be specific and precise.
In order to satisfy the need for specificity and preciseness, measurable
descriptors are needed to be integrated in each identified sign or symptom. These
measurable descriptors may be qualitative (severity, extent, level, or appearance as
verbalized by the patient) or quantitative (overtly measurable in numerical terms like
amount, quantity or size) in nature. These data serve as evidences of the level, extent,
or severity of the manifestations demonstrated by the patient. These measurable
evidences serve as the benchmark data that are the bases for the corresponding
measurable desired outcomes for the plan of care.
For example, a patient verbalized pain and described it as 7 of 10 in the pain
severity scale. Desired outcome should be the alleviation of pain from 7 of 10 to 3-4
of 10 within 1-2 hours after appropriate interventions are provided.
Nursing Diagnosis
The North American Nursing Diagnosis Association (NANDA) (1990) defined
nursing diagnosis as a clinical judgment about individual, family or community
responses to actual or potential health problems or life processes. Nursing diagnosis
provides the basis for selection of nursing interventions to achieve outcomes for
which the nurse is accountable (cited in Carpenito-Moyet, 2007).
Table 4 shows that the students have sufficient application of the nursing
diagnosis components. The nursing students were able to state their identified
problem using NANDA Taxonomy. They were able to match their findings with the
appropriate nursing diagnosis.
However, in the first session, more than half of the participants provided signs
and symptoms that were not consistent with their assessment findings. The nursing
49
diagnosis were not complete, some were not appropriate, some were not relevant, a
few signs and symptoms did not show evidence to support the nursing diagnosis.
Table 4
Analysis of Nursing Diagnosis Components
Yes No Score preta- Yes No Score preta-
n=12 tion n=12 tion
Nursing Diagnosis
Criteria
1. Nursing diagnoses
are appropriately 10 2 0.83 8 4 0.67
prioritized
2. Problem statement
is based on
12 0 1.00 12 0 1.00
NANDA
Taxonomy
3. Nursing diagnosis
correspond to the
actual, potential or 12 0 1.00 12 0 1.00
risk problems of
the patient
4. Related factors
caused or
contributed to the 11 1 0.92 11 1 0.92
change in health
status or problem
5. Signs and
symptoms
supporting the
5 7 0.42 6 6 0.50
nursing diagnosis
are consistent with
assessment findings
Average Rubric 2.25 Suffi- 2.17 Suffi-
Score (n=12) cient cient
The first patient has a number of health problems that were manifested.
Despite of a number of clearly identifiable health problems, all of the participants
identified only one problem. This may be attributed to the way they used to submit
their NCPs. It is interesting to note that various nursing diagnosis were arrived at by
the students. Even with the same nursing diagnosis, there were variations in how they
identified the etiologic factor or the related to factor or the cause of the condition.
Further they listed diverse manifestations. The relationship with inadequate
assessment practices and mismatch in the nursing diagnosis is evident in the related
factors used by some of the students. These disparities existed despite having books
50
to refer to. This may imply that comprehension and application gaps exist. The
following were the nursing diagnosis identified by the students in case 1 (note that
these were transcribed verbatim):
• fluid volume excess related to inability of kidneys to produce urine secondary
to chronic renal failure; excess sodium intake; fluid shifting and decreased
ability to pass out urine as evidenced by swelling on left extremity (nonpitting
edema)
• fluid volume excess related to compromised, regulatory mechanism and excess
sodium intake as evidenced by presence of edema, crackles, abdominal
distention, increased RR, increased BP and imbalances in electrolytes
• excess fluid volume r/t decreased kidney function as evidenced by greater
intake than output, edema on lower extremities and altered electrolyte level
The patient’s health condition showed: impaired tissue perfusion; fluid
volume, excess; and the imbalance nutrition, less than body requirements. These
nursing diagnoses were correctly identified by the students. However, they wrote
only one in their NCP. Another concern here is on the connections or relatedness
factor between the problems they had identified, the cause of the problem and the
manifestations of the problem. The problems identified by the researcher in the
diagnostic statements made by the students were as follows:
a. Prioritization of client’s health problems or nursing diagnosis.
• Although the participants identified actual problems, three were not able
to identify the priority problem of the patient.
b. Appropriateness of the related factors or etiologic factors that explained the
cause of the problem.
• Some of the participants were not able to provide the appropriate factors
that supported the diagnostic problem statement.
c. Appropriateness and relevance of the signs and symptoms that were
identified to support the nursing diagnosis.
51
• A number of nursing students wrote signs and symptoms not written in
their assessment findings. Some signs and symptoms that were made
as evidences of the patient’s health problem did not support the
nursing diagnosis.
d. Only one nursing diagnosis is identified by the participants throughout the
four sessions.
• The practice of the nursing students to identify and write down only one
nursing diagnosis is a sharp contrast to the results of the study of
Palese, et al. (2009). In their study, students identified an average of
5.1 actual or risk nursing diagnoses and 1.2 collaborative problems.
The disparity indicated deficiencies in how the students in the local
study applied what they learned.
The nursing process and nursing diagnosis are considered as critical elements
in the nursing curriculum as emphasized in CHED Memo 14 as well as an important
key responsibility in providing safe and quality nursing care advocated by the BON.
Emphasis should be imparted to the nursing students to learn how to identify the
appropriate problems and supported by signs and symptoms complete with
measurable descriptors.
According to Carpenito-Moyet (2010), the failure of faculty to integrate the
nursing process and diagnoses into the learning experiences resulted to students
spending endless hours creating a care plan document that does not improve the
student’s likelihood of utilizing nursing diagnosis after graduation.
The problems in the formulation of nursing diagnosis statements revealed in
this part of the study imply deficiencies on how the nursing process was applied by
the students. The inappropriateness and lack of relevance of some of the signs and
symptoms identified to support the nursing diagnosis shown in this study increases
the likelihood that inappropriate interventions may be formulated and carried out.
This was underscored by del Bueno (2005) that one of the gaps among newly hired
RN graduates is accurate identification of vital sign changes but inappropriately
52
identifying the nursing diagnosis that resulted in formulating inappropriate
interventions.
When erroneous nursing diagnosis is copied in the book with its corresponding
interventions, the likelihood for an error to be committed to the patient also increases.
This early, there is a need to implement measures in order to correct the way the
students think and do nursing care related activities in order to prevent harm to the
patients.
Rationale
The rationale represents the scientific explanation of why and how the health
problem developed and is manifested by the patient. It is a required component of the
nursing care plan in order to show the relative understanding of the student on how
the condition developed. This should start by tracing the actual information from the
patient of what contributed to the development of the health problem. It is in this
component of the care plan that the student demonstrates his/her understanding of
man in relation to his environment as a factor in influencing health.
The biological/physiological, psychological, socio-cultural and/or spiritual
dimensions of man are influenced during his interactions with the environment. In
this component, the student demonstrates his/her knowledge in health-illness
progression that is known as the pathophysiology. It may also be labeled as
dysfunctions or mal-adaptations singly or in any combination of the bio-pscyho-
socio-cultural-spiritual dimensions of a human being.
The progression of a health problem is one of the central themes in Roy’s
Adaptation Model which supports the rationale component of this study. The
rationale component of the nursing care plan necessitates that information gathered
during history taking and in conducting physical examination must be complete,
appropriate, relevant, shows evidences of dysfunctions or maladaptations—
biologically, psychologically, socio-culturally and spiritually—that are inter-related.
The rationale component is the counterpart of the pathophysiological processes that
occur during illness or disease state in a medical perspective.
53
Roy’s Adaptation Model resembles the counterpart explanation in nursing
perspective of how human beings mobilize their coping processes in order to adapt
and function well in response to a stimulus.
Table 5 shows the analysis of rationale component of the nursing care plan.
Table 5
Analysis of Rationale Components
Yes No Score preta- Yes No Score preta
n=12 tion n=12 -tion
Rationale Criteria
1. Predisposing, precipitating,
intervening factors identified
contribute to the biological,
5 7 0.42 6 6 0.50
psychological, social, or
spiritual dimensions of the
patient
2. Predisposing, precipitating,
intervening factors identified
5 7 0.42 6 6 0.50
are consistent with the history
of the patient
3. The effects of the biological,
psychological, social or
spiritual dysfunction to the 10 2 0.83 11 1 0.92
client are appropriately
explained
4. Signs and symptoms
manifested are consistent with
the biological, psychological, 11 1 0.92 12 0 1.00
social or spiritual dysfunctions
happening to the patient
5. Initial actions undertaken by
the patient to address his
1 11 0.08 2 10 0.17
health problems were
appropriately identified
6. Outcomes of the initial actions
undertaken by the patient is
appropriately described 0 12 0 0 12 0
(improvement or deterioration)
7. Dysfunctional process ends up
with the appropriate nursing 11 1 0.92 11 1 0.92
diagnosis
(n=12) cient cient
The following described how the students formulated their rationale in Session
1 patient, singly or in combination:
• Predisposing factors were not identified by some participants.
54
• Medical focus. The results indicated the propensity to explain what has
been going on in the patient’s condition in a medical orientation rather than
nursing related focus.
• Actions undertaken by the client at the onset of the signs and symptoms
were not identified.
• Outcomes of the initial actions taken by the patients were not identified.
The actions undertaken by the client at the onset of signs and symptoms
resemble Roy’s coping processes inherent among human beings when confronted
with threatening stimuli.
The outcomes of initial actions taken by the patients resemble Roy’s extent of
adaptation to stimuli that are demonstrated either as positive leading to healthy
functioning or as negative adaptation leading to illness or disease condition.
The NCP evaluation criteria that included the need to identify the bio-pscyho-
social-spiritual influences in the health-illness state of the patients, the actions
undertaken during the onset of the signs and symptoms, initial outcomes of the initial
actions taken by the patients are new. Hence, all the students were not able to include
these. Table 6 shows that the nursing students sufficiently applied the criteria
described in the rationale component.
Planning / Desired Outcomes

Craven and Hirnle (2007) describe planning as the development of strategies
designed to ameliorate client problems. The plan of care is aimed at directing client
care activities, promoting continuity of care, focus charting requirements and allow
for delegation of specific activities. Planning involves a deliberate and systematic
way of arriving at a decision and solving problems. The nurse refers to the client’s
assessment data and diagnostic statements for direction in formulating client goals
and designing the nursing interventions required to prevent, reduce or eliminate the
client’s health problems (Kozier, et al., 2004).
The students were taught to formulate their plan based on the “SMART”
model: specific, measurable, attainable, realistic and time-bounded. However, there
55
were no definite guidelines that were established. Hence, there was no uniformity on
how the students applied this guide.
Table 6
Analysis of Planning Criteria
NCP Components Session 1 Rubric I nter- Session 2 Rubri I nter-
Yes No Score preta- Yes No c preta-
n=12 tion n=12 Score tion
Planning Criteria
1. Existing problems are
prioritized according to
10 2 0.83 10 2 0.83
urgency of need or
concern
2. Goals have reasonable
10 2 0.83 8 4 0.67
time frame
3. Goal statement reflect an
improvement of the 2 10 0.17 3 9 0.25
problem identified
4. Outcomes criteria reflect
an improvement of the 1 11 0.08 2 10 0.17
signs and symptoms
5. Overall plan are related
to the problem identified 11 1 0.92 11 1 0.92

(n=12) cient cient
Table 6 shows that the nursing students sufficiently applied the criteria for
planning. However, almost all demonstrated deficiencies in stating their goals of care
in an improved condition and in using the signs and symptoms identified in their
assessment as basis for their nursing care outcomes.
Wilkinson (2007) suggests that when stating goals of care and outcomes, the
opposite of the nursing diagnostic statement should be preferred since it is the
intended outcome that is tried to be achieved. She also suggests that when
formulating outcome statements, it must bear specific and measurable descriptors in
order to be useful for planning and evaluating care. This means that right from the
history taking, physical examination and subsequent assessments and monitoring,
specific and measurable descriptors should form part of the data gathered to describe
the signs and symptoms of the patient. This will form part of the measurable outcome
wherein progress or deterioration can be appraised. The role of the completeness of
data with appropriate specific and measurable descriptors that are relevant in the
56
patient’s condition and providing the evidence that supports the clinical decisions
that should be inter-related among the various components of the nursing care plan
are highlighted at this stage.
Wilkinson’s suggestion validates the criteria used by the researcher in
evaluating the contents of the components of the nursing care plan. It further supports
the significance of the CARER (completeness, appropriateness, relevance, use of
evidence, and relatedness) characteristics of the evaluation criteria.
In the first two sessions, most of the goals and outcomes were behaviorally
focused despite of the obvious need to prioritize the resolution of the physiologic
problems. The following examples illustrated how their plans and outcomes were
formulated (transcribed verbatim):
a. For the nursing diagnosis identified as Excess Fluid Volume:
• After 8 hours of nurse-patient interaction patient will be able to: verbalize
under standing of individual dietar y and fluid r estrictions; demonstr ate
behaviors to monitor fluid status and r educe r ecurr ence of fluid excess; list
signs that r equir e further evaluations
• After 40 hours of nur sing interventions, the client will be able to: display
appr opriate urinary output of at least same level as fluid intake; maintain
vital signs within the nor mal range; eliminate edema; enumerate the
importance of fluid balance; perfor m techniques to ensur e fluid balance
• After 8 hours of nursing inter vention client will be able to: r epor t/ver balize
absence of difficulty of br eathing; stabilize fluid volume as evidenced by
balance in input and output and vital signs; after 5 days of nur sing
inter vention, the client will be able to establish nor mal fluid and electr olyte
balance; will be fr ee of edema
• After 40 hours of nursing interventions, client will be able to maintain vital
signs within nor mal range; stabilize fluid volume as evidenced by balanced
output
• After 40 hours of nurse-client inter vention, the client will be able to
stabilize fluid volume as evidenced by balanced intake and output;
57
verbalize changes in physical appearance especially on the enlargement of
the abdomen and lower extr emities; state under standing of individual fluid
/dietar y r estrictions; demonstrate behaviors to monitor fluid status and
r educe r ecur r ence of fluid excess
• After 5 days of nursing inter ventions the client will be able to stabilize fluid
volume; ver balize understanding of individual dietar y fluid r estr ictions;
demonstr ate r educed r ecurr ence of fluid excess
• After 8 hours of nursing inter vention client will be able to verbalize
under standing of individual dietar y r estr ictions; stabilize fluid volume as
evidenced by balanced input and output and vital signs within client’ s
nor mal limits; demonstrate behavior s to monitor fluid stats and r educe
r ecurr ence of fluid increase; list signs that r equir e further elimination;
after 8 hour s of nursing intervention, the client will be able to stabilize fluid
volume as evidenced by imbalance intake and output, vital signs with
client’ s nor mal limits, stable weight and fr ee of signs of edema;
demonstr ate behavior s to monitor fluid status and r educe r ecurr ence of
fluid excess; list signs that r equire further evaluation
• Client would be able to stabilize under standing of dietar y and fluid
r estr ictions; stable fluid volume as evidence by absence of edema and vital
signs within nor mal limits; be awar e of the signs and symptoms of such
disease; elicit comfort
b. For the nursing diagnosis identified as Imbalance Nutrition less than body
requirements
• After 40 hours of nurse client interaction will be able to demonstr ate
progr essive weight gain towar d goal; verbalize understanding of causative
factors when known and necessar y intervention; demonstrate behaviors,
lifestyle changes to r egain and/or maintain appr opriate weight.
• After 5 days of nurse client inter action the pt will be able to: improve/gain
body r equirements and nutrients; change life style and behavior s.
58
c. For the nursing diagnosis identified as Impaired Tissue Perfusion
• Regain nor mal RBC level; maintain adequate tissue per fusion
The goal statements formulated by the students were rather complicated and
lacking in terms of direct usefulness in helping the patients in the improvement of
their manifestations. The statements further demonstrated the complicated structure
that they have learned or copied from elsewhere. This is one aspect where
enhancements need to be carried out. The priority problem of the patient is
physiologic in nature. Thus, the priority plans and interventions should have been
directed towards helping solve the excretion of excess fluid as manifested by edema
and the gap between the fluid intake and fluid output of the patient. Plans should
include physiologic as well as behavioral outcomes.
I mplementation / I nterventions
In this component of the student nursing care plan, interventions were listed.
The interventions were classified as independent and collaborative and listed in
outline form. An examination of the interventions indicated that most of the students
listed assessment-related or monitoring-related interventions.
Table 7 shows that the nursing students had deficient level of application of
the components in intervention in session 1. They have improved in session 2 by
attaining a sufficient level of application. It is a revelation that the deficiencies in
providing interventions were related to: hygiene and self-care; discharge
planning/referral/outpatient follow-up consultations; inspiring/motivating/emotional
support; and spirituality. These interventions can be categorized as independent
nursing by nature. Thus, they may be considered as independent nursing
interventions.
Wilkinson (2007) advocates that interventions are selected in order to facilitate
promoting wellness or preventing, correcting, or relieving health problems.
Table 7 shows the analysis of the implementation/intervention components.
59
Table 7
Analysis of Implementation/Intervention Components
NCP Components Session 1 Rub- I nter- Session 2 Rubric I nter-
Yes No ric preta Yes No Score pretation
n=12 Score -tion n=12
Implementation Criteria
1. All collaborative nursing
interventions directly help 11 1 0.92 11 1 0.92
attain the outcome criteria
2. All independent nursing
interventions directly help 3 9 0.25 5 7 0.42
attain the outcome criteria
3. Assessment-, monitoring-
related activities are provided, 11 1 0.92 11 1 0.92
relevant and applicable
4. Medications-related
interventions are provided, 9 3 0.75 10 2 0.83
5. Exercise, rest , sleep,
environment modification-
related interventions are 3 9 0.25 7 5 0.58
provided , relevant and
applicable
6. Treatment, laboratory, safety &
comfort-related interventions
9 3 0.75 8 4 0.67
are provided, relevant and
applicable
7. Hygiene-and self-care-related
interventions are provided, 1 11 0.08 2 10 0.17
8. Out Patient / Follow-up
consultations, referral-related
0 12 0 1 11 0.08
interventions are provided,
9. Diet-related interventions are
provided, relevant and 7 5 0.58 7 5 0.58
applicable
10. Inspiring/Motivating,
Psycho-emotional support-
related interventions are 0 12 0 2 10 0.17
provided, relevant and
applicable
11. Spirituality related
interventions are provided, 0 12 0 1 11 0.08
12. Teaching / Health
education-related interventions
7 5 0.58 8 4 0.67
are provided, relevant and
applicable
Average Rubric Score (n=12) 1.33 Defici 1.58 Sufficient
ent
Interventions need to be drawn specifically in order to address the outcomes

associated with each nursing diagnosis.
60
Justifications
Kozier, et al. (2004) concur that the purpose of justifications in the student
nursing care plan is to provide the scientific principle given as the reason for
selecting a particular nursing intervention. They also agree in requiring students to
cite supporting literature for their stated rationale or justification.
All participants provided explanations of the interventions based from books.
The downside however is, students depend so much in books that they tend to copy
whatever is written in the books regardless if the information is complete,
appropriate, relevant, shows evidence that it is effective, and related in helping the
patients in improving their manifested signs and symptoms or not.
Evaluation
The nursing care plans were not evaluated in this study since they were not
implemented. Ideally, the care plan serves as a guide by the students in providing
care. Care plan should be evaluated every end of the shift or as the need arises
especially when the client’s condition calls for more frequent monitoring and
assessments.
The appropriate outcomes identified in the planning component should be re-
assessed for progress—whether attained, signs of progress or signs of deterioration
are demonstrated by the patient.
Whatever the outcomes are after the end of shift, status of the patient should be
reported—documented, shared or endorsed with the team and in the incoming shift.
This element of communication is very vital in ensuring that patient care needs are
brought to the attention of all care providers.
Evaluation is essential in the nursing care plan because it allows the nurse to
monitor the progress of the patient whether interventions were effective or not. The
need to revise the nursing care plan may be necessitated in case signs of
improvements are not demonstrated by the patient. Its either the assessment findings
were not accurate, the nursing diagnosis or the clinical judgment is inappropriate, the
61
plans may not be relevant, the interventions may not be relevant or not effective to
the patient’s case.
Each patient has his own uniqueness. This uniqueness is manifested in
variations in coping, adaptability, cooperation and response to illness and treatments.
On the significant interaction between the effects of gender and NAT/CSAT

Scores grouping on the written NCP mean scores when using the school’s NCP
model and rated using the NCP Scoring Criteria
The nursing care plans submitted in the first and second session were analyzed
and scored using the NCP Evaluation Criteria, NCP Scoring Rubric and NCP
Grading Guide. The two NCP scores were averaged and subjected to 2-way
ANOVA. Table 8 shows the SPSS output.
Table 8
Results of the 2-way ANOVA to test the significant interaction between the effects of
gender and NAT/CSAT Scores grouping on the written NCP mean scores when
using the school’s NCP model (n=12)
Type III Sum Partial Eta
Source of Squares df Mean Square F Sig. Squared
Corrected Model 32.505a 5 6.501 17.870 .002 .937
Intercept 63079.350 1 63079.350 173394.159 .000 1.000
Gender .594 1 .594 1.633 .248 .214
NATCSATGrouping 30.003 2 15.002 41.237 .000 .932
Gender * 1.908 2 .954 2.622 .152 .466

NATCSATGrouping
Error 2.183 6 .364
Total 63114.038 12
Corrected Total 34.688 11
a. R Squared = .937 (Adjusted R Squared = .885)
62
The results of the 2-way ANOVA indicate that there is a statistically
significant main effect of NAT/CSAT Scores Grouping, F(2,12) = 41.237, p<.005 on
the NCP scores using the school’s model. The partial Eta squared indicated that 93.2
percent of the variance in the NCP scores is attributed to the NAT/CSAT scores
grouping. In other words, there is a statistically significant difference in the mean
scores of the NCPs using the school’s model when grouped according to their
NAT/CSAT scores. There is no statistically significant main effect of gender and no
interaction between gender and NAT/CSAT grouping.
The pairwise comparisons for gender indicate that both males and females
with very high NAT/CSAT scores have no significant difference in their NCP scores
(using the school’s NCP model) with those having low NAT/CSAT scores (p>.05)
and have significant difference with those having very low NAT/CSAT scores
(p<.005). Those with low NAT/CSAT scores have significant difference in their
NCP scores with those having very low NAT/CSAT scores (p<.005). The results are
consistent with the outcome of the 2-way ANOVA that there is no statistically
significant difference in the scores when grouped according to gender. The findings
suggest that those with very low NAT/CSAT scores demonstrated difficulties in
formulating NCPs. Gender may not be a factor in this study since the NAT/CSAT of
both genders were approximately almost similar.
Knowing the cognitive abilities of learners may help teachers design lessons
that will optimize learning especially those who have below average cognitive skills.
A study revealed that cognitive abilities are important determinants of academic
success. In this same study, findings also revealed that affective traits have no effect
on aptitude and achievement. Meaning, nursing traits are non-cognitive and ability
measures are cognitive (Magno, 2010).
Newton, Smith, Moore, & Magnan (2007) studied the relationship of
scholastic aptitude and nursing aptitude in relation to the academic achievement in
baccalaureate nursing program. The findings showed that scholastic aptitude and
nursing aptitude together predicted 20.2% of the variance in early academic
63
achievement, with scholastic aptitude accounting for 15.4% of the variance (cited in
Newton & Moore, 2009).
These two studies confirm that nursing is an endeavor that requires a lot of
higher order thinking skills. Formulating nursing care plans may be complicated to
those who have deficiencies in skills that required analyzing, interpreting, evaluating
and making critical decisions.
Therefore, it is the teacher’s job to know the cognitive capabilities of the
nursing students whom she/he is supervising in order to provide the necessary
guidance and coaching. In so doing, the nursing student may be able to catch up with
the lessons, requirements and demands of the program.
On the Perceived Difficulties Encountered by the Nursing Students in the

Formulation of the Nursing Care Plan
The nursing students expressed their perceived difficulties encountered in the
formulation of nursing care plan through a sit down discussion. Based on their
clinical experiences, the following thematic cluster of responses reflected their
difficulties (transcribed verbatim):
A. NCP Component: Assessment

- I do not know what to assess
- How to better assess and delve fur ther into the dimensions that need
attention
- To pinpoint pr oblem of patient
- To thoroughly assess patient’ s pr oblem (ver bal or non-ver bal cues)
- M or e on assessment, and what to ask the patient
- I r ealized the importance of assessment, but it is difficult
- In conducting inter view, clients cannot answer , you cannot get substantial
data
- Focus on assessment, but not sufficient since I have difficulty on how to
deal or addr ess people/patients
64
Assessment begins with the nurse’s first encounter with the patient. It
involves the systematic collection of data about the patient’s nursing needs and the
use of these data to formulate nursing diagnoses. It includes a nursing history and is
carried out for the purpose of determining the patient’s state of wellness or illness
and is best accomplished as part of a planned interview. This component in the
nursing process provides the nurse an opportunity to collect data by physical
examination from head to toe and all body systems; by getting the patient’s history
logically presented in a patient’s view (thus subjective information); and to include
laboratory data. A thorough and accurate assessment of a patient’s problems or
condition depends on the completeness and accuracy of data collected (Hawks,
2008).
All data collection should be well-organized and thorough. There is no room
for bias in data collection, since the nurse’s mind must be open to clues and cues that
might otherwise be missed. Thus, assessment being the first step in the nursing
process is crucial to the whole process, the steps being interrelated, interdependent
and recurrent.
The participants realized the importance of assessment. The perceived
difficulty experienced by the nursing students when assessing patients represents
communication issues.
A participant related that she has difficulty in assessment because of
hesitations on her part that she may invade the privacy of the client and may ask too
personal questions. This perception may be explained by a basic social psychological
problem of "saying the right things to patients" in the clinical setting, which was
preceded by the antecedent problem of "fear of saying the wrong things to patients."
This analysis came up in a study on how baccalaureate nursing students
communicate with patients in the clinical setting and posits that communication is a
symbolic event and that individuals create the meaning of an event while engaged in
the event. She explains that during interactions, nursing students engage in creating a
meaning of nursing based on their interpretations of a symbolic event. In this case,
65
the nursing students engaged in creating a meaning of why they hesitated to explore
further or why they experience anxiety when assessing patients (Kotecki, 2002).
Assessing and exploring the anxieties of students and leading them to find
means to overcome these barriers is a vital role that clinical instructors need to play.
Helping the students in overcoming their psychological barriers may create lasting
impact in terms of developing their confidence and competence in providing safe and
quality care.
B. NCP Component: Nursing Diagnosis

- Pr ioritization of nursing diagnosis – CI would not agr ee (five students
verbalized this!)
- Pr oblem prioritization – difficult
- Identifying and prioritizing the problem
- I had a hard time in making diagnosis
- I am not able to prioritize what should be the patient’ s problem
- I just focus on prior itizing based on symptoms, physiological then
psychological
- I have a difficult time to prior itize based on signs and symptoms and what
is prioritized problem
In a discussion with three (3) nursing alumni, focusing and recalling during their
nursing students’ experiences, the difficulties in formulating nursing care plan, the
following key points were noted.
“I was struggling ever y time duty week comes, I have difficulties in assessing
the client. Assessment is one of the most difficult par t in making NCP.”
“ For mulating a correct nur sing diagnosis for your client is difficult because, I
only have few assessments in connecting one sign to another symptom.”
“ I have difficulty assessing signs and symptoms.”
“ I have difficulty in choosing and prioritizing the appr opriate nur sing
diagnosis and finding appropriate nursing inter ventions.”
66
“ Choosing the appropriate intervention to be done is needed and you also
have to base it is the institution, available equipments or ther apy in that ar ea for
your goal to be met.”
“ You need to be ver y proficient when checking the patient, sometimes the
diagnostic tests are not complete and no laboratory r esults.”
“ I have difficulty in matching my assessment findings with the nursing
diagnosis and the pathophysiology.”
After data collection is organized, analyzed, and summarized, the nurse

identifies the patient’s health problem – actual or potential and states the nursing
diagnosis concisely and precisely. The nursing diagnosis consists of three (3) parts
namely: a) the patient’s needs/problems stated using the NANDA classification; b)
the etiology of the problem or the underlying cause; and c) the clustered specific and
measurable signs and symptoms identified during assessment that support the
identified nursing diagnosis. The nursing diagnosis is a clinical judgment about
individual, family or community to health problems and developed based on data
obtained from nursing assessment. Validation and prioritization of nursing diagnoses
is a necessary step to confirm with the patient’s condition based on data gathered and
interpreted.
The quality of data gathered during assessment has a bearing in formulating
nursing diagnosis. Meaning, incomplete data, inappropriate clustering of data,
inclusion of irrelevant data that do not show evidence and relatedness to a patient’s
condition certainly create difficulties among students. A gap in making effective
choices result when there is lack of congruence among the information considered in
making decisions. Their difficulties may be explained by their lack of attention in
gathering complete nursing history and performing complete physical examination to
their patient. This was evident when despite of instructions by the researcher to
gather complete nursing history and perform complete physical examination,
incomplete reports were still reflected in their nursing care plan.
67
Studies confirmed that the accuracy of nursing diagnosis formulated by nurses
varied widely from high to low. It is suggested that high accurate nursing diagnoses
are essential in order to come up with interventions that will guide the attainment of
positive health outcomes. Critical thinking abilities are identified as the core nursing
skill that need to be developed in order to improve the accuracy all nursing decisions
and actions (Lunney, 2003).
The results of the focus group discussion indicate that after one year of clinical
exposure among the nursing students, critical thinking skills were not yet fully
developed or optimized. Hence, it is the role of the teachers to facilitate the
development of critical thinking skills needed in interpreting, analyzing, and
eventually making decisions based on completeness, appropriateness, relevance, use
of evidence, and relatedness among the information in each of the component of the
nursing care plan.
C. NCP Emphasis: Varied Approaches

- Some clinical instr uctors pr efer simple yet wor kable NCP, some want
complicated
- CI would not agree on pr oblem identified
- CI’ s ar e not consistent with their for mat
- CI’ s not at all helpful in assisting students in making NCP
- CI’ s ar e not clear on what they r equir e, want or emphasize
In a discussion with three (3) clinical instructors focusing on nursing students’
difficulties in formulating NCP, the following key points were noted:
- As a CI, I look into completeness of assessment data, cues and should jive
with nur sing diagnosis.
- I look into completeness, accur ate, r eliable data connected with subjective
and objective assessment.
- Histor y is part, risk factor s, physical examination, how specific they assess
and it should be r elated to the nursing diagnosis they for mulate
68
- Pr iority nur sing diagnosis and appropriate. It is r elated to disease process
as evidence by assessment findings
- Ther e should be holistic assessment, student nurse-client inter action or
significant others, r ead chart and labor ator y r esults
- Diagnosis is connected to assessment and r elated to the problem at hand,
and matched together
- Students do not match the diagnosis with assessment. Ther e should be
r elationship and appropriateness of problem identified, according to
etiology and signs and symptoms
As a whole, the general difficulties extracted from the various experiences of

the nursing students, shared by the alumni, and validated by the observations shared
by the clinical instructors were on: a) assessment; b) prioritization of nursing
diagnosis; and c) coping and responding to varied clinical instructors’ emphasis and
focus in formulating nursing care plans.
The observations shared by the clinical instructors validated the need to guide
the students in the way they are applying and utilizing the concepts of the nursing
care plan. In a way, it also showed the diversity in styles, approaches, and methods of
teaching utilized by clinical instructors. This diversity, also expressed by the nursing
students, contributed to the confusions experienced by the students on how and what
to apply or utilize as evidenced by deficiencies in their nursing care plan outputs. In
short, there is a need to lay down clear directions in how to help the nursing students
develop their skills.
Profetto-McGrath et al. (2003) state that specific reasoning skills and
knowledge sources for planning nursing care seem to influence the formulation of
nursing diagnoses. They further argued that the accuracy of diagnoses seems to be
related to a nurse’s capacity for critical thinking and for applying his/her reasoning
skills (cited in Paans, 2011).
Facione (2000) posits that dispositions towards critical thinking that include
attitudes of being open-minded, truthseeker, analytic, systematic, inquisitive and
69
mature may influence the accuracy in coming up with an accurate nursing diagnoses.
Further, reasoning skills that include inductive and deductive skills that include
analyzing, inference, and evaluation were considered as essential in the diagnostic
process (cited in Paans, 2011).
Gulmans (1994) categorized knowledge needed to develop diagnostic
statements into: (a) declarative knowledge (‘know that’) associated with the ability of
a diagnostician to correlate facts, concepts, and procedures; and (b) procedural
knowledge (‘know how’) that refers to having the skills and knowing the rules on
how to apply declarative knowledge (cited in Paans, 2011).
Cholowski & Chan (1992), Hasegawa et al.(2007), and Lunney (2008)
recommend that knowledge about a patient’s case history and knowledge about how
to analyze relevant patient data should be considered a central factor in being able to
derive accurate diagnoses (cited in Paans, 2011).
In the foregoing studies cited by Paans, emphasis was placed in the very
important role of developing and using critical thinking skills. Critical thinking starts
the moment the nursing student engages with the patient. Gathering complete,
appropriate, relevant, evidence-based and related information demonstrate the
utilization of critical thinking skills. Inductive and deductive thinking are utilized
singly or in combination in order to ascertain the completeness of supporting data,
arriving at the appropriate decisions, identifying relevant outcomes of care and
interventions based on evidence and relatedness in order to make sure that safe,
competent and quality nursing care are provided to the patient.
In this study, the difficulties expressed by the students were part of learning
the proper way of thinking. These difficulties portrayed a picture that they were
exerting efforts to arrive at the appropriate decisions and come up with safe plan of
care. It shall be appreciated in the latter part of this study when enhancements were
introduced aimed at improving the way they think and do nursing care-related
activities.
70
On Nursing Care Plan Components Taught, Applied, Corrected and Evaluated
in the Classroom and the Clinical Area
In the survey done to the nursing students/participants, results showed that the
Nursing Care Plan components were indeed taught in the classroom through the
course/subject offered in Health Assessment and Foundations in Nursing both
offered in the 1st year curriculum (CHED Memo 14, 2009). The NCP components
were delivered by lecture-discussion, hand-outs were provided, audiovisual aids and
LCD projections, and simulations as teaching-learning strategies were utilized in the
classroom set-up. These were further enhanced and strengthened in the clinical area
exposures by individual clinical instructors as applied in an actual case of the
patient/client.
Classroom discussions of the nursing process and the nursing care plan were
directly applied in the various related learning experience (RLE) activities both in the
classroom and clinical area. These were reflected in demonstration-return
demonstration sessions, nursing case study (NCS) and case presentation done either
as an individual or group work. Table 9 shows a summary of the NCP components:
Taught and Applied.
Table 9
Summary of NCP Components: Taught and Applied
Classroom Clinical Area
During 1st year: (CHED M emo 14, 2009)

- Health Assessment
- Foundations in Nursing
- Lecture-Discussion
- Provided with handouts/guides
- Discussion of nursing process - Given guidelines and handouts
- Examples given - Review of classroom discussion
- Application to an actual, existing patient
During 2nd year: to include abnormal cues, laboratory
- Taught objective and subjective data results, subjective and objective data
- Demonstration/return demonstration
During 3r d year: - Nursing Care Study and Case Presentation
- Included actual, abnormal cues, risk factors,
strengths and weaknesses
- Orientation done to various parts of NCP
- Reference includes NANDA books
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Practice and application of the NCP components were shown through
examples that were relevant in both normal and abnormal findings. Assessing a
patient done by interviewing was emphasized to reflect appropriateness, relevance
and therapeutic communication. Given a particular patient, simulation and practice
on a recommended format was applied.
As to the nursing students’ experiences on how the components of the NCP
were corrected, they expressed that clinical instructors followed guidelines or criteria
that have been set. Corrections were made based on appropriateness of findings,
interventions, justifications. CI’s also gave examples as to how to properly make
observations and if goals of care were met, and common errors were cited. All of the
nursing students though would prefer to know how they were graded/evaluated and
what areas they need to improve. Table 10 shows a summary of the NCP
components: Corrected and Evaluated in the classroom and clinical area.
Table 10
Summary of NCP Components: Corrected and Evaluated
Classroom Clinical Area
à Follow guidelines/criteria set à Some corrections were made without

à Corrections made on appropriateness of explanations
findings, interventions, justification à Grading may not be explained
à CI gave examples for correct statements à Some CI cross out findings not
à Common errors cited appropriate
à Corrected papers returned à Graded with side notes, with corrections
but not discussed
à Graded based on completeness
à We need to be guided how it should be
done right
A closer look into the components of the Nursing Care Plan as taught and
applied in the Bachelor of Science in Nursing curriculum revealed that efforts were
evident to put theory into practice, concepts into action, and knowledge gained into
the formation of skills. Data also implied that based on the nursing students’
experiences, a strong and felt need to address nursing student-clinical instructor
working relationship were expressed especially on Nursing Care Plan as corrected
72
and evaluated,. This can be established through step-by-step guidance, sit-down
discussion, or one-on-one dialogue wherein provision of feedbacks and improving
the written NCP benefit both the quality of learning of students and the quality of
care rendered to patients/clients.
On How the Proposed Enhanced M odel Addressed I ssues and Concerns

Currently Encountered with the School’s Nursing Care Plan M odel
Phase 3 of the research process was the introduction of a Proposed Model:
Nursing Care Plan Enhancement. A one (1) hour interactive lecture-discussion took
place between the nursing students/participants and the researcher. Contents of this
proposed model included key components of the nursing care plan presented in a
flow diagram (Appendix G), a detailed format of the enhanced NCP (Appendix H),
an Acronym for quick recall of interventions (AMETHODIST, Appendix G) and in
the entire nursing process (CARER) for evaluation purposes (Appendix H). The
participants were very receptive.
Phase 4 of the research process requested the nursing students/participants to
formulate a nursing care plan of an identified patient in the Medical Ward done in
two different occasions. Utilizing the Nursing Care Plan Evaluation Criteria
(Appendix J) and the Nursing Care Plan Scoring Rubric (Appendix K) an NCP grade
was computed. An NCP grade summary was generated using the nursing care plan
scores (Appendix L).
Figure 3 shows the graphic representation of the improvement in the individual
participants’ nursing care plan scores.
The average nursing care plan scores has increased in Sessions 3 and 4 when
the enhancements were applied by the nursing students compared to their scores in
Session 1 and 2 when they had their usual way of formulating their nursing care
plans.
In order to demonstrate the improvements attributed to the introduction and
implementation of the enhancements to the nursing care plan, a comparison was
made in the contents of the first session and the third session from a randomly
73
Figur e3
NCP Average Grade Summary
selected nursing care plan of a study participant. The choices for the first and third
sessions were made on the basis that the two patients have similar health problems
with almost similar manifestations.
The Nursing Care Plan Enhancement reflected clear, direct and significant
information the nursing students have identified, included and indicated in the
component of assessment. These findings can guide nurses in planning the care of the
client. The assessment findings in Session 3 NCP were: more complete with specific
and measurable descriptors compared to the presentation written in Session 1 NCP;
clustered data were more appropriate, relevant, and evidences both subjective and
objective - for the health problem are more related. The information provided in the
assessment findings set the tone for the formulation of a clinical judgment. Table 11
shows the comparison of assessment done in Session 1 and Session 3.
The set of information formulated in the Nursing Diagnosis included a biophysical
priority and attention for the patient that nurses need to attend and to care for. Signs
and symptoms support the diagnosis and etiology of the patient’s problem and
showed a better explanation with conciseness. The nursing diagnosis in Session 3 is
more complete, appropriate, relevant, and evidences clearly supported the problem.
74
The data established clear relatedness from problem statement, to etiology, to the
supporting manifestations. Table 12 shows the comparison of nursing diagnosis in
Session 1 and Session 3
Table 11
Comparison of assessments in Session 1 and Session 3
Session 1 Session 3
“nagabanog ang akon tiil kag guya; Subjective:
nagahabok man ang akon tiyan as -“gapalanghubag ang akon tiil mge duwa na ka semana,
verbalized by the patient. nagasakit pa gid gani kag indi ko magiho basi tungod sa akon
Presence of adventitious breath sounds arthritis”
(crackles) upon auscultation at lung
fields; swelling on the left lower Objective:
extremity; dullness of abdomen upon -with pitting edema on both legs (grade1 :2mm); pallor on
percussion; abdominal girth 112 cm; the ventral aspect of the hands; pain on the knee joint if
bowel sound not audible; with non-pitting edema is present 10/10 and 1/10 if edema is absent
edema at left lower extremity; increased -March 24, 2011 CBC findings revealed decrease in the
creatinine (18.36 mg/dl), BUN (125.28) following blood components:
and potassium (6.30meq/l) Hct-0.15L/L; Hgb-50g/l; RBC-1.68 10^; platelet 130 x
10^g/l;
-March 24, 2011 ABG: pH 7.31; pCO2 22.3; PO2 153.3;
HCO311.1; UTZ-minimal ascites
Table 12
Comparison of nursing diagnosis in Session 1 and Session 3
Session 1 Session 3
Fluid Volume Excess Fluid Volume Excess
r/t inability of kidneys to produce urine secondary to related to ongoing kidney disorder
chronic renal failure; excess sodium intake; fluid
shifting and decreased ability to pass out urine
aeb swelling on left extremity (nonpitting edema) as evidenced by pitting edema (grade 1) on
(only one manifestation was reflected) both legs; pallor on the ventral aspects of both
hands and decrease in the levels of Hct, Hgb,
RBC and UTZ findings of minimal ascites
75
Implementation of Nursing Care Plan shall include interventions that are
appropriate, holistic and relevant to the client’s condition. Viewing the patient as a
total person with his bio-psycho-social and spiritual needs can facilitate quick
recovery as quality care is rendered by nurses. Table 13 shows the comparison of
interventions in Session 1 and Session 3.
Nursing interventions are classified as independent and collaborative. The acronym
AMETHODIST stands for: A- Assessment related; M -Medications related; E-
Exercise, Sleep, Rest, Environmental Modification related; T-Treatment, laboratory,
safety, comfort related, H -Hygiene related; O-Outpatient Follow-up / Referrals/
Discharge planning related; D-Diet related; I -Inspiring / motivating / emotional
support related; S-Spirituality / Sexuality related; and T-Teaching related.
The key to the care plan are the interventions that should be implemented in
order to help alleviate, improve manifested signs and symptoms, provide comfort,
ensure safety, and prevent complications. The written care plan should provide
complete, appropriate, relevant, based on evidence of effectiveness of interventions,
and related interventions to help improve the condition of the patient. The written
care plan equipped with these qualities ensures provision of safe, quality care
designed to the individual needs of patients.
Table 13
Comparison of interventions in Session 1 and Session 3
Session 1 Session 3
Independent / Collaborative Independent
Collaborative
A ssessment =Note amount and -monitor CBC, -monitor vital signs every
rate of fluid intake ABG, Blood hour
related
from all sources. chemistry -monitor input and output
Orally, intravenous (creatinine, every shift
and so forth BUN)
=monitor vital signs
and auscultate for
breath sounds and
76
determine for the
presence of crackles
and congestion
=note for presence of
edema and measure
abdominal girth
=Note for fever
=review laboratory
data such as BUN,
creatinine,
hemoglobin,
hematocrit,
electrolyte
M edications Administer Calvit BID; Administer meds as ordered

medications such as NaHCO3 1 and following the 10 rights of
related
diuretics tabTID; drug administration
Amlodipine 10g
OD HS;
clonidine
100mcg PRN;
Motilium 10mg
1 tab TID
E xercise, Stress need for Limit excessive moving and

mobility and frequent help the client while he
Sleep, Rest,
position changes to performs activities
Environmenta
prevent stasis
l Modification
Related
T reatment, Restrict fluid and Infuse packed -instruct the client to elevate
sodium intake as RBC as ordered the affected extremities (both
laboratory,
ordered by physician by physician lower)
safety,
Elevate extremities, -remind the patient to comply
comfort
change position with ordered laboratory
related
frequently -instruct to limit fluid intake
as ordered
77
H ygiene /
Not provided Perform sponge bath or bed
Self-care bath
related
O utpatient Not provided Not provided
Follow-up /
Referral /
Discharge
Planning
D iet related Not provided Avoid / limit Ensure that the patient is
taking oily and adhering to the diet
salty foods as prescribed
ordered
I nspiring/ Not provided -Motivate the client to

cooperate in the therapeutic
motivating/
regimen and other
emotional
interventions
support
-Talk with the client about
related
his goals in life and happy
moments
Spirituality /
Not provided -ask the client to verbalize
his beliefs about his
Sexuality
condition and correct them if
related
inappropriate to the condition
of the patient
T eaching /
Instruct client/family -provide health teaching
in use of voiding regarding the actions that
health
record would lead to the
education
stabilization of the amount of
related
body fluids in the body such
as dietary restrictions (low
salt and limit fluid intake)
-provide teachings about the
disease and to correct the
patient’s misunderstandings
78
Figure 4 shows the average scores of the participants in each of the
components of the nursing care plan in Sessions 1, 2, 3, and 4. The data shows that
there were demonstrable improvements in the way assessment data were presented,
nursing diagnosis, rationale, planning and interventions were formulated in Sessions
3 and 4. Sessions 1 and 2 outputs of the nursing students reflected the product of one
year of application of what they learned since the second year. Sessions 3 and 4
reflected the product of just two sessions of utilization of the enhanced nursing care
plan model. Further practice using the enhanced nursing care plan model would
allow the students to develop clearer and more precise thinking, doing, and feeling in
the way care is to be provided to the patients.
The interventions using the enhanced model (AMETHODIST Model) provides
more holistic, complete, appropriate, relevant, based on evidence, related, safer and
quality care to the patient. Provisions for biologic-psychological-socio-cultural-
spiritual-related interventions were included in the model to ensure that genuine
holistic care is provided in any health-related problem that is presented by patients.
F igure 4
Nursing Care Plan Scores Per Component Per Session
79
The nursing students need to learn and internalize the value of gathering
complete, specific, and measurable information. They should patiently practice
taking complete nursing history and perform complete physical examination on the
first day of their clinical duty. They should learn to validate their findings. This will
enhance the way they think, do, and feel as a nurse.
On the significant interaction between the effects of gender and NAT/CSAT

Scores grouping on the written NCP mean scores when using the enhanced NCP
model and rated using the NCP Scoring Criteria
The nursing care plans submitted in the third and fourth sessions were
analyzed and scored using the NCP Evaluation Criteria, NCP Scoring Rubric and
NCP Grading Guide. The two NCP scores were averaged and subjected to 2-way
ANOVA.
The results of the 2-way ANOVA indicate that there is no statistically
significant main effect of NAT/CSAT Scores Grouping, F(2,12) = 2.583, p>.05 on
the NCP scores using the enhanced model. In other words, there is no statistically
significant difference in the mean scores of the NCPs using the enhanced model
when grouped according to their NAT/CSAT scores. There is no statistically
significant main effect of gender and no interaction between gender and NAT/CSAT
grouping (p>.05).
The results indicated that those who have very low NAT/CSAT scores were
able to adopt the enhanced model and contributed to an improvement on the way
they understood and applied the model. The results further demonstrated that the
review of concepts in nursing with the integration of Roy’s Adaptation Model in the
enhanced NCP model contributed significant improvements on the way the students
understand how nursing care plans should be formulated as demonstrated by the
improved outputs in sessions 3 and 4.
A very encouraging result was the obliteration of the differences in the scores
across cognitive abilities among the participants with just two sessions of using the
80
enhanced NCP model. This would mean that the enhanced NCP model showed
promise in improving the way students think, analyze, arrive at clinical judgments,
and in using evidence in solving health problems. The results further suggest that
teaching and guiding students to become competent, safe, and quality care providers
is attainable regardless of cognitive abilities through collaborative efforts between
teachers and learners.
On the significant difference in the nursing students’ written NCP Scores when
using the school’s model and the enhanced model
The scores of the nursing care plans during the first and second sessions and
the third and fourth sessions were averaged and subjected to paired sample t Test.
The results yielded t-5.002, df11, p<.001 suggesting that there is statistically
significant difference in the NCP mean scores in sessions 1 & 2 (M=72.5) compared
to sessions 3 & 4 (M78.75).
The results revealed improvements on how the students formulated their
nursing care plans using the enhanced model.
The results also implied that the NCP evaluation criteria, NCP scoring rubric
and NCP grading matrix have provided objective scoring of the nursing care plans.
81
Chapter 5
SUM M ARY OF FI NDI NGS, CONCLUSI ONS, and RECOM M ENDATI ONS
This chapter presents the summary of findings, conclusions and recommendations.
Summary of Findings
The result of this descriptive-analysis of the Nursing Care Plan Based on
Nursing Students’ Clinical Experiences may be summarized as follows:
1. The nursing students’ understanding of the concept of the Nursing Care Plan is
based on:
a. Nature
The Nursing Care Plan is a systematic tool, step by step process and for
nurses as a guide for proper patient care management.
b. Components
The Nursing Care Plan involves a process of assessment, planning,
implementation and evaluation of care rendered to the patients.
c. Purpose/Goal
The Nursing Care Plan provides quality patient care, promotes optimum
health of the client, gives effective delivery of care and achieves a
healthy state of the patients. It also enhances nursing knowledge and
skills.
2. The contents of the written nursing care plan formulated by the nursing
students were analyzed utilizing the Nursing Care Plan Evaluation Criteria and
Nursing Care Plan Scoring Rubric. The result revealed that the following
components are deficient: Nursing History and Physical Examination and
Implementation of Interventions. The results revealed that the following
components are sufficient: Assessment, Nursing Diagnosis, Rationale and
Planning.
82
3. The results of the 2-way ANOVA indicated that there is a statistically
significant main effect of NAT/CSAT Scores Grouping, F(2,12) = 41.237,
p<.005 on the NCP scores using the school’s model. The partial Eta squared
indicated that 93.2 percent of the variance in the NCP scores is attributed to
the NAT/CSAT scores grouping. There is no significant effect on the scores
according to gender (p>.05).
4. There were perceived difficulties encountered by the nursing students in the
formulation of the nursing care plan. The focus group discussion revealed a
thematic cluster of responses based on their clinical experiences of the nursing
students. These areas are:
a. NCP Component: Assessment – nursing students’ difficulty to gather
relevant, specific, comprehensive patient data
b. NCP Component: Nursing Diagnosis – nursing students’ difficulty
prioritizing patients’ problems
c. NCP Emphasis: Varied Approaches – nursing students’ difficulty to
cope and respond to varied clinical instructors emphasis and focus in
formulating nursing care plan.
These perceived difficulties are also confirmed by the nursing alumni and
nursing instructors.
5. The concept and components of the Nursing Care Plan were taught both in the
classroom and applied in the clinical area as stipulated in the Bachelor of
Science in Nursing curriculum. Data also implied that the Nursing Care Plan
can be corrected and evaluated if nursing students know and be given feedback
as to the areas that need correction and improvement.
6. The Proposed Model for Nursing Care Plan Enhancement has addressed the
issues and concerns currently encountered in the standard nursing care plan
model. The introduction of the components were presented in a flow diagram,
a detailed format, and an acronym for the interventions (AMETHODIST) and
nursing process evaluation (CARER) for quick recall by the nursing students.
83
7. There is no statistically significant difference in the mean scores of the NCPs
using the enhanced model when grouped according to their NAT/CSAT scores
(p>.05). There is no statistically significant main effect of gender and no
interaction between gender and NAT/CSAT grouping (p>.05).
8. There is statistically significant difference in the NCP scores when using the
school’s NCP model (M=72.5) and when using the enhanced NCP model
(M78.75), t -5.002, df11, p<.001.
Conclusion
Based on the clinical experiences of the nursing students in formulating
Nursing Care Plan, the following conclusions were drawn on the basis of the research
findings:
1. The Nursing Care Plan is an important and powerful tool to guide nursing
students / nurses in providing quality patient care and not just a subject
requirement for grading purposes.
2. The nursing students need guidance, supervision and assistance both in the
classroom and especially in the clinical area on the components of assessment,
nursing diagnosis and implementation of interventions in order to reflect a
holistic approach to nursing and patient care.
3. The nursing students’ perceived difficulties and gaps in evaluation of Nursing
Care Plan can be addressed by the recommendations stated in this study.
4. The nursing care plan and nursing process concepts require higher order
thinking skills and aptitude for critical analysis and application.
5. The Nursing Care Plan Enhancement Model can be adapted and utilized as a
guide for nursing students for quick access and recall during formulation of the
nursing care plan.
Recommendations
Through this descriptive analysis study of the Nursing Care Plan based on the
Nursing students’ clinical experiences, the following recommendations are to be
explored in the areas concerned:
84
1. Bachelor of Science in Nursing Curriculum – CHED Memo 14 course/subject
offering of Health Assessment and Foundations in Nursing are introduced
during 1st year students, while clinical areas and duty are done during 2nd year
and higher year levels. This set-up may need to be reviewed as this may be the
cause of why nursing students have difficulty in assessment and the nursing
care plan.
2. College of Nursing Course Syllabus – The need to allocate more time for
classroom inputs, utilize various teaching-learning strategies, and to allow
more application of concepts into actual patient settings in the hospital during
related learning experiences and duty.
3. College of Nursing Instructors – The urgent call and effort in providing the
necessary guidance and supervision in all aspects of patient care in order to
equip the nursing students with the needed competencies in analyzing,
interpreting, decision-making and prioritizing health problems/needs of the
patients.
4. College of Nursing Students - The nursing profession involves thinking,
feeling and doing, therefore, the cognitive, affective and psychomotor abilities
of the nursing students require more guidance, supervision and continuous
provision of feedbacks in order to improve. The Nursing Students – should
develop skills in critical thinking by practicing and keep on practicing. They
should learn to consistently and properly use and apply the various
components of the nursing process in formulating a nursing care plan as a
framework in enhancing critical thinking and decision making in order to
provide safe and quality nursing care.
5. College of Nursing Administrators – The creation of a review committee on
the nursing care plan practices of different clinical instructors and establishing
an acceptable enhancement on the areas of assessment and evaluation should
be considered.
6. Future Researchers – The conduct of future studies aimed at improving
nursing education and nursing practice are encouraged. They might consider
85
replicating this study and consider its benefits especially in relation to the
improvement not only in passing percentage in the Nurse Licensure
Examination but most importantly, its impact on the quality of patient care.
86
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APPENDI CES
92
Appendix A
SAM PLE APPROV AL SH EET
GRADUATE SCH OOL OF NURSI NG
12 March 2011
APPROVAL SHEET
(Dissertation Proposal)
The Dissertation Proposal entitled: “Nursing Care Plan: Based on Nursing

Students’ Clinical Experience” prepared and submitted by Joel G. Patalagsa,
candidate for Doctor of Philosophy in Nursing of the Graduate School has been
reviewed and approved by the panel of evaluators.
PANEL OF EVAL UATORS
1. Original Signed
2. Original Signed
3. Original Signed
4. Original Signed
5. Original Signed
93
Appendix B
LETTER TO THE DEAN OF THE COLLEGE OF NURSING
March 15, 2011
Dean, College of Nursing
Dear Dean:
Greetings! The ultimate goal of nursing education program is to train nurses to

become competent, safe, high quality care service providers. One of the basic skills
that we need our student nurses to develop is a high level of proficiency in
formulating nursing care plans that will help in the healing and recovery of their
patients. As part of the requirements for the degree, PhD in Nursing, a study entitled
“Nursing Care Plan: Based from Nursing Students’ Clinical Experience” is to be
conducted. One of the objectives is to explore ways to improve how we train our
students based on the findings of this study.
The study will involve twelve (12) third year student nurses who will be chosen
purposively. The study will be conducted at the medical ward of the Regional
Hospital. The students will interview patients in order to gather data for their nursing
history, conduct physical assessment, access medical records for treatments and
medications. They will then proceed to the library to formulate their NCPs which
will be evaluated. The procedure will be repeated four times. The first two sessions
will involve allowing the students to do their usual activities and using the school’s
NCP model. The last two sessions will involve introducing enhancements based on
their outputs.
In this regard, may I request your permission to conduct the study. May I also request
an access to the NAT scores and CSAT scores of the selected study participants for
their profile.
I am hoping for your kind approval to carry out this undertaking.
Thank you very much.
Very truly yours,
Joel G. Patalagsa NOTE: ORI GI NAL SI GNED

(PhD in Nursing Candidate) AND APPROVED
94
Appendix C
LETTER TO THE CHIEF OF HOSPITAL
March 15, 2011
Chief of Hospital
Regional Hospital
Dear Chief of Hospital:
Greetings from St. La Salle! The ultimate goal of nursing education program is to
train nurses to become competent, safe, high quality care service providers. One of
the basic skills that we need our student nurses to develop is a high level of
proficiency in formulating nursing care plans that will help in the healing and
recovery of their patients. As part of the requirements for the degree, PhD in Nursing,
a study entitled “Nursing Care Plan: Based from Nursing Students’ Clinical
Experience” is to be conducted. One of the objectives is to explore ways to improve
how we train our students based on the findings of this study.
the outputs that they provide.
In this regard, may I request your permission to allow us conduct the study at the
medical ward, access the medical records, interview patients, and collaborate with
the nurses and the medical officer on duty during their data gathering sessions. Rest
assured that all information will be held with strict confidentiality and we will engage
with the patients with utmost respect. I will personally supervise the student nurses in
all of these engagements.
I am hoping for your kind approval to carry out this undertaking.
Very truly yours,

NOTE: ORI GI NAL SI GNED
Joel G. Patalagsa AND APPROVED
(PhD in Nursing Candidate)
95
Appendix D
LETTER TO THE CHIEF NURSE
March 15, 2011
Chief Nurse
Regional Hospital
Dear Chief Nurse:
Greetings from St. La Salle! The ultimate goal of nursing education program is to
train nurses to become competent, safe, high quality care service providers. One of
the basic skills that we need our student nurses to develop is a high level of
proficiency in formulating nursing care plans that will help in the healing and
recovery of their patients. As part of the requirements for the degree, PhD in Nursing,
a study entitled “Nursing Care Plan: Based from Nursing Students’ Clinical
Experience” is to be conducted. One of the objectives is to explore ways to improve
how we train our students based on the findings of this study.
the outputs that they provide.
In this regard, may I request your permission to allow us conduct the study at the
medical ward, access the medical records, interview patients, and collaborate with
the nurses and the medical officer on duty during their data gathering sessions. Rest
assured that all information will be held with strict confidentiality and we will engage
with the patients with utmost respect. I will personally supervise the student nurses in
all of these engagements.
I am hoping for your humble approval for this undertaking.
Very truly yours,

Joel G. Patalagsa AND APPROVED
(PhD in Nursing Candidate)
96
Appendix E
INFORMED CONSENT FORM
Title of the Study: “Nursing Care Plan: Based on Nursing Students’ Clinical
Experience”
March 18, 2011
Dear _____________________________________ :
You are being invited to participate in a study on “Nursing Care Plan: Based
from Nursing Students’ Clinical Experience”. Specifically, you will be asked to
gather patient’s information, conduct physical examination of the patient, access
medical records of the patient and formulate a nursing care plan. The purpose of this
study is to understand how you formulate your nursing care plan based on your
acquired knowledge and experience.
You are also invited to participate in audio recorded interview sessions
because the researcher believes you are able to provide a holistic view of how you
apply your acquired knowledge. The researcher also believes that you are able to
discuss, from your perspective, the knowledge gaps and learning needs that you may
have.
The study will involve at least four (4) sessions involving pre-conferences,
actual interview with patients, accessing medical records, going to the library to
formulate a nursing care plan, and then interviews. The duration of each session
depends on the progress and interests that may arise while conducting your
interviews to the patient, formulation of your nursing care plan, and the interviews.
As the sessions unfold, you can choose not to answer any question asked. If you
decide to withdraw from the study, simply leave the room. There are no
consequences for not answering a question or withdrawing from the study. Because
97
of the nature of the interview, all data you have shared prior to the time of
withdrawal will remain in the data set.
The schedules arranged with the administrators of the study setting are on:
March 19, 2011, 1:30PM
March 25 & 26, 2011, 8:30AM
March 29, 2011, 8:30AM
March 31, 2011, 8:30AM
The researcher suggests that you come at least 45 minutes before the scheduled
engagements in order to discuss matters prior to the conduct of each scheduled study
session.
There are no known physical risks for participating in this study. However,
you may sometimes feel emotionally uncomfortable if reflecting on an unpleasant
experience. If this happens, simply let the researcher know. At the end of the session,
the researcher will then provide you with names and contact information of
counseling and/or mental health services available for you.
Although there are no direct benefits to you for participating in the interview
and discussion session, you will be providing the researcher with valuable
information that will influence how nursing programs, affiliating agencies and the
College of Nursing will provide support to your learning needs. Consequently, you
will be enhancing the teaching-learning environment by participating in this study.
Because this is a group session, other participants will know of your
participation. However, before starting the session, the researcher will remind
everyone about the confidential nature of the discussion. As well, the researcher will
be using other strategies intended to protect your identity. For example, all
identifying information like your name will be removed from the transcript and
replaced with a code. Identifying events will be modified in such a way as to protect
your identify and the identity of those you work with. All results of the study will be
reported in aggregate form. Your name and/or identifying information will not be
made public.
98
Once the audio record is transcribed, the audio record will be deleted. All
transcripts from the study will be stored in a locked cabinet located in the
researcher’s home. Data will be kept for 5 years and destroyed at this time. Only the
researcher will have access to the data.
Findings from this study will be presented at conferences and published in
relevant nursing journals. The findings will also be discussed with nurse educators,
hospital administrators, and College of Nursing Administrators so that strategies
might be developed to better support learning needs of our students. If you wish to
review the completed project prior to its release to the public, please contact the
researcher at jgp_1960@yahoo.com.
Questions regarding your rights as a participant in this research may be
addressed to the Office of the University Research Center.
I have read (or have been read) the above information regarding a study about
“Nursing Care Plan: Based from Nursing Students’ Clinical Experience”, and
voluntarily consent to participate in this study.
__________________________________________ (Printed Name of Participant)
__________________________________________ (Signature of Participant)
__________________________________________ (Date)

AND APPROVED
99
Appendix F
Review of metaparadigm of nursing with the integration of Roy’s Adaptation Model
• Person – biological, psychological, socio-cultural, spiritual dimensions

• Environment
• Coping processes
• Adaptive modes
• Health
• Nursing
Purpose of nursing care:

• promotion of health • facilitate healing, recovery
• prevention of diseases • assisting patients towards peaceful
• restoration of health death.
• alleviation of suffering • ensuring active participation in the
delivery of holistic healthcare
100
Appendix G
Nursing Care Plan Enhancements
Nursing Care Plan Components:
1. Assessment:
• Collection of data (Complete, Appropriate, Relevant, based on Evidence,
Related)
o History (complete) (See Nursing History Guide)
o Physical examination findings (See Physical Examination Matrix)
o Diagnostic study data (laboratory findings)
o Should be specific and measurable
o Look for evidence of problems, risks, strengths, weaknesses
2. Nursing Diagnosis (Complete, Appropriate, Relevant, based on Evidence,

Related)
• Judgment made about the assessment findings.
• Interpret, verify, label findings
• Judgment can be a problem, risk, wellness/strength
• PES format (Problem statement using NANDA, Etiology, Signs/Symptoms
3. Rationale (Pathophysiology) (Complete, Appropriate, Relevant, based on

Evidence, Related)
• Model:
Precipitating Factors / Predisposing Factors / Risk Factors
Biological/physiological, Psychological, Socio-cultural, Spiritual Factors that contribute to the
health-illness condition
Initial signs/symptoms (actual: describe level of severity)
Initial means of coping initiated (describe briefly)
Biological/physiological, psychological, social-cultural, spiritual progression of condition

(with REFERENCES)
Adaptation status
(brief statement if initial coping efforts were successful or not)
Aggravation of signs and symptoms (describe events leading to hospitalization and the severity of
s/s manifested)
NANDA diagnostic statement
101
4. Planning (Complete, Appropriate, Relevant, based on Evidence, Related)
• Prioritizing identified problems
• Determining goals of care
a. Should be:
i. Specific, measurable, attainable, realistic, within time frame
ii. Should be directed towards the improvement of patient’s
signs/symptoms, attainment of patient’s need or resolution of
patient’s health-illness related concern
• Setting outcomes criteria
• Model
Time frame
Goal statements (paraphrasing the identified NANDA problem statement into its
improved condition)
As evidenced by: (enumeration of improved version of signs and symptoms

indicated in nursing diagnosis as outcomes of care)
5. Implementation (Complete, Appropriate, Relevant, based on Evidence,

Related)
• Categorize care interventions using the AMETHODIST Model
• Indicate all collaborative interventions (those prescribed by the attending
physicians, dietitians and other members of the heath team involved in
providing care to the patient)
• Care with interventions relevant and appropriate for the client’ condition
a. A – assessment-, monitoring-related
b. M – medications-related
c. E – exercise-, sleep-, rest-, environment modification-related
d. T – treatment-, diagnostic procedures-, safety and comfort-related
e. H – hygiene-, self care-related
f. O – outpatient follow up-, referral-, consultations- and discharge
planning- related
g. D – diet-related
h. I – inspiring-, motivating-, emotional support-related
i. S – spirituality / Sexuality-related
j. T – teaching/health education-related
6. Justification (Complete, Appropriate, Relevant, based on Evidence, Related)

• Rationale of each action or intervention with references
102
7. Evaluation (Complete, Appropriate, Relevant, based on Evidence, Related)
• evaluate goal achievement after every shift or as often as needed
a. check if outcomes are achieved
b. revise care plan if needed
c. check and validate accuracy of assessment data
d. check if nursing diagnosis is correct and complete
e. check if outcomes are specific, measurable, attainable, realistic, within
time frame
f. check if nursing interventions are appropriate
103
Appendix H
Enhanced NCP M odel
104
105
106
Appendix I
School’s NCP Model
107
Appendx J
NURSING CARE PLAN EVALUATION CRITERIA
Nursing History Criteria Yes No

1. Nursing history is obtained
2. Information is complete
Physical Examination Criteria
1. Physical examination is done
2. Information is complete
Assessment Criteria
1. Data clustered represent evidence of problems or risks for problems
2. Signs observed complement and validate the symptoms verbalized by
the client
3. Data describing client’s symptoms are specific and have measurable
descriptors
4. Data describing client’s signs are specific and have measurable
descriptors
5 Signs and symptoms or needs expressed by the patient are adequate to
come up with nursing diagnosis (5 or more combined for actual or risk
problems; at least 3 if client is to be discharged or is improved)
Nursing Diagnosis Criteria

1. Nursing diagnoses are appropriately prioritized
2. Problem statement is based on NANDA Taxonomy
3. Nursing diagnosis correspond to the actual, potential or risk problems
of the patient
4. Related factors caused or contributed to the change in health status or
problem
5. Signs and symptoms supporting the nursing diagnosis are consistent
with assessment findings
Rationale Criteria
1. Predisposing, precipitating, risks factors identified represented
biological, psychological, socio-cultural, or spiritual dimensions of the
patient
2. Predisposing, precipitating, risks factors identified are consistent with
the history of the patient
3. The effects of biological, psychological, socio-cultural, or spiritual
dysfunction to the client are appropriately explained
4. Signs and symptoms manifested are consistent with the biological,
psychological, socio-cultural, or spiritual dysfunction happening to the
client
108
Yes No
5. Initial actions undertaken by the patient to address his health problems
were appropriately identified
6. Outcomes of the initial actions undertaken by the patient is
appropriately described whether improving or deteriorating
7. Dysfunctional process ends up with the appropriate nursing diagnosis
Planning Criteria
1. Existing problems are prioritized according to urgency of need or
concern
2. Goals have reasonable time frame
3. Goal statement reflect an improvement of the problem identified
4. Outcomes criteria reflect an improvement of the signs and symptoms
5. Overall plan are related to the problem identified
Implementation Criteria
1. All collaborative nursing interventions directly help attain the outcome
criteria
2. All independent nursing interventions directly help attain the outcome
criteria
3. Assessment-, monitoring-related activities are provided, relevant, and
applicable
4. Medications-related interventions are provided, relevant, and
applicable
5. Exercise, rest, sleep, environment modification-related interventions
are provided, relevant, and applicable
6. Treatment, laboratory, safety & comfort-related interventions are
provided, relevant, and applicable
7. Hygiene and self-care-related interventions are provided, relevant, and
applicable
8. Outpatient / follow-up consultations, referral-related interventions are
provided, relevant, and applicable
9. Diet-related interventions are provided, relevant, and applicable
10.Inspiring/motivating, psycho-emotional support-related interventions
are provided, relevant, and applicable
11.Spirituality/ sexuality-related interventions are provided, relevant, and
applicable
12.Teaching / Health education-related interventions are provided,
relevant, and applicable
109
Justification Criteria Yes No
1. All interventions have justifications
2. Justification or rationale of all interventions are accurate and explains
the relationship in helping the client’s condition
Evaluation Criteria
1. Daily end of shift evaluation of outcomes are documented
2. Evaluation statements are consistently related to the outcomes criteria
established
Punctuality Criteria
1. NCP is submitted promptly as prescribed by the clinical instructor
110
Appendix K
NURSING CARE PLAN SCORING RUBRIC

Interpretation of Extent of Application
Component Very Sufficient : Sufficient : Deficient : Very Deficient :
3 2 1 0
Nursing History Obtained full Obtained only Obtained only 1 Did not obtain
nursing history 8 to 15 of the to 7 of the nursing history
categories categories
Physical Conducted full Conducted Conducted only Did not conduct
Examination physical only 8 to 15 of 1 to 7 of the physical
examination the categories categories examination
Assessment Meets all criteria Meets at least Meets only 1 or Did not meet any
and more 3 or 4 criteria 2 criteria criteria or no
answer made
Diagnosis Meets all criteria Meets at least Meets only 1 or Did not meet any
answer made
Rationale Meets all criteria Meets at least Meets only 1 to Did not meet any
and more 4 to 6 criteria 3 criteria criteria or no
answer made
Planning Meets all criteria Meets at least Meets only 1 or Did not meet any
answer made
Implementation Meets all the Meets at least Meets at least 4 Meets 0 to 3
criteria and more 8 to 11 criteria to 7 criteria criteria
Justification Meets all criteria 1 criteria fully 1 criteria is Did not meet any
met; plus partially met criteria or no
the other and answer made
criteria is the other
partially met criteria is not
met
Evaluation Evaluation made Evaluations Evaluations No evaluation
and consistent made on some made on made
with all outcomes outcomes that outcomes not
set in outcomes were set and stated in
criteria. others not outcomes
included in criteria.
outcomes
criteria.
Evaluation done Evaluations Evaluation not
daily not done daily. done daily.
Punctuality Submits on time Late 1 day in Late 2 days in Late 3 days or did
stipulated submission submission not submit at all
111
Appendix L
NURSING CARE PLAN SCORING GUIDE
Raw Score Equivalent Raw Score Equivalent

24 100.00 12 70.71
23 96.53 11 69.82
22 93.06 10 68.93
21 89.58 9 68.04
20 86.11 8 67.14
19 82.64 7 66.25
18 79.17 6 65.36
17 75.69 5 64.46
16.8 75.00 4 63.57
16 74.29 3 62.68
15 73.39 2 61.79
14 72.50 1 60.89
13 71.61 0 60.00
112
Appendix M
I NTERVI EW GUI DE
Focus Group Discussion
1. Please tell us your objectives in participating in this study.

2. Please tell us what comes into your mind when you formulate nursing care
plan.
3. What aspects in the formulation of the nursing care plan do you find
difficulties?
4. What is your concept of nursing care plan?
5. What more must you know in formulating nursing care plan?
6. How was the nursing care plan taught, applied, corrected and evaluated in the
classroom and clinical area?
Key Informants: USLS Nursing Alumni:
1. What are the difficulties you encountered in the formulation of nursing care
plan?
2. Why do you consider these as difficulties?
3. What specific difficulty can you cite and give example?
4. Does this difficulty happen every time you formulate NCP?
Key Informants: USLS Clinical Instructors
1. What are your thoughts on the nursing care plans formulated by the students?
2. How do you correct the nursing care plans?
113
CURRI CULUM VI TAE
JOEL GONZALES PATALAGSA

Block 59 Lot 31, San Dionisio Subdivision
Brgy. Granada, Bacolod City
Philippines 6100
Mobile phone #: +0966565121977
E-mail Address: jpatalagsa@ksu.edu.sa
jgpatalagsa@hotmail.com
EDUCATI ONAL BACK GROUND
Graduate School : Doctor of Philosophy in Nursing, May 2011

University of St. La Salle – Bacolod City
Dissertation : “Nursing Care Plan: Based on Nursing Students’
Clinical Experience”
Master in Nursing, May 2007

University of St. La Salle – Bacolod
Project Paper “The Relationship of Length and Status of Employment
to Patient Safety Perception, Knowledge, Awareness,
and Practices among Nurses”
College Bachelor of Science in Nursing

Graduated March, 1981
University of San Carlos – Cebu City
LI CENSURE EXAM I NATI ON
Passed Philippine Nurse Licensure Examination held May - June

1981
SCH OLASTI C H ONORS / AW ARDS RECEI VED
M eritorious Teaching Award AY 2005-2006

AY 2006-2007
AY 2008-2009
AY 2009-2010
W ith High H onors PhD in Nursing Class 2011
Academic Excellence Award Master in Nursing Class 2007
Clinical Excellence Bachelor of Science in Nursing Class 1981
114
W ORK I NG EXPERI ENCES
December 2012—Present Assistant Professor

College of Nursing
King Saud University
Riyadh, Kingdom of Saudi Arabia
June 2011—December 2012 Academic Consultant

Academic Advising
Research Advising
Research Review
Free Lance
Bacolod City, Philippines
June 2004—June 2011 Assistant Professor

College of Nursing
University of St. La Salle
Bacolod City, Philippines
1998 – 2002 Distributor Account Manager

Reckitt Benckiser (Phils.)
Western Visayas, Philippines
1997 – 1998 District Sales Supervisor

First Choice Food Corporation
Mindanao, Philippines
1994 – 1997 Sales Supervisor

VGL Distributors Corporation
Visayas, Philippines
1982 – 1993 Sales Representative

Zuellig Pharma Corporation
Visayas, Philippines
ACTI VE PROFESSI ONAL AND COM M UNI TY I NVOLVEM ENT
• Philippine Nurses Association, Negros Occidental Chapter, Lifetime Member

• Philippine Nursing Research Society, Member
• Beta Nu Delta Nursing Society, Member
• Beta Nu Delta Institutional Review Board, Member-Reviewer
• Beta Nu Delta Nursing Society – Negros Chapter, Consultant
115
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Chapter 2 REVI EW OF RELATED LI TERATURE 17

Chapter 3 M ETH ODOLOGY 31

Chapter 4 PRESENTATI ON, ANALYSI S AND 38

Chapter 5 SUM M ARY OF FI NDI NGS, CONCLUSI ONS AND 82

“Quality challenges facing nursing education are always changing...”

Indeed change has implications in every dimension of man’s existence

Statement of the Problem

Vygotsky’s Sociocultural Theory of Development

Commission on H igher Education (CHED) M emorandum 14, Series of 2009

Significance of the Study

REVI EW OF RELATED LI TERATURE

Framework of the Nursing Education in the Philippines

Participants of the Study

Rubric Scores I nterpretation

Research problem number 4, to determine the perceived difficulties

Validity of the Research I nstrument

Reliability of the Research I nstrument

Statistical Tool and Treatment of the Data

Data Gathering Procedure

PRESENTATI ON, ANALYSI S AND I NTERPRETATI ON OF DATA

On the Nursing Students’ Understanding of the Concept of Nursing Care Plan

B. Components of the Nursing Care Plan

Nursing History and Physical Examination

Planning / Desired Outcomes

Average Rubric Score 1.83 Suffi- 1.83 Suffi-

Interventions need to be drawn specifically in order to address the outcomes

On the significant interaction between the effects of gender and NAT/CSAT

Corrected Model 32.505a 5 6.501 17.870 .002 .937

Intercept 63079.350 1 63079.350 173394.159 .000 1.000

Gender .594 1 .594 1.633 .248 .214

NATCSATGrouping 30.003 2 15.002 41.237 .000 .932

Gender * 1.908 2 .954 2.622 .152 .466

Error 2.183 6 .364

Corrected Total 34.688 11

a. R Squared = .937 (Adjusted R Squared = .885)

On the Perceived Difficulties Encountered by the Nursing Students in the

A. NCP Component: Assessment

B. NCP Component: Nursing Diagnosis

After data collection is organized, analyzed, and summarized, the nurse

C. NCP Emphasis: Varied Approaches

As a whole, the general difficulties extracted from the various experiences of

During 1st year: (CHED M emo 14, 2009)

à Follow guidelines/criteria set à Some corrections were made without

On How the Proposed Enhanced M odel Addressed I ssues and Concerns

M edications Administer Calvit BID; Administer meds as ordered

E xercise, Stress need for Limit excessive moving and

I nspiring/ Not provided -Motivate the client to

Nursing Care Plan Scores Per Component Per Session

On the significant interaction between the effects of gender and NAT/CSAT

This chapter presents the summary of findings, conclusions and recommendations.

Alfaro-LeFevre, R. (2002). Applying nursing process: Promoting collaborative care

SAM PLE APPROV AL SH EET

GRADUATE SCH OOL OF NURSI NG

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