Review Article, J Nurs Patient Care Vol: 2 Issue: 1
Application of the Nursing Process, a study from the Students' Experience
Jara-Sanabria F* and Lizano-Perez A
University of Costa Rica, USA
Received: November 10, 2016 Accepted: February 01, 2017 Published: February 08, 2017
Citation: Jara-Sanabria F, Lizano-Perez A (2017) Application of the Nursing Process, a study from the Students’ Experience. J Nurs Patient Care 2:1.doi: 10.4172/2573-4571.1000110
The Nursing Attention Process is a method of caregiving that employs scientific fundaments. Its use promotes reflexive assistance, critical thinking and is a primary source of autonomy in the profession, it is also linked to professional development in the education context. Nevertheless, there isn’t enough evidence in Costa Rica to establish the characteristics of its application. Thus, a phenomenological qualitative study was conducted which proposed 1. To determine the meaning given by nursing students at the University of Costa Rica to the method's application. 2. To distinguish the manner in which it was being used. To do this, documents and interviews of a sample of 5th year nursing students were analysed. The results show that the way the method was conducted differed between participants and the meaning given to its use was related to three categories: knowledge, experience and teaching. In this study the meaning given to the implementation experiences and the way to use it as well as the difficulties with its use were understood. However, to understand the phenomenon in depth in Costa Rica, it is considered essential to continue with the exploration of the subject.
Keywords: Nursing attention process; Costa Rica; Article review; Qualitative research; Nursing education research
The Nursing Attention Process (PAE in Spanish) is 5 phase (assessment, diagnosis, planning, implementation and evaluation) systemized method, which is employed since the mid-twentieth century is used to organize caregiving scientifically [1,2]. Authors like Hagos et al.  and Shelile  give an integrative character between theory and practice that promotes professional development, improving the skills of problem solving and decision making and increasing the quality of service provided.
Despite all its benefits, Bayindir ; Pecina ; and Unsal et al.  have shown that frequent use is interpreted as routinary caregiving actions; it is incomplete or omitted and presents implementation difficulties, especially in the diagnostic phase. Can et al. ; and Carpenito  link these findings to the lack of disciplinary taxonomies, low level of quality in the universities, emphasis on the discussion of medical diagnoses, lack of knowledge and skills related to previous PAE experiences, little motivation, excessive number of assignments in the health services, emphasis on administrative tasks and hospital routine.
As in many other geographic areas, the PAE has an important place for nursing in Costa Rica, so much that its use is regulated by the 7085 law, it is the subject of discussion for national policy in Nursing (College of Nurses of Costa Rica, 1987, 2011) and is used as an educational and evaluative strategy by the School of Nursing at the University of Costa Rica (EEUCR) . However, the country studies on the subject are old and scarce, so it is unknown the use that it is being given.
In order to provide evidence to the topic a phenomenological qualitative study, based on ontological contributions of the philosopher Martin Heidegger, aimed to determine the meaning given by nursing students from the UCR to the implementation of the PAE and distinguish the manner in which it was being used.
The research was approved by the scientific ethics committee and had the collaboration of twenty three 5th year Nursing students (5 males and 18 females) during 2014. This was chosen by complete sampling, the entire population could participate in the study, however only 38% of the students gave their consent. At the time of the investigation, participants were enrolled in the nursing intervention with the mayor adulthood module, where they performed community and hospital practice with this population and developed a weekly task of research in the process of health of a user and proposed a care plan.
During the 1st semester of 2014 these documents were requested to the participants, as well as a self-assessment of their PAE implementation. In total 26 groups of documents (3 were discarded because they were incomplete), were analysed based on Berman et al.,  Hernández ; Coneição et al. ; Herdman  and Johnson et al. . Then in the 2nd semester, phenomenological interviews were coordinated, in which a 9 open ended questions guide (previously accepted by the counsellors of the study) was used.
13 interviews were conducted in total, of which saturation theoretical saturation was obtained. All of them were conducted in the university campus, were recorded on audio and had an average duration of 49 minutes. Transana 2.60 Demonstration was available for transcriptions and the analysis was based on the Gibbs  methodology which proposes open and axial coding. Finally, information was triangulated between data, theories and researchers, in order to assess the validity of analysis results.
Results and Discussion
Regarding the research tasks, it was found that the theories and conceptual models were only mentioned, partially, in 8 of the 23 documents, specifically, only Dorothea Orem, Imogene King and Marjory Gordon proposals were included. In the assessment, the information that was the most repeated was the pathological and pharmacological treatment history of the individual. Regarding care plans on average, each student proposed five diagnoses, corresponding to pathophysiological descriptions or mixtures with standardized languages: “Loss of skin integrity and development of trophic lesions associated with decreased sensitivity due to diabetic neuropathy and self-care deficit in impaired health”.
Regards the planning, the actions were headed towards the individual or family and towards rehabilitation, health promotion and disease prevention. However, in most cases there was no linkage with diagnostics and in other cases, it only accounted for hospital routines: “Mobilization assistance. Railings kept in adequate height. Chair fastening. “The evaluation showed limited use of standardized criteria, students wrote down what they expected to observe after the intervention or left the box with blank.
Lastly, the study of the self-reports, showed that some students had a positive assessment of the PAE, while others didn’t. However, all participants said they postponed or dispensed their actions due to time constraints, workload, the level of interaction with the family and the hospital resources. Through this section differences were evident in the execution of the nursing process phases, the importance that participants granted to certain information over another; and the existing disorientation to establish professional judgments.
Now, there were 3 thematic units extracted from the interviews: knowledge, experiences and teachings. The first one showed that in the early career year, participants had vague conceptions and stereotypes about nursing and its method, however, these ideas were modified through education and university experiences, increasing their technical and analytical skills “The whole picture opened to me, I realized that it’s not merely caring, but through knowledge acquisition one gets, situations can be improved” But still expressed permanency of doubts in the use of diagnostic and evaluative phases.
Throughout the experiences, participants expressed that in the first academic years, the application of the method was reduced, they couldn’t find purpose, and it focused on the practice of specialized techniques and restricted the development of care plans. “The teacher told us, in small groups, the structure of the plan, no process as such ... the idea has been just that, make a plan”. However, over the years and incorporating different teaching strategies, such as use of concept maps or additional readings, the use of the PAE changed considerably, making participants feel safe and in the need of its use.
Participants also mentioned the experiences obtained through the incorporation to working environments (community and hospital) where university practices were performed. They could perceive that in health services there were no facilities to apply the method, for example, they generally had high workloads, a system centered on the curative model, omission of the use of disciplinary theories; and few opportunities for analysis and critical discussion.
Therefore, they concluded that there are tangible conditions that interfere with the PAE and produce the loss of autonomy in the practice “... the Caregiving that is done is not directly due to those needs identified by the nurse through that process, but that of the doctor’s telling thirty degrees header, value saturation, sit on chair and that kind of stuff, they are said because another professional says so”.
Finally, the thematic unit neither of teaching, showed that participants considered that during the early years of career, teachers did not explain or offered nor in depth or enough literature to understand the PAE. However, in the last three semesters of career and, by the incorporation of strategies such as conceptual maps, PAE implementation guides and greater teacher support, they began to feel more confident and satisfied with the application. “...You can see the growth that has taken place, compared the first plan drafted, it is very different from the plans and the entire display that one makes now”. Despite the progress, they did not rule out that some educational approaches continue to be heterogeneous and there are doubts that remain about the method, specifically in the diagnostic and assessment phases [16,17].
Through the results it became clear that the application of the PAE differed among students, since the data to which each of them gave emphasis, the registration form, the model of diagnostic classification and the use of theories and conceptual models was not homogeneous. These findings were similar to those in the investigations by Pecina  and Unsal et al.  in which a pathophysiological approach to practice, work routine and laziness and motivation had weakened the systemic implementation of the PAE. Furthermore, it was also found that in these studies the participants had difficulty expressing diagnostic statements and linking all phases of the PAE.
As well in the narrative, there was a perceived advancement in the understanding and use of the method, which produced feelings of security and satisfaction. Research such as Bayindir et al. ; Can et al.  and Shelile  found that the PAE is conceived as a tool that promotes professional development, especially if its use is frequent and has teaching accompaniment. However, the diversity of teacher evaluation criteria or little bibliographical support caused them difficulty in the integration of theoretical and practical knowledge, adoption of knowledge systems of other professions or inconvenience for the development of critical thinking aspects that participants shared in the early years of career.
Through this research, it was possible to understand how the participants used the method, the conceptions of it and the difficulties encountered in implementing it, highlighting various criteria of application. This element, as well as putting in risk the caregiving continuity, reduces the institutional impact of nursing. While the study led to many findings, the understanding of the phenomenon in Costa Rica requires more research, for example the exploration of the reasons why the use of international taxonomies in education and health Services is disposed, as well as the understanding of the phenomenon in community settings or studies with quantitative approaches.
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