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A study on Methods to organize the Nursing process
for Daily management
Hirotsugu TAKAHASHI1 Masahiko MUNECHIKA2<Masaaki KANEKO3
1Waseda University, >
2Waseda University, >
3Waseda University, >
Abstract
Due to the several errors that have occurred in medical institutions in recent years, concern about the quality of healthcare is increasing. Therefore, it is very important for medical institutions to ensure a high quality of nursing service, which plays a role in supporting many patients who have been hospitalized.
Therefore, it is important to structure the daily management of nursing services for their continuous improvement. Further, it is necessary to structure and visualize the actual business process in terms of appropriate units.
However, due to the complexity of nursing, there is no definite method of structuring and visualizing the nursing process. Therefore, no method for daily management in the nursing process has yet been defined. In this study, a method for structuring this process for daily management has been proposed, which was obtained by interviewing to nurses and performing a bibliographic survey. The nursing process is visualized as a process flowchart by the structure proposed in this study. This flowchart enables verification of the present operating standards and provides an opportunity for its improvement.
Furthermore, determining medical indicators and devising a method for effectively managing the nursing process have been considered using a process flowchart for structuring the method of daily management. Based on the results, a methodology for the daily management of nursing in medical institutions is developed.
Key word: Daily Management, Nursing Care, Medical Indicator, Process Flow chart
1. Introduction
Nursing support is provided to patients staying at the hospital, and it plays an important role in healthcare services. Therefore, it is important for medical institutions to ensure a high quality of nursing care. At the same time, the method for managing the actual business process is important, and it is necessary to structure and visualize this in terms of appropriate units.
However, day-to-day nursing care includes various activities such as assistance to doctors and cares aimed livelihood support for patients. Since the daily management of the nursing process is difficult, no method for structuring it has been established thus far.
This study aims to structure the daily management of the nursing process to realize continual improvement of nursing care. Daily nursing practice includes nursing care, and the activities that require nurses to make a decision and manage on their own accord comprise the nursing process.
2. The Issues involved in Visualizing the Nursing Process
For the daily management of the nursing process, it is necessary to visualize the actual activities involved in nursing. Visualizing the process of nursing is difficult due to its complexity, and it presents the following issues.
1. The distribution of the functions between the nursing process and the diagnosis and treatment process is undecided.
The nursing process was defined as mentioned above. Doctors manage activities related to the diagnosis and treatment process. However, the daily role of nursing care involves various activities, and some of these activities overlap with those of diagnosis and treatment. Therefore, it is difficult to precisely define the nursing process.
2. Units structuring the nursing process have not been clearly defined.
Literature for nursing describes various activities involved in nursing care. However, these activities have not been classified and hierarchized appropriately. For instance, although aspiration prevention and help with eating are described as nursing activities in literature, they are not properly structured. From the above information, it can be observed that the units structuring the nursing process have not been clearly defined.
3. It is difficult to visualize complicated nursing activities.
In general, business processes in the industry are static. However, nursing care depends on the patient’s condition, which is dynamic and changes with time. Therefore, nursing care is provided as required, and the activities involved are very complicated. As a result, it is difficult to visualize the nursing process reflecting the complicated activities involved.
In this study, the issues mentioned above are considered to obtain solutions to structure the nursing process. The solutions to these issues are discussed in the third chapter.
3. Structuring the Nursing Process
3.1 Consideration of Method to Structure the Nursing Process
The nursing process is structured in this study and visualized using the following process flowchart describing the business process.
(1) Identifying and Classifying Various Activities Involved in Nursing Care to Resolve Issue 1
Issue 1 rendered it difficult to define the nursing process. Therefore, nursing cares are determined cyclopaedically by bibliographic survey. Further, based on the nurses’ opinions, the identified activities are classified into 2 types: the nursing process and the diagnosis and treatment process. Table 1 enlists some activities belonging to the 2 process types.
Table 1. Classification of Nursing Care
(2) Decision of Units for Structuring the Nursing Process
The business process of nursing flow is comprehended to structure the nursing process. Therefore, the general structure of the nursing process was elucidated by obtaining the nurses’ opinions and performing a bibliographic survey. Based on the results, it was determined that the nursing process can be divided in the following 4 phases defined as PDCA (Plan-Do-Check-Act): formulating a nursing care plan, providing care, evaluating the plan, and modifying it. Furthermore, the “providing care” phase contains various activities; therefore, it would not be effective to manage this phase at the same hierarchy as the other phases described above. Therefore, PDCA can be viewed as an outline of the nursing process and is defined as the first hierarchy of this process.
Then, the method to structure the nursing process for providing care is considered. The nursing activities described in literature have not been classified and hierarchized appropriately, so the units structuring the nursing process have not been defined. Therefore, the activities in the nursing process classified in point (1) are further classified according to the type of care provided, for example, helping a patient walk (using a walker, stick, etc.), move using a wheelchair, and walk by stretcher are classified into the same category, i.e., help with moving and walking. Further, preventing aspiration is considered to be in the category of help the patients eat, and it is not considered as a separate activity. Therefore, preventing aspiration is categorized under helping the patients eat, and the other activities are defined similarly. The activities classified as mentioned above are defined as the second hierarchy of the nursing process. Thus, 14 processes were classified into the second hierarchy.
Procedures that were categorized under each of the processes of the second hierarchy were classified into the third hierarchy. Thus, the nursing process was structured using 3 hierarchies. Table 2 shows some details regarding this process.
Table 2. The 3 Hierarchies of the Nursing Process
The entire structure of the nursing process is shown in Table 2, which is visualized as a process flow chart. Thus, the process flow chart is used to describe the nursing process in the units shown in Table 2, which enables its visualization.
Moreover, it is necessary to show not only the units but also the activities described in the process flow chart. Therefore, the activities that constitute the flowchart in each hierarchy are organized according to the following items: the nursing phase, admission, formulating the nursing care plan, providing care, evaluating the plan, modifying the plan, and discharge. Table 3 shows some details regarding this process.
Table 3.Activities Constituting the Nursing Process
The activities described in the process chart for each hierarchy are enlisted in Table 3. Table 3 is used to describe the nursing process structured using 3 hierarchies as a process flow chart.
(3) Consideration of the Method to Describe the Process Flow chart Reflecting Patient conditions.
Nursing care depends on the patient condition, which is dynamic and changes with time. Therefore, it is difficult to describe the process flowchart of the nursing process as a static flow. Although the flow of a process flowchart is fundamentally described using arrows, the flow of the nursing process investigated in this study is described independently as event-driven activities. Further, conditions activating event-driven activities are used to describe the process flow chart, which reflects the complicated activities involved in nursing.
3.2 Format of the Nursing Process Flowchart
It is necessary to consider the format of the nursing process-flow-chart. Therefore, the items, 4W (who, when, where, and what), information, clinical instruments, documents, and medical indicators related to each process are collected from a daily management perspective, by referring to the QC process chart in industry and the format proposed by SHIMONO[16].In addition, the conditions activating event-driven activities are taken in the format as described in point (3). Figure 1 presents a detailed flowchart of this process.
Figure 1 Format of the Nursing Process Flowchart
The daily standard of operating, which is ambiguous, can be objectively investigated to describe the process flow chart in the format shown in Figure 1. Since the resource in each process can be organized, it becomes easy to specify a process using a problem and its causative factor and link the process to an improvement. Furthermore, since details such as the conditions of activating event-driven activities are indicated, it can also be used for educational purposes, such as for training junior or new nurses.
3.3 Description of the Nursing Process Flow chart
According to the method described in the previous section, the nursing process flow chart was described using 3 hierarchies. A part of the result is shown in Figure 2.
Figure 2 The Nursing Process Flow chart Described in 3 Hierarchies
Figure 2 shows 3 hierarchies of the nursing process flow chart: the second hierarchy describes the process flow chart of the category “help with cleaning” and the third hierarchy describes the process flowchart of the category “bed and bath.” At the first hierarchy, a nursing care plan is devised for patients who were hospitalized, and care is provided according to this plan, which constitutes the second hierarchy of the process flowchart. As described in Section 3.1 (3), these are activated driven by events; therefore, these activities are described in the form of a base. The process flow chart for the category “help with cleaning” is selected in Figure 2 (thick lines).
Furthermore, activities such as “bed and bath” and help with taking bath exist in the process flow chart under “help with cleaning” category in the second hierarchy. Therefore, activities are selected according to the patient conditions, and the process structure moves to the third hierarchy, i.e., the operating procedure (dotted lines). Further, the process structure is assessed and modified after providing care at the first hierarchy, and a modified nursing care plan is devised again.
4. Verification of the Validity of the Process Flow chart Proposed in this Study
4.1 Verification of the Description Possibility by the Process Flow chart Proposed in this Study
It is necessary to verify whether it is possible to describe activities of the nursing process by using the process flow chart proposed in this study. In order to verify whether the daily activities that are currently performed can be described by the flowchart, job analysis was carried out in hospital A. In this analysis, the time taken to perform the activities, the content of the activities, and the care provided to the patients were recorded in minutes for 5 days by focusing on the activities performed by 1 nurse. Further, it was investigated whether these activities could correspond to the nursing process flowchart (Table 2) devised in this study and to the list of nursing activities (Table 3). A part of the result is shown in Table 4.
Table 4 Results of the Job Analysis
The investigation revealed that all activities could be described, except for the activities involved in the diagnosis and treatment process, those that have not been properly defined, clerical jobs, and job rotation. Clerical jobs do not correspond to other nursing activities because the process flowchart proposed in this study describes the nursing care provided to individual patients. However, all care provided to a patient can be described; this is sufficient to ensure a high quality of nursing care for patients. Thus, the process flow chart proposed in this study exhaustively describes the nursing process.
4.2 Verification of the Improvement Effect by Application in a Hospital
In order to verify the improvement effect of the proposed method, the method was applied to hospital B, and the nursing process flow chart was described in 6 wards. The process flow charts requested for description included the first and second hierarchies: help with cleaning, help with eating, and swallowing instruction and training. The result of the application is shown in Table 5.
Table 5 Results obtained by application
Table 5 reveals that certain points of the standard are indefinite. For example, in hospital A, reappraisal for fall prevention was not performed in many wards. When the Ns in hospital B were evaluated, it was found that no reappraisal standard was established in hospital B. Since a patient condition is dynamic, it is necessary to act accordingly. In other words, since proper care is not provided according to the patient condition, it is considered that as the method of providing care may pose problems.
Further, in hospital L, it was found that the instruction and training manual for swallowing was not available. For instruction and training for swallowing, it is required that suitable tests, instructions, and training be provided according to the swallowing ability of the patient. Moreover, in order to ensure the quality of nursing, it is essential to standardize and document such methods.
As mentioned above, the absence of important documents and processes could be checked by describing a process flow chart. Although improvements are necessary by actually defining a medical indicator, it is considered possible to connect to an operating improvement by visualizing the nursing process by the proposed method. Therefore, the process flow chart proposed in this study is considered to be appropriate from the viewpoint of an improvement in operations.