1. No audio. Recording preparation.
Health IT Workforce Curriculum Version 4.0

2. The Culture of Health Care
Nursing Care Processes
Welcome The Culture of Health Care: Nursing Care Processes. This is Lecture b.
The component, The Culture of Health Care, addresses job expectations in health care settings. It discusses how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.
Lecture b
This material (Comp 2 Unit 6) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC This material was updated in 2016 by Bellevue College under Award Number 90WT0002.
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit

3. Nursing Care Processes Learning Objectives
Describe what nurses do and how they are trained (Lecture a).
Discuss the role of certified nursing assistants (Lecture a).
Describe how nurses make clinical decisions and assess patients (Lecture b).
Identify the settings where nurses work (Lectures a, c).
Discuss the procedures that nurses perform (Lecture c).
Identify nursing career opportunities. including those not involved with direct patient care (Lectures a, b, c).
By the end of this unit, Nursing Care Processes, students will be able to:
Describe what nurses do and how they are trained
Discuss the role of certified nursing assistants
Describe how nurses make clinical decisions and assess patients
Identify the settings where nurses work
Discuss the procedures that nurses perform
Identify nursing career opportunities, including those not involved with direct patient care

4. The Nursing Process, Clinical Judgment, and Assessing the Patient
This lecture covers
The nursing process, including clinical judgment
Nurses and legal expectations
Nurses and societal expectations
How nurses help improve patient care
This lecture discusses the nursing process, including how nurses use clinical judgment and assess the patient. This lecture also discusses how nurses meet legal and societal expectations and the roles that nurses can play in improving patient care.

5. Clinical Judgment A skill that helps nurses assess and treat patients
Includes
Gathering health information by asking questions, examining the patient, and other means
Learning about other issues that affect the patient, such as cultural values
Used in the nursing process
Clinical judgment is a skill that nurses and other health care providers use to learn what health problems a patient has. Nurses also rely on clinical judgment in deciding how to manage those problems.
When a nurse first works with a patient, he or she might not have much information about what is wrong. The nurse can find out what is wrong by observing the patient, asking questions of the patient or the patient’s family, looking at the patient’s chart, examining the patient, and interpreting all of this information.
A nurse’s clinical judgment does not depend only on technical and scientific skills, however. The nurse also relies on his or her perceptions and gathers non-health information. For example, the nurse might need to learn how the patient and the patient’s family feel about the health problem, what their social situation is, what their coping skills are like, and what their cultural values are.
Nurses use clinical judgment as part of the nursing process, which is a systematic way of treating patients. The nursing process is explained later in this lecture. 5

6. Factors That Affect Clinical Judgment
Clinical judgment is influenced by the nurse’s education, experience, values, and other issues
Clinical judgment might reflect a nurse’s biases or prejudices
Clinical judgment is not based entirely on facts. A nurse’s clinical judgment skills also reflect his or her own education, personal knowledge, experience, values, politics, and perspective.
For example, a nurse’s knowledge of a particular patient can affect decision making. The nurse might know that a patient responds poorly to certain types of treatment. The nurse might also know how other patients have responded to certain treatments, and he or she might base patient care decisions on this knowledge.
Unfortunately, a nurse might also draw on personal biases or prejudices when making decisions about patient care. 6

7. The Role of Intuition in Clinical Judgment
Cognitive continuum theory: All judgments include both intuition and analysis
Intuition = “gut feeling” or insight
Analysis = study or reasoning
Nurses sometimes use intuition in making judgments
Nurses are more likely to use intuition in stressful situations
The cognitive continuum [COG-nih-tiv con-TIN-u-um] theory states that all judgments are based on a combination of both intuition and analysis. Intuition means a gut feeling or insight that is not based on facts. Analysis in health care means careful reasoning about all patient information to determine the nature of the illness and what the next steps should be.
Nurses do sometimes use intuition to make decisions about patient care. Research shows that nurses’ decisions tend to be more intuitive when they are under time pressure and are dealing with situations that are complicated and unclear. Conversely, nurses’ decisions tend to be more analytical when they are dealing with situations that are structured and clear.
Even if a nurse uses more intuition than analysis to make a clinical decision, he or she needs to be able to explain the reason for the decision. 7

8. Evidence-Based Decision Making
A type of decision making that uses research, the nurse’s knowledge and experience, and patient preferences
Often used when giving patients medication or providing acute care
For other clinical decisions, nurses often prefer talking to colleagues
Evidence-based decision making emphasizes the utilization of scientifically proven diagnostic and treatment methods for patient care. However, the decision-making process needs to allow for the nurse’s knowledge and experience and the patient’s preferences.
Researchers have found that nurses are most likely to look up published research data when they need to give medication or provide acute care. They also keep up with new research through continuing education courses.
For help with many clinical decisions, however, nurses prefer talking to nursing colleagues or other health care professionals. 8

9. The Role of Critical Thinking in Clinical Judgment
Focuses on accurate, reasonable, and fair solutions to problems
Helps nurses avoid bias
Improves with reflection
To make effective decisions, nurses must think about a problem thoroughly and try to find an accurate, reasonable, and fair solution. This type of thinking is called critical thinking. One of the goals of critical thinking is to avoid biases, stereotypes, and prejudices.
The patient benefits when a nurse uses critical thinking to make a clinical decision. Ideally, the nurse looks carefully at the problem and the context of the problem, considers his or her own biases, and considers several possible treatment options.
Critical thinking skills improve when a nurse reflects on whether or not a decision had a good outcome. Nurses who take the time to analyze their own decision-making can make better decisions in the future. 9

10. Examples of Clinical Decisions
A nurse modifies breastfeeding recommendations to improve a patient’s well-being
A nurse chooses an intervention that is least likely to harm a hospitalized infant
Many nurses make a wide variety of clinical decisions every day. For example, in one case, a new mother was exhausted as a result of breastfeeding and felt guilty that she could not keep up with the guidelines she had been given. Her nurse shortened the recommended time that the mother should breastfeed. This nurse decided that improving the mother’s well-being was more important than adhering to the hospital’s breastfeeding guidelines.
A nurse might also use clinical decision-making skills to choose between several different options for patient care. For example, a researcher documented a situation in which a nurse had to respond to a breathing problem in a hospitalized newborn. The nurse chose a type of intervention that was least likely to interfere with recent surgery the infant had undergone. 10

11. Five-Step Nursing Process
All nurses follow a system called the nursing process when they are working with patients. Nurses use clinical judgment skills throughout the nursing process in order to create the best possible outcome for each patient.
The nursing process is a holistic system that treats both the problem and the patient. It allows the nurse to evaluate both the immediate health problem and the context of the problem, such as how the health problem affects the patient and the patient’s family. The nursing process has five steps: assessing the patient, diagnosing the problem, creating a plan of care, implementing the plan, and evaluating how well the plan works. The following slides explain each step of the process.
The nurse must document all steps of the nursing process in the plan of care so that other health care providers who care for the patient can then follow the plan. The plan of care can also be used to evaluate how well treatment is working.
6.1 Chart: By Vivian Todhunter and CAST, CC-BY

12. Assessing Assessment can include Asking questions
Looking at physiologic data (shows how the patient’s body is functioning)
Examining the patient
Putting the problem in context
Checking the patient’s and family’s educational needs
To assess a patient, the nurse asks questions, observes the patient, and examines the patient as needed.
A nurse asks the patient, or the patient’s family, about the history of the health problem. The nurse also looks at physiologic [fiz-zee-o-lah-jick] data, which shows how a patient’s body is functioning, through test results on the patient’s chart or through a physical exam.
In the assessment, the nurse also considers the context of the problem. This can include the patient’s attitude and behaviors as well as the patient’s or the family’s cultural beliefs, spiritual beliefs, lifestyle, and financial resources. The nurse also considers the patient and/or the patient’s family needs for education about a relevant health topic. 12

13. Diagnosing The diagnosis considers
Current health problems
Current non-health problems
Risk of future health problems
Possible link to a larger syndrome
Unlike a medical diagnosis of disease, a nursing diagnosis can change as the patient’s response changes
The nurse then develops a nursing diagnosis. She or he considers the health problems that need to be addressed and any non-health issues that could affect treatment. The nurse also needs to think about, and plan for, the patient’s risk of other health problems and whether the patient’s current health problem is part of a larger syndrome.
Nursing diagnoses usually differ from medical diagnoses. A medical diagnosis, which refers to a disease, is made only by a physician, advanced practice nurse, or physician assistant. In contrast, a nursing diagnosis describes a patient’s physical, sociocultural, psychological, and spiritual response to an illness or potential health problem. For as long as a disease is present, the medical diagnosis never changes, but a nursing diagnosis evolves as the patient’s responses change.
Some examples of nursing diagnoses are anxiety, confusion, diarrhea, fatigue, hopelessness, impaired parenting, and risk of violence. 13

14. Planning The plan of care can include
Prioritizing problems
Setting short-term goals
Setting long-term goals
The plan is discussed with the patient and other health care team members
The nurse makes sure resources are available
The next step in the nursing process is to develop a plan of care for the patient.
If the patient has several health problems, the nurse prioritizes them, treating the most urgent problem first.
Next, the nurse works with the patient or the patient’s family to set measurable short-term and long-term health goals. These goals help the patient manage, resolve, or prevent health problems. If the patient is healthy, the nurse might work with the patient to set wellness goals, such as losing excess weight.
Then the nurse decides how to help the patient meet these goals. The nurse discusses the plan of care with other health care team members and with the patient. The nurse also makes sure that all the necessary resources are available to carry out this plan. 14

15. Implementing Implementation needs to involve the patient
The nurse might help, teach, counsel, or monitor the patient
The nurse records how the plan is working
After the plan is created, the nurse may work with other caregivers and other health care providers to implement the plan. To make the plan as successful as possible, the patient and/or the patient’s family are included in the implementation.
The nurse might do a variety of tasks to implement the plan. For example, the nurse might directly help the patient, teach or counsel the patient or the patient’s family, or monitor how well the patient is doing. The nurse also records how well the plan is working. 15

16. Evaluating The plan of care might be changed if Evaluation is ongoing
The patient’s health changes
Resources change
Evaluation is ongoing
Many things can change after the nurse implements the plan of care.
There might be a change in the patient. For example, the patient might respond better or worse than expected to treatment.
Even if the plan is working well for the patient, resources might change for the nurse and other health care providers. For example, staff changes might affect how the treatment plan is carried out.
The nurse conducts an ongoing evaluation of how well the plan of care is working, and he or she changes the plan as needed. 16

17. Societal Expectations of Nurses
Nurses are seen as caring, nurturing, and self-sacrificing
Nurses need to follow protocols and regulations and to stay up to date in their specialty
Traditionally, Western society has viewed nurses as caring, nurturing, and self-sacrificing. In the past, nursing was often provided by religious orders, and it was sometimes even seen as spiritual. Although nurses receive training in science and technical skills today, they are still expected to be compassionate and nurturing. These traits help nurses respond well to patient needs.
Nurses are now expected to do more than provide compassionate care. They need to follow protocols, standards of care, and regulations; use technology; and stay updated on new developments in their area of specialty. 17

18. Legal Issues: Informed Consent and Patient Privacy
Informed consent: Patient needs to understand the risks and benefits of any diagnostic or treatment procedure
Patient privacy: Under the law known as HIPAA, health care providers must keep the patient’s health information private
Like other health care providers, nurses need to understand their legal responsibilities. Five important legal issues for nurses are informed consent, patient privacy, documentation, dosing, and reporting.
Before caring for a patient, in most cases the nurse must make sure that the patient understands the planned treatment and its risks and benefits. If possible, the patient should sign a document showing that he or she has provided informed consent for the treatment.
Nurses, along with other health care providers, also must protect the privacy of a patient’s health records. The Health Insurance Portability and Accountability Act of 1996, or HIPAA [hip-uh], states that providers may share a patient’s health information only with people who are authorized to see it. The nurse may be involved with working with the patient in signing various HIPAA forms. 18

19. Legal Issues: Documentation, Dosing, and Reporting
Nurses must document all care provided
Nurses must administer medications correctly
Right drug
Right patient
Right dose
Right time
Right route (oral, rectal, injection, etc.)
Nurses must report any abuse allegations to authorities
Nurses also need to adequately document all the care that they give to a patient. This documentation creates a legal record, so it needs to be clear, objective, and thorough.
Medication errors cause hundreds of thousands of deaths and injuries in the United States every year, and nurses and their employers can be held liable. Nurses are expected to give the right drug to the right patient, at the right dose, at the right time, and by the right route.
If a patient shares that he or she, or that someone else, was abused, nurses are legally obligated to report this information to the appropriate authorities. For example, a patient might make an allegation of domestic abuse, child abuse, or sexual abuse. 19

20. The Nurse’s Role in Quality Improvement
Nurses can serve many roles in improving healthcare:
Develop standards of care
Participate in institutional reviews
Report medication errors
Because most nurses interact often with patients, they often have experience and insights that can enable them to help improve the quality of health care. Nurses can develop standards of care for institutions or help measure the quality of care that patients receive. For example, nurses might help an institution review patient charts, interview patients about their care, and observe interactions between health care providers and patients to measure the quality of patient care.
Many institutional accrediting and licensing agencies also look at the rate of medication errors when rating an institution. Researchers have found that medication errors are often caused by poor systems and poor communication within hospitals and other organizations. By reporting medication errors, nurses can help remedy such problems and protect patients. 20

21. Nursing Care Processes Summary – Lecture b
In making clinical judgments, nurses rely on two types of information:
Objective (based on facts)
Subjective (based on the patient’s inner experiences)
Clinical judgment is used by nurses in the five-step nursing process
Nurses also help protect patients’ legal rights and improve patient care
This concludes Lecture b of Nursing Care Processes. In summary, nurses use clinical judgment to make the best decisions about patient care. Clinical judgment takes into account both facts, such as a patient’s blood pressure and pulse, and more subjective information, such as a patient’s coping skills or cultural needs.
Nurses use their clinical judgment skills when following the five-step nursing process for treating patients. The nursing process includes assessing the patient, diagnosing the problem, creating a plan of care, implementing the plan of care, and evaluating the plan of care.
Along with providing patient care, nurses can play important roles in protecting patients’ legal rights and improving patient care.

22. Nursing Care Processes References – Lecture b
American Nurses Association. (2016). The nursing process. Retrieved from
Auerbach, D. I., Staiger, D. O., Muench, U., & Buerhaus, P. I. (2013). The nursing workforce in an era of health care reform. New England Journal of Medicine, 368(16), Retrieved from
Ballantyne, H. (2016). Developing nursing care plans. Nursing Standard, 30(26), 51-60
Barker, J., Linsley, P., & Trueman, I. (2016). Clinical Judgement and Decision Making. Evidence-based Practice for Nurses and Healthcare Professionals, 45.
Critical Thinking Community. (2013). Critical thinking: Where to begin. Retrieved from
George, T. P. (2013). How nurses can encourage shared decision making. Nursing2015, 43(8), 65-66
Kieft, R. A., de Brouwer, B. B., Francke, A. L., & Delnoij, D. M. (2014). How nurses and their work environment affect patient experiences of the quality of care: a qualitative study. BMC health services research, 14(1), 249. Retrieved from
Mayo, A. M, & Duncan D. (2004). Nurse perceptions of medication errors: What we need to know for patient safety. Journal of Nursing Care Quarterly,19(3), 209–217. Retrieved from
Nursing Degrees.com. (2016). Nursing legal issues: How to protect yourself. Retrieved from
No audio.

23. Nursing Care Processes References – Lecture b Continued
Phaneuf, M. (2008). Clinical judgement: An essential tool in the nursing profession. Retrieved from
RNCentral.com. (2016). What is a nursing care plan and why is it needed? Retrieved from
Robert, R.R., Tilley, D.S., and Petersen, S. (2014). A power in clinical nursing practice: concept analysis on nursing intuition. MedSurg Nursing Sept.-Oct. 343+
State of Connecticut Department of Developmental Services. (2009). Nursing standard: Nursing process #NS Retrieved from
Tanner, C. A. (2006). Thinking like a nurse: a research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204–211. Retrieved from
Thompson, C., Cullum, N., McCaughan, D., Sheldon, T., & Raynor, P. (2004). Nurses, information use, and clinical decision making--The real world potential for evidence-based decisions in nursing. Evidence Based Nursing, 7, 68–72. Retrieved from
No audio.
Charts
6.1 Chart: By Vivian Todhunter and CAST, CC-BY. 23

24. The Culture of Health Care Nursing Care Processes Lecture b
This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC This material was updated in 2016 by Bellevue College under Award Number 90WT0002.
No audio.
Health IT Workforce Curriculum Version 4.0