RESEARCH ARTICLES
Public university students' ease and/or difficulties in preparing nursing progress notes
Daniela Maack SilveiraI; Maria Cristina ChagasII; Silomar IlhaIII; Glaucia Dal Omo NicolaIV; Fabiani Weiss PereiraV
I
Nurse. Postgraduate Program in Nursing, Federal University of Rio Grande. Brazil. E-mail: dmaacksilveira@yahoo.com.br
II
Nurse. Master Degree, Postgraduate Program in Nursing of the Federal University of Rio Grande. Brazil. E-mail: maria25cris@yahoo.com.br
III
Nurse. Specialist in Urgency, Emergency and Trauma. Master Degree in Nursing and Ph.D. by the Postgraduate Program in Nursing of the Federal University of
Rio Grande. Scholar of Personnel Improvement Coordination of Higher Education/Social Demand Program. Rio Grande do Sul, Brazil. E-mail: silo_sm@hotmail.com
IV
Nurse. Master Degree in Nursing by the Postgraduate Program in Nursing of the Federal University of Rio Grande. Brazil. E-mail: glaucianicola@hotmail.com
V
Nurse. Master Degree, Postgraduate Program in Nursing of the Federal University of Rio Grande. Scholar of Personnel Improvement Coordination of Higher
Education/Social Demand Program. Rio Grande do Sul, Brazil. E-mail: enffabiweiss@hotmail.com
DOI: http://dx.doi.org/10.12957/reuerj.2015.7267
ABSTRACT
This qualitative, descriptive study to discover the factors that facilitate/hinder preparation of nursing progress notes by nursing undergraduates at a public university was conducted in April 2012 by means of a semi-structured questionnaire applied to 13 8th and 9th semester undergraduate nursing students at Rio Grande do Sul Federal University. From data analysis using thematic content analysis, three categories emerged: nursing progress notes, an instrument for communication and care; organization and optimization of time; and the undergraduate nursing teaching process. It was concluded that the teaching displayed divergences on record keeping, while lack of time and the absence of nursing staff record-keeping during practical activities hindered effective preparation of nursing progress notes.
Keywords: Nursing process, nursing students, nursing records; client progress.
INTRODUCTION
The nursing process (NP) stands out as a technology of care which directs the sequence of logical reasoning improving the quality of care through the systematic clinical evaluation, also serving as a foundation for education, research, and management. It must be used by nurses, because through it there is the possibility to organize and ensure the continuity of information of the nursing team, allowing to evaluate their efficiency and effectiveness 1. Also, the NP supports the inter-relationships between the subjects involved in taking care and care, setting up an alternative to reconnect the nurse of their clientele2.
The NP was introduced in Brazil in the 70s, by Wanda de Aguiar Horta, and consists of six phases: nursing history, nursing diagnosis, assistance plan, nursing prescription or care plan, nursing evolution and prognostic nursing3. Currently, the NP is organized into five interrelated and interdependent stages: nursing history, nursing diagnoses, nursing planning, implementation and nursing evaluation4.
Thus, it is relevant to explain the purpose of nursing records, because these are considered the referential of the nursing work process. Through it, is possible to ensure the communication between members of the healthcare team, and thus, ensure the continuity of the information for the various areas, favoring the teaching, research, verification of legal aspects and customer service warranty5. Also, it is known the importance of every stage of NP, especially Nursing Evolution (NE), which is the daily or journal report of successive changes that occur in humans, while under professional assistance3:67.
The NP teaching at the Federal University, where this research was developed, is part of the curriculum since the creation of the course. The theoretical framework is the model of Wanda Horta, which is based on the Theory of Basic Human Needs (TBHN). The NP was initially ministered in the discipline of Nursing Fundamentals, on the 3rd and 4th semester, and later came to be ministered in the Introduction to Nursing discipline. The discipline has a total workload of 45 hours ministered in three hours per week, and approximately 15 hours of practical activities. The current Political Pedagogical Project of the nursing course of the study institution has NP as one of the axes curriculum drivers, and its standardization in the disciplines of great concern of the Course Coordination and Nucleus Teaching Structuring6.
The nursing evolution suggested by the School of Nursing, where this research was developed, is based on the SOAP model - Subjective: Information provided by the patient or family as the main complaint and other information. Objective: factual and measurable data obtained during the examination, as the signs and symptoms observed, vital signs and laboratory results. Assessment: The conclusions based on subjective data and collected objectives and formulated as nursing diagnoses. Plan: Strategy to alleviate the problem of the patient. This plan should include short- and long-term actions6.
It is expected to contribute to the reorientation of nursing education and construction of new knowledge about the subject, in addition to indirectly benefit customers by providing them a better quality of care. This is the relevance of this study.
Thus, one wonders: which factors that facilitate/hinder the development of the nursing evolution for graduate students? In an attempt to answer this question, the objective of this study was to identify the factors that facilitate/hinder the development of the nursing evolution for graduate students of a public university.
LITERATURE REVIEW
The nursing process is the scientific basis that supports the nursing actions, being considered an orderly and systematic way of acting of the nurse to identify and address problems raised by the patients. Its implementation has the following advantages: facilitate data documentation, support the raising of problems and development of systematically nursing interventions, develops a common nursing language that facilitates communication with staff and develop evaluation means of care7.
The steps of the nursing process are: Nursing history - Is an essential phase for the occurrence of the success of the other phases. Data is collected through interviews, observation, and physical examination. Thus, the history of nursing results of objective and subjective information reported by the patient in the interview. It should be concise, without repetitions, allowing immediate care program8.
Nursing diagnosis - Consists in the interpretation and grouping of data collected in the first stage and culminating in the decision making about diagnostic concepts that will guide the planning and implementation of assistance. It represents, more accurately, the responses of a human individual or collective, at any given time of the health-disease process, and constitutes the basis for future actions (interventions) with the client, aiming to overcome the identified problems4.
Nursing planning - Consists in the overall determination of the results expected by the patient, and the specific nursing interventions determined by human needs, identified in the diagnostic step. This phase is performed through a daily routine of nurses that coordinates the actions of the team. Planning involves routing actions, supervision, guidance, support and implementation of nursing interventions/care, being the sum of all the actions developed by the nursing team in patient care3.
Implementation of nursing – It is the achievement of certain actions or interventions in the nursing planning stage4. During this phase, the nurse continues collecting data and validating the planning already done, since it is essential to update the information. The prescription of nursing is the daily routine that coordinates the action of the nursing staff in the care appropriate to meeting the basic and specific needs of the human being. The nursing prescription should be based on the priority care3.
Nursing assessment – It is a deliberate process, systematic and continuous of verification of changes in the person's, family or human community responses, at any given time of the health condition to determine if the actions or nursing interventions reached the expected result4. After the implementation of care, each step must be evaluated to determine if the diagnostic persists, if the goals have been met or are by the reality of the patient and if they are accepting the interventions being performed3.
METHODOLOGY
This is a descriptive research with qualitative approach9, conducted with 13 nursing graduate students from the 8th and 9th semester of the Undergraduate Course in Nursing of a the Federal University of Rio Grande do Sul, with eight graduate students of the 8th semester and five of the 9th semester.
The inclusion criteria of the study subjects were to be coursing the 8th or 9th semester of the Undergraduate Course in Nursing, being performing Supervised Internship I and II in medical units, surgical clinic, pediatrics, maternity or intensive care, in the month of April 2012.
It was decided to carry out the research with graduate students in 8th and 9th semester, because they were in the completion process of the course, and, with more experience regarding the application of NP, particularly the records of the nursing evolution. Thus, the nursing graduate students from 1st to 7th semester and those who for some reason were not conducting Supervised Internship I and II were excluded from the study.
Data collection occurred in April 2012, through a semi-structured questionnaire. At first, a structured questionnaire with open questions about the NP was distributed to the participants, and a collecting time was scheduled. In the second phase, the completed questionnaire was read along with the respondent, for its validation, as well as to answer questions and to deepen the answers.
Data were analyzed through Bardin10 content analysis, following the three steps of the method. First, we tried to make an exhaustive reading of the data, followed by the organization of the material and the formulation of hypotheses. In sequence, the exploration of the material was performed, i.e., it sought to encode gross data. In the third and final stage, the data were interpreted and the themes delimited by the understanding of emerging meanings of evidence.
The ethical and legal principles were considered involving research with human beings, according to Resolution nº 466/2012 of the Ministry of Health 11. It was previously distributed the Informed Consent to the research participants, in two vias, one to the participant and another to the researcher. It remained the anonymity of deponents, where they were identified by star names. The research project was approved by the Ethics and Research Committee in the Field of Health of the Federal University of Rio Grande (CEPAS/FURG), under number 188/2011.
RESULTS
The data analysis generated three categories - Nursing evolution: an instrument of communication and care; Organization and time appreciation; and NP Teaching at graduation.
Nursing evolution: an instrument of communication and care
According to the survey responses, the graduate students consider important the registration of Nursing Evolution in customer records. It is emphasized as an instrument of communication between health professionals and the nursing staff. This is where the professional registers all information concerning the care making visible their work and, above all providing opportunities for customer assessment and the determination of the chosen behavior, as the following statements.
The registration of nursing evolution is important for the next shift nurses can stay informed of what occurred during the shift. (Vega)
It facilitates communication [between health professionals] in different shifts [work]. (Spica)
It is through the development of nursing that we can record all care provided [by nursing], shows the actual work. (Alhena)
Despite knowing that the nursing evolution is an important instrument of communication and care, some graduate students report that the health team of the units does not value NP and little use medical records held by scholars coming to resist its implementation.
[...] Often the evolution of nursing will not be read by colleagues. (Sírius)
The resistance of professionals in realizing the developments [...] The evolution of nursing is always in a second stage. (Nunki)
Nursing records, when not made in the client's medical record, and do not constitute a legal document, prevent effective communication between staff as noted in the study site that still uses the traditional book of occurrences.
In the construction of the written record is not easy to sit down and develop a patient properly with a full nursing process, by the unit demand, then we just recorded the most relevant daily changes in a black notebook, and the changes are not made. (Capella)
Organization and time appreciation
Nursing graduate students perceive NE as an instrument of communication and care. However, eight of the thirteen study subjects reported difficulties in relation to time organization. Some mentioned not haveing time to evolve, and others believe that spend too much time with evolution, still referring to team unity devalues the time they use to make records, making them uncomfortable when executing them.
When I elaborate, my nursing developments are not complete for lack of time. We overload us of tasks, and there is a lack of time to make a good evolution. (Vega)
One difficulty is the development of the nursing evolution in a long time, I would like to develop in the shortest time. (Altair)
Facilitate [nursing staff] too little because it not yet become a practice for everyone. Thus, the difference who doe, causes discomfort for others. (Spica)
There is also the lack of priority on the part of the graduate students participating in this study, as shown in the following statement:
The difficulty is the demand of the unit and at the same time the desire to learn in a short space of time, which still do not feel safe as we would like, thus, ends up giving priority to other activities. (Capella)
PE teaching at graduation
When asked about the NP teaching, all graduate students reported that it facilitated the development of nursing evolution, providing subsidies for the construction of the records, on the other hand, many of them mentioned that there are differences among teachers about the achievement of the records, which hinders its implementation.
I feel safe elaborating nursing records after teaching and approach taught at the academy. (Nunki)
Each discipline that we pass, as well as each professional [teacher] taught their way to carry out the registration, and this ends up creating a mess in the development [of evolution]. (Nunki)
Only in the matter of each teacher demand in a different way, that makes learning difficult. (Polaris)
The perception of the graduate students of this study reiterates this question since they consider the different ways to approach as a difficulty. However, some highlight that the understanding of the NP takes place throughout the course, as is observed in the following statement:
In SAE discipline, the nursing diagnosis was unclear. I understand that at the sixth semester at gerontogeriatry discipline. (Adhara)
Despite considering that the NP teaching in the institution under study facilitated the development of nursing evolution, certain academics highlighted their difficulty in recording it, especially the subjective data.
I believe that the objective of the development would be an ease. The difficulty would be the subjective part because we have to pay attention to the patient's behavior compared to the accuracy of their answers. (Alhena)
My facilities are related to the care that I realize, all that I observe it becomes easier to register than what the patient reports. I have difficulties to develop and record the evolution when I have only the information spoken by the patient. (Adhara)
In the statements, it is not clear if the subjective aspects are more difficult to register because it was not sufficiently understood by graduating (difficulty in communication) or because they are more difficult to assess (difficulty in clinical reasoning).
DISCUSSION
The records performed by the nursing staff are intended to provide information about assistance provided to the client, ensuring the communication between members of the healthcare team, ensuring continuity and information update. They provide legal support and, therefore, security, since they are the only document that describes all the nursing actions with the client12. Studies show the hospital as a place of constant exchange of information and experiences through inter-relations, being communication an ideal tool for the effectiveness of services2-5.
In this sense, the nursing annotation is extremely important, because its absence may expose clients to risks, not ensuring the quality and appropriate assistance5. Research developed in the UK with 19 professors from a nursing school emphasizes the importance of research with students and teachers about the NP and the proper conduct of the nursing notes because the development of systematization of nursing care is possible through the records13.
The inadequacy and insufficient records could compromise customer service because they prevent that the right information is securely transmitted to other professionals, and stay invisible to the nursing before the law and other health team members14. A study carried out in a general ICU emphasizes that misinformation or barely registered can intervene negatively on customer recovery, and remit to the hypothesis that the care was not addressed in a comprehensive and individualized way5.
The subjects reported difficulties in making the NP due to the lack of time/long time spent in doing it, difficulting to do other activities. A study performed in the UK, with 19 teachers, showed that in practice, although the teachers emphasize and develop strategies for academic training for NP teaching, most nurses do not use it on their professional practice14.
In contrast to this study, a survey conducted in Bolivia showed that the NP is related to the motivation of workers and the headship of the institution, and also to the local university, making the suggested strategies take more direct action to operationalize NP, with the development of instruments, filling out forms for the initial evaluation of nursing, and changing teaching plans of the Undergraduate Course in Nursing15. In Brazil, there are several studies pointing to certain difficulties of care practice, as the incomplete development of NP, incomplete records, among others 5-16-17.
These difficulties can be attributed, among other factors, to the nurse's workload, showing the importance of reflection on this issue. The nurse, by daily workload, often not offers adequate attention to the client about the nursing notes, which is not justified, because the records are used to ensure that the care was conducted and as a legal document for customer and professional safety5. Also, it may be related to the lack of nurses' time to make the nursing records as a result of lack of priority of this task. Thus, they should seek alternatives that enable a qualified practice that is also marked by the quality of the recordings14.
The subjects of this study indicated that there are differences among teachers about the achievement of the records, which makes difficult such execution. In a survey performed by teachers from the same institution under study, one can realize that there is no uniformity in language, about the nursing process and its stages, including the approach to the subject, which causes difficulties both in teaching and in learning18.
Research performed in three Higher Education institutions in the city of João Pessoa/PB showed that despite the concern in the rescue of the binomial theory and practice, the free observation allowed to infer that there is a dissociation between what is learned in theory and what is observed in practice. Thus, teachers refer certain difficulty degree as to teaching, especially for the nursing diagnosis, due to the skills required to implement it. It further states that there is fragmentation in the construction of knowledge and dislocation in NP teaching, leading to difficulties in the perception of students in integrating the disciplines of the course about the teaching of this process2.
From this perspective, the appreciation of subjectivity depends on previous stimuli, such as the phenomena analysis for different looks, locating it in time and social context, seeking the most diverse relational factors, as well as possible future repercussions19. With critical thinking, the individual reveals conditions to exercise other mental operations such as analysis, synthesis, evaluation, interpretation, application and decision-making, indispensable to implement the NP7.
The full nursing records are considered one of the main indicators of quality of nursing care. Decision nº 115/2006 of the Nursing Regional Council of Rio Grande do Sul regulates the nursing records must be legible, complete, clear, concise, objective, timely and preceded by time and date12. The NP is a systematic and continuous process of verification of changes in the person's, family or human community responses, at any given time of the health and disease process, to determine if the actions or nursing interventions reached the expected result4.
CONCLUSION
This study is considered satisfactory because it was possible to identify that subjects value NP and recognize the importance of records for nursing and patient. It is reinforced that the NP provides organization of work, continuity of the provided care, to ensure more qualified assistance, allowing the visualization of nursing work and, therefore, increased professional recognition.
The subjects highlighted difficulties to prepare the nursing evolution in their practical activities, due to time, i.e., they reported that the unit of service demand makes it difficult to follow the evolution of patients in a fully way. Also, they mentioned discomfort before the nursing staff of the practice fields that do not use the NP records. The subjects showed the NP teaching as a facilitator in the development of nursing records, and which should be implemented by the initial series, but reported that there are differences among teachers about records which hinders its execution.
As a limitation of this study, the time to perform the research is emphasized, that needed to meet the deadline for completion, and thus, not all the data came to be categorized. The data do not sufficiently worked makes a gap for conducting other studies to deepen the same theme. The integration of this survey with other studies conducted with teachers, academics, nurses provides a basis for a research question that has been widely studied in the institution.
It is hoped that this work brings contributions to the NP teaching and academics, especially the end of the course trainees, spend to assume their role in the implementation of this process, arousing the interest and understanding of the nursing staff of practice fields for this technology.
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