Abstracts

UPDATING ARTICLE

Nursing process: difficulties for its utilization in practice^* Corresponding Author: Emilia Campos de Carvalho Av. Bandeirantes, 3.900 - Monte Alegre Ribeirão Preto - SP - Cep: 14040-902 E-mail: ecdcava@usp.br

Proceso de enfermería: resultados y consecuencias de la utilización para la práctica de enfermería

Emilia Campos de Carvalho^I; Luciana Kusumota^II

^IFull Professor of Ribeirão Preto Nursing College, Universidade de São Paulo - USP - Ribeirão Preto (SP), Brazil

^IIPhD Professor of Ribeirão Preto Nursing College, Universidade de São Paulo - USP - Ribeirão Preto (SP), Brazil

^{Corresponding Author} Corresponding Author: Emilia Campos de Carvalho Av. Bandeirantes, 3.900 - Monte Alegre Ribeirão Preto - SP - Cep: 14040-902 E-mail: ecdcava@usp.br

ABSTRACT

This paper discusses the main difficulties for the utilization of the nursing process in practice, especially those activities regarding the development and use of clinical reasoning. It also discusses nursing conquests and challenges in the use of this method in providing quality nursing care and its relationship with new trends in health care.

Keywords: Nursing process; Nursing care; Health

RESUMEN

El presente relato señala las principales dificultades para el uso del proceso de enfermería, en especial de aquellas vinculadas a la elaboración y modelos del raciocinio clínico. Muestra, aun, las conquistas y desafíos para la práctica de enfermería en el uso de este método de cuidar y sus relaciones con las nuevas tendencias de la asistencia a la salud.

Descriptores: Proceso de enfermería; Atención de enfermería; Salud

INTRODUCTION

The changes in nursing practice are associated to methodological and philosophical assumptions, besides the ethical and legal aspects that are involved with the profession, as well as the available scientific knowledge. In this context the Nursing Process should be considered as an option.

The Nursing Process (NP), whose purpose is providing an approach to identify the clients, family and community's needs and implement the necessary care according to the situation identified⁽¹⁾ has been denominated, in our environment, by distinct terms, the most common of which is Nursing Healthcare Systematization ( Sistematização da Assistência de Enfermagem -SAE ), differing from the North-American literature⁽²⁾.

Its usage is considered an essential nurse attribution^(3-5); however, factors inherent to the nursing process structure itself, its stages teaching, the healthcare practice characteristics and scenarios, and finally, professionals' abilities and competences regarding their usage⁽²⁾.

As a consequence, clinical disagreements occur, resulting in healthcare insufficient quality and damages to the professional autonomy⁽⁶⁾. Clinical disagreements are understood as divergences between the real situation and the professional's inference regarding the patients' situation, due to a range of factors.

The literature⁽⁷⁾ points out the disagreements related to the examiner (as their characteristics, the sensorial capacity variation, the tendency of registering inferences instead of evidences, expectations establishment prior to the process and the restrict competence) to the examined subject (biological variations, disease or therapy effects, memory and attention focus, and disagreements among examiners/tests) and exams/data collection (inappropriate environment, hindered interaction between examiner and the examined subject, and diagnosis instruments misusage or hindered usage), and finally, the disagreements related to the diagnosis process itself (nursing specificity influence; complexity of the diagnosis process; diagnosis categories influence, besides having to deal with the responsibility and other group's expectation towards the diagnosis).

It also warns that the errors in the diagnosis process vary, they can be: omission (when relevant data are ignored), by premature conclusion (the diagnosis cannot be justified by the existing data), by incorrect synthesis (data available are contrary to the conclusions) and by inadequate synthesis (conclusions that may be supported by the data are not extracted)⁽⁸⁾.

It is important to consider that the clinical disagreements are also related to the therapeutic process and the expected results⁽⁶⁾. In order to minimize them, professionals should consider that the intervention selection has to be directed towards the individual with a certain diagnosis (and not to the diagnosis itself), that it is influenced by the patient's condition, resources availability, costs and team experience; they should also consider the intervention objective and the final healthcare goal, which depends on the professional's experience.

During the NP different development stages, professionals may use different techniques, instruments and methods to obtain data.

Considering their interest in finding out the patient's clinical state, identifying a clinical evidence, or even correctly using the available material to obtain it and record data, the result originated from such initial stage may or may not lead to correct interpretations, that is, accurate, observing the possible errors among the ones above mentioned (Illustration 1).

In order to analyze data professionals use, depending on their proficiency level and clinical experience, different methods for the diagnosis reasoning^(9-14): a pattern recognition, or the inductive reasoning (comparison), usually employed by professionals with vast experience in a certain field; the decision trees model, or the driven knowledge (algorithm), such as, for instance, the activities to be developed during an emergency situation where the healthcare professional follows guidelines depending on the presence or absence of certain evidences; the hypothetical-deductive method, also called the preliminary hypothesis generation or information processing (pre-hypothesis); the method of exhaustion or reasoning and knowledge integration, such as, for instance, the RISNER⁽¹⁵⁾ model, considerably employed in graduation studies.

The clinical reasoning path through the subsequent stages can equally be either performed appropriately, correctly, and coherently, or subjected to biases, which will lead to results different from what was expected (Illustration 1).

RESULTS AND CONSEQUENCES OF ITS UTILIZATION FOR THE PRACTICE

Some strategies⁽²⁾ potentialized the NP usage in Brazil; among them, the most important ones are: the informatics utilization within the practice scenarios; better work conditions for the nursing team; better remuneration; permanent education processes adoption by the healthcare providing institutions; the existence of legislation providing for the mandatory usage of either NP or SAE; the healthcare quality control movement, which developed NP result indicators;

Moreover, the outcomes of numberless researches on the dynamics and cognitive processes were involved in the nursing process development, the healthcare models available in the literature and the movement towards the usage of Taxonomies or Classifications of the Nursing Phenomena (North-American Nursing Diagnosis Association - NANDA), Nursing Intervention Classification (NIC)⁽¹⁷⁾, Nursing Outcomes Classification (NOC), International Classification for Nursing Practices (ICNP)⁽¹⁹⁾ among others; having its usage divulged in different healthcare scenarios^(20-24).

It is relevant to mention the important role the task force created by the Associação Brasileira de Enfermagem (Brazilian Nursing Association) had divulging ICNP⁽¹⁹⁾ and searching for terms to be included in such classification, related to Collective Healthcare, denominated, in our environment, Classificação Internacional das Práticas em Saúde Coletiva - CIPE-SC Project^(22,25-26).

However, in spite of all achievements obtained and perspectives broadened, a question comes up: is Nursing prepared to the new healthcare model being consolidated?

The healthcare sector has experienced the change from the model focused on the disease to a management model which considers the individual with a disease, their participation in the diagnosis and therapeutic process, and values the quality of the healthcare provided⁽²⁷⁾.

Some events are leading the hospital healthcare to deal with high complexity at the same time the residential healthcare has increased, as well as the precocious prevention and detection, de-hospitalization, the usage of hospital/day, among other strategies that favor the healthcare assistance out of the hospital⁽²⁸⁾.

Along with this movement, changes in the user/healthcare providing institutions relationship can be perceived, where marketing precepts applied to healthcare are valued⁽²⁹⁾.

In this sense, the literature has pointed out the concept of magnetic institution, where the stimulating work environment, pleasant to professionals, with more productivity, a better healthcare assistance quality, retains the competent professionals and consequently reduces the team turnover^(30-31). In this scenario, the patients, professionals, and institutions win (Illustration 2).

CHALLENGES TO NURSING AND THE NURSING PROCESS USAGE

Nursing, when searching for the excellence expected and the healthcare model in development, aiming to become and be recognized as a magnetic institution, still faces several challenges, from which we highlight: nursing team members development and capacitation to recognize and develop the NP⁽²⁾; instruments usage, valid and reliable methods and procedures in order to obtain data from patients and clients; accurate therapeutic and diagnosis clinic reasoning development⁽¹⁰⁾; overcoming barriers so that research results are implemented in practice⁽³²⁾; selecting the best interventions based in clinic evidence outcomes^(23,33); adopting terminology so as to identify the nursing phenomena, favoring the development of guidelines supported by research results^(23-24,34); using electronic results and other information and communication technology usage⁽³⁵⁾, besides preparing teaching institutions for technological capacitation^(36-37).

FINAL CONSIDERATIONS

Transforming the present challenges into success involves more than the nurses' individual will. A project has to be developed so that the goal can be reached. To do so, politicians, institutions and different teams' will and involvement are vital.

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* Lecture presented at the XIV Congresso Brasileiro de Enfermagem em Nefrologia and I Simpósio Internacional de Enfermagem em Nefrologia - Curitiba (PR), 2008.

3. Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei nº 7498, de 25 de junho de 1986. Dispõe sobre a regulamentação do exercício da enfermagem, e dá outras providências. Diário Oficial da União, Brasília (DF). 1986; Seção 1 de 25 de junho.

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