Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

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6. Evaluate the outcome. 7. Reflect and learn.

Assessing (Chapter 15) is based on sound knowledge of what is normal and what is abnormal, and involves the sys- tematic collection of data and the use of intuition to decide what data to collect. Identifying health problems (Chapter 16) involves skills in interpretation, analysis and inference, as well as a well- developed self-awareness that enables the identification of biases and reduces erroneous assumptions. Planning care (Chapter 17) involves clinical judgement and decision making, as well as identification of the appropri- ate level of engagement, and incorporating creative solutions to problems. Implementing care (Chapter 18) is dependent on knowl- edge of best practice, and on decision making that is informed by legal and ethical standards of practice. Evaluating care (Chapter 19) also requires skills in analysis and inference. The final chapter in Unit 3, Chapter 20, discusses documen- tation , which involves the communication and explanation of decision making and actions undertaken. The common thread running through each of the interre- lated components in the process of care is the need for active clinical reasoning through the analysis of information or data, the application of knowledge gained through education and experience, and the recognition of the influences that we each bring to the situation. Thoughtful practice should occur throughout the process of care, and requires all the compo- nents of clinical reasoning. EVALUATION AND REFLECTION In practice, clinical reasoning, problem solving and decision making do not always occur in a linear fashion because prac- tice does not take place in the controlled environment of the laboratory, but in real life. Once the clinician has recognised that there is a problem, the available information must be processed by thinking critically, creatively and intuitively, a judgement reached, a decision made and an action taken, or not. Then the action needs to be evaluated: did the decision and the action taken resolve the problem? Reflection on the decision, the action and the outcome may be short and sharp, occurring at the same time, or may occur later when the sit- uation may allow for deeper reflection. The complete process is often cyclical in nature; once you have completed the process, you often go back to the beginning and repeat the process again until the problem has been resolved. Contemporary clinical practice has become extremely complex. Clinicians may be caring for a number of signifi- cantly ill people at any given time, and will be confronted with a range of situations that require clinical reasoning, judgement and decision making. In a normal shift, a clini- cian may be required to make a decision every minute (Bucknall, 2000). Not every decision is followed by an action, as this might not be necessary. The clinician may be involved in many of these cycles in any shift and make countless decisions and take numerous actions. In addition,

Revisit Table 14-2 and create a new, more detailed, table merging the information in Table 14-2 with this summary of the steps required for thoughtful practice. Although the actions taken following a judgement and decision may be diverse and complex, they are not disorgan- ised or unstructured. The actions may be described through an organised series of steps called the process of care, as follows. PROCESS OF CARE The next component of thoughtful practice, as shown in Figure 14-1, is the series of actions known as the process of care . (See Figure U3-1 for how person-centred processes of care fit within the model of thoughtful practice.) This term refers to the way in which care is organised through a series of actions undertaken in response to the individual needs of the person. Although each care encounter, or clinical situa- tion, is different, clinicians need a structured approach to developing these processes. It is in the processes of care that your skills in clinical reasoning and judgement are enacted in a person-centred way, through a series of actions that meet the needs of the person while preserving their humanity. Figure 14-2 illustrates the process of care diagrammati- cally. It is important to be cognisant of the fact that the real world is complex and sometimes chaotic, and does not always conform to a diagram. Despite this, Figure 14-2 does allow for an understanding of the interrelated components that constitute the process of care. Each of the components of the process of care, as illus- trated in Figure 14-2, is linked to steps within the clinical reasoning process, and is described in one of the chapters in Unit 3, as follows.

Assessing

Identifying health problems

Evaluating care

Implementing care

Planning care

Figure 14-2 Process of care