Jansson Inger, Pilhammar Ewa, Forsberg Anna
School of Social and Health Sciences, Halmstad University, Halmstad, Sweden.
Open Nurs J. 2009 Aug 31;3:56-64. doi: 10.2174/1874434600903010056.
The nursing process can be viewed as a problem-solving model, but we do not know whether use of the whole process including care plans with interventions based on nursing diagnoses improves nurses' ability to carry out assessments. Therefore, the aim of this study was to illuminate and describe the assessment and decision-making process performed by nurses who formulated individual care plans including nursing diagnosis, goals and interventions or who used standardized care plans when a patient was admitted to their ward for care, and those who did not. Data collection and analysis were carried out by means of Grounded theory. Nurses were observed while assessing patients, after which they were interviewed. The main concern of all nurses was to obtain a foundation for nursing care based on four strategies; building pre-understanding, creating a caring environment, collecting information on symptoms and signs and performing an analysis from different perspectives. It appeared that the most important aspect for nurses who did not employ care plans was the medical reason for the patient's admission. The nurses who employed care plans discussed their decisions in terms of nursing problems, needs and risks. The results indicate that nurses who formulated care plans were more aware of their professional role.
护理程序可被视为一种解决问题的模式，但我们并不清楚运用包括基于护理诊断的干预措施的护理计划在内的整个程序是否能提高护士进行评估的能力。因此，本研究的目的是阐明并描述当患者因护理入住病房时，制定包括护理诊断、目标和干预措施的个性化护理计划的护士或使用标准化护理计划的护士，以及未使用护理计划的护士所进行的评估和决策过程。采用扎根理论进行数据收集和分析。在护士评估患者时对其进行观察，之后对他们进行访谈。所有护士的主要关注点是基于四种策略为护理奠定基础；建立预先理解、营造关怀环境、收集症状和体征信息以及从不同角度进行分析。似乎未采用护理计划的护士最重要的方面是患者入院的医学原因。采用护理计划的护士从护理问题、需求和风险方面讨论他们的决策。结果表明，制定护理计划的护士更清楚自己的专业角色。
