DESCRIPTION

The Ohio Board of Nursing operates under Chapter 4723 of the Ohio Revised Code (4723 ORC), which provides the law regulating the practice of nursing in Ohio. The law specifies the scope of practice for both registered and licensed practical nurses. Rules (chapter 4723 of the Ohio Administrative Code or 4723 OAC) provide more structure for how the nurse is expected to carry out components of the law, including scope of practice. This study describes how the licensed nurse is expected to use nursing process and critical thinking to remain in adherence with law and rule.

OUTCOME
The learner will be able to describe how use of clinical judgment aligns with expectations cited in Ohio Board of Nursing Law and Rules (Category A).

1.6 contact hours of Law and Rules (Category A) will be awarded for successful completion of this independent study.

This independent study was developed by: Pamela S. Dickerson, PhD, RN-BC, FAAN. The author and planning committee members have declared no conflict of interest.

DISCLAIMER

This content is designed for educational purposes only, based on law and rule in effect on 10/1/18. This information is not designed for legal advice; please consult an appropriate attorney or organizational authority for legal questions. Please consult the Ohio Board of Nursing (OBN) website, www.nursing.ohio.gov, periodically for updates, and read the Board’s quarterly publication, Momentum, for additional information.

The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation (OBN-001-91) .

Expires 11/1/2020

DIRECTIONS

1. Please read the below article carefully.

2. Complete the post-test, evaluation form and the registration form.

The post-test will be reviewed. If a score of 70 percent or better is achieved, a certificate will be emailed to you. If a score of 70 percent is not achieved, a notification of the final score and instructions on how to take a second post-test will be emailed to you. We recommend that this independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be issued.

If you have any questions, please contact the Ohio Nurses Association’s CE department at info@ce4nurses.org.

STUDY

Introduction

The Ohio Board of Nursing operates under Chapter 4723 of the Ohio Revised Code (4723 ORC), which provides the law regulating the practice of nursing in Ohio. The law specifies the scope of practice for both registered and licensed practical nurses. Rules (chapter 4723 of the Ohio Administrative Code or 4723 OAC) provide more structure for how the nurse is expected to carry out components of the law, including scope of practice. This study describes how the licensed nurse is expected to use nursing process and clinical judgment to remain in adherence with law and rule.

Terminology

As used in law and rule (4723 ORC and 4723 OAC), the term “registered nurse” (RN) applies to a person who has completed the educational program for a registered nurse, has satisfactorily completed the licensure examination for the registered nurse, and is licensed in Ohio either by examination or by endorsement. Advanced practice registered nurses, while having an advanced scope of practice specified in law, are first and foremost registered nurses, so all laws and rules related to the registered nurse apply to advanced practice registered nurses.

As used in law and rule (4723 ORC and 4723 OAC) the term “licensed practical nurse” (LPN) applies to a person who has completed the educational program for a practical nurse, has satisfactorily completed the licensure examination for the practical nurse, and is licensed in Ohio either by examination or by endorsement. Note that some states use the title LVN (licensed vocational nurse). This is an equivalent licensure; just different terminology.

As used in law and rule (4723 ORC and 4723 OAC), the term “licensed nurse” applies to both registered and licensed practical nurses. Terminology used in this study will mirror that of law and rule.

Nursing law and rule refer to “patient” rather than client, resident, or other terms used in different settings, though the concept is that the nurse provides care for a person needing that care, regardless of what that person is called in various practice arenas. It is in the context of OBN law/rule that the term “patient” will be used in this study.

Scope of Practice

The scope of practice for both registered and licensed practical nurses is delineated in law (4723.01 ORC). Scope of practice provides the authority under which the RN and LPN provide care for patients in this state. Only by clearly understanding the defined scope of practice can the nurse have a framework for implementation of the nursing process and critical thinking skills.

The scope of practice for the registered nurse is encompassed in the following definition (4723.01 (B) ORC):

“Practice of nursing as a registered nurse” means providing to individuals and groups nursing care requiring specialized knowledge, judgment, and skill derived from the principles of biological, physical, behavioral, social, and nursing sciences. Such nursing care includes:

• Identifying patterns of human responses to actual or potential health problems amenable to a nursing regimen;
• Executing a nursing regimen through the selection, performance, management, and evaluation of nursing actions;
• Assessing health status for the purpose of providing nursing care;
• Providing health counseling and health teaching;
• Administering medications, treatments, and executing regimens authorized by an individual who is authorized to practice in this state and is acting within the course of the individual’s professional practice;
• Teaching, administering, supervising, delegating, and evaluating nursing practice”

The scope of practice for the licensed practical nurse is stated as follows (4723.01(F) ORC):

“The practice of nursing as a licensed practical nurse” means providing to individuals and groups nursing care requiring the application of basic knowledge of the biological, physical, behavioral, social, and nursing sciences at the direction of a registered nurse or any of the following who is authorized to practice in this state: a physician, physician assistant, dentist, podiatrist, optometrist, or chiropractor. Such nursing care includes:

• Observation, patient teaching, and care in a diversity of health care settings;
• Contributions to the planning, implementation, and evaluation of nursing;
• Administration of medications and treatments authorized by an individual who is authorized to practice in this state and is acting within the course of the individual’s professional practice on the condition that the licensed practical nurse is authorized under section 4723.17 of the Revised Code to administer medications;
• Administration to an adult of intravenous therapy authorized by an individual who is authorized to practice in this state and is acting within the course of the individual’s professional practice, on the condition that the licensed practical nurse is authorized under section 4723.18 or 4723.181of the Revised Code to perform intravenous therapy and performs intravenous therapy only in accordance with those sections;
• Delegation of nursing tasks as directed by a registered nurse;
• Teaching nursing tasks to licensed practical nurses and individuals to whom the licensed practical nurse is authorized to delegate nursing tasks as directed by a registered nurse.”

The scope of practice statements include important information about what the nurse is expected to do in the context of providing nursing care. A significant consideration is that law and rules regulating nursing practice are not facility or specialty specific – they apply to all nurses in any environment in which nursing care is delivered. Therefore, strong use of nursing process and clinical judgment skills in any setting will serve the purposes of protecting the license of the nurse and protecting the clients for whom he/she provides care.

Nursing Process

The steps of the nursing process are delineated in rule, specifically 4723-4-07 OAC for the registered nurse and 4723-4-08 OAC for the licensed practical nurse (http://codes.ohio.gov/oac/4723-4). Information about nursing process is part of the chapter which addresses standards of practice relative to registered nurse or licensed practical nurse. This chapter provides information about practice standards which are deemed to be “minimally acceptable” standards of safe and effective nursing practice. Remembering that the purpose of the Ohio Board of Nursing is to “actively safeguard the health of the public through the effective regulation of nursing care” (www.nursing.ohio.gov), these minimum standards are essential components of public protection in regard to nursing practice. There is not a choice, therefore, as to whether or not these rules should be followed; in order to protect the public, these minimum standards must be met.

Nursing Process for the Registered Nurse

In implementing the scope of practice as delineated in law, the registered nurse follows the rules regarding use of nursing process. These rules are found in 4723-4-07 OAC. The rule stipulates that the steps of the nursing process are cyclical in nature, not linear. In other words, it is not expected that the registered nurse will progress systematically through the five steps of the nursing process. As the patient’s condition changes, the focus of the nurse will change – implementation of a plan of care may be revised as new assessment data shows that the patient’s condition is getting better or worse.

The rule specifies that the registered nurse collaborates with the patient, family, significant others, and other members of the health care team in applying the steps of the nursing process. In other words, the nurse does not make decisions in a vacuum, but participates actively as a member of the team of people providing care and support for the client. This focus on team-based care is consistent with Institute of Medicine competencies identified as far back as 2003 and more current emphasis by the Interprofessional Education Collaborative (Hawkins, 2016) and the National Collaborative for Improving the Clinical Learning Environment (2018). Current evidence shows that team-based collaboration and effective communication are critical strategies to improve patient safety.

There is further stipulation in 4723-4-07 OAC that the registered nurse will use clinical judgment in applying the nursing process. The concept of clinical judgment will be explored later in this study.

For all steps of the nursing process, the rules state that the RN will complete the step in an “accurate and timely manner”. Accuracy is clear – accurate data should be collected from all sources, including the patient, the family, other members of the healthcare team, previous documentation, laboratory reports and results of testing, and any other resources appropriate to provide a clear picture of the patient’s status. The term “timely” is less clear – what is a timely assessment? This term is not defined in rule. What is considered timely in any given situation depends on the judgment of the nurse. There may be situations where waiting an hour to assess a patient is too long; there may be times when a once-a-shift assessment is adequate. Because this decision is based on the nurse’s judgment and analysis of evidence, the nurse should be able to provide support for his/her decision if needed. In other words, the nurse is accountable for the decision about how frequently assessments are needed for each individual patient. It is important to note that some facilities or nursing units have policies regarding how often assessments should be completed. These policies may be based on best practice standards, guidelines from professional associations, requirements of funding sources, or other criteria. The board of nursing does not regulate facilities or other employers of nurses. Rather, requirements of the board of nursing are based on minimally safe standards to be applied by the nurse to protect the patient. These rules must be followed, regardless of facility policy. Facility policy can be stricter than law or rule, but the nurse is, at a minimum, required to follow nursing law and rule.

As noted in rule, the steps of the nursing process for the RN include assessment, analysis and reporting, planning, implementation, and evaluation. Each step will be discussed individually here, though again it is important to remember that the steps of the process are implemented cyclically, not sequentially.

Assessment

Assessment means collection of data. This includes both subjective data (that which is told to the nurse by the patient, family member, or another source) and objective data (that which the nurse sees, hears, or smells, or otherwise observes or accesses through accepted testing methods. For example, the wife’s report that her husband is weak and tired all the time is subjective data, while the husband’s current blood pressure and hemoglobin/hematocrit levels are objective data.

Data may be collected from a variety of sources. Sometimes data are conflicting, and the nurse must seek clarification. The patient being seen in an emergency room may state that he follows his diabetic eating plan, though his wife states that he rarely does so. Both pieces of data are valid, from the perspective of the person sharing the information. The RN clarifies these two pieces of subjective data by asking the client questions such as “what is included in your eating plan?”, “what did you have for breakfast this morning?”, or “how do you decide what you’re going to order when you go to a restaurant?” Additional questions for both the patient and his wife will be valuable in helping the nurse collect data that will be most relevant to the subsequent development of a plan of care.

The registered nurse may seek assistance from other members of the healthcare team in collecting assessment data. The rule specifies that “the registered nurse may direct or delegate the performance of data collection”. These terms refer to other parts of nursing law/rule that define direction and delegation. Brief explanations are provided here; there are other independent studies that specifically addresses the processes of direction and delegation.

Direction is defined in rule as “communicating a plan of care to a licensed practical nurse” (4723-4-01(B)(6) OAC). The LPN has a license and is accountable for practicing under that license. However, the scope of practice for the LPN in law (4723-.01(F)) specifies that the LPN always practices upon receiving direction from a  registered nurse, physician, physician assistant, dentist, podiatrist, optometrist, or chiropractor. In other words, the LPN does not practice independently.

Imagine the scenario where Mr. Jones is being admitted to a medical-surgical nursing unit. He is reportedly in stable condition and is being admitted from home in preparation for hip replacement surgery. The RN knows that vital signs need to be obtained and general observations about Mr. Jones’ condition need to be determined. However, the RN is attending to a patient who is actively dying, and she is not able to see Mr. Jones right now. The RN can appropriately provide direction regarding the assessment of Mr. Jones to the LPN. The LPN, upon receiving this direction, can take Mr. Jones’ vital signs, collect other subjective and objective data about his condition, document those findings, and share information with the RN. If the findings of the LPN’s data collection indicate that Mr. Jones needs more in-depth assessment right away, the LPN shares that information with the directing RN, who can then decide whether she should leave her current patient to see Mr. Jones, find another RN to see Mr. Jones, or take any other action deemed appropriate.

Delegation is referred to in rule as “transfer of responsibility for the performance of a selected nursing task from a licensed nurse authorized to perform the task to an individual who does not otherwise have the authority to perform the task” (4723-13-01(B) OAC). The RN delegates to an unlicensed person, not another person with a license. This unlicensed person is referred to by different terms in different setting, but common terms are nurse aide, nursing assistant, patient care assistant, nursing technician, or patient care technician. These are all unlicensed individuals, regardless of whether they are “state-tested” or “certified”. Even though they have learned to perform various tasks associated with care of patients, they are not allowed to perform those tasks unless and until they receive delegation to do so from a person who (1) has the ability and authority to perform the task, and (2) has the authority to delegate the task. Note that the term here is “task”, not “care”. Unlicensed persons have the ability to perform tasks for which they have been deemed competent, but do not have the ability to provide nursing care. The ability to provide nursing care is limited to RNs and LPNs who have licenses and scopes of practice allowing them to do so.

In the above scenario where Mr. Jones is being admitted to the medical-surgical nursing unit, it could well be that both the RN and the LPN are busy with other important activities. The RN could delegate the task of taking Mr. Jones’ vital signs to the nursing assistant. This is a task which is delegable, the RN knows how to do the task and has the authority to delegate, and he knows that the aide has been checked off on her ability to take vital signs. It would not, however, be appropriate for the RN to tell the nursing assistant to “take a look at Mr. Jones and let me know if there is anything I should be concerned about”. While the LPN may receive direction to collect further assessment data, the nursing assistant does not have the knowledge, skill, ability, or authority to do so. The best way for the RN to delegate this vital sign collection task to the nursing assistant would be to say, “Please go to room 407 and take Mr. Jones’ temperature, respirations, pulse, and blood pressure. I’d appreciate your letting me know within 15 minutes what those are.” This provides clear information to the nursing assistant regarding the patient, the task, and the time frame. The nurse is not abdicating responsibility for assessment; he is wisely using available resources to help him collect the data necessary to form the basis for future steps in the nursing process.

The final step under assessment in the rules regarding nursing process is documentation of the collected data. There is no specification as to what data need to be documented, where the data need to be documented, or the time frame for the documentation. The RN is expected to use good judgment in making those decisions. Depending on the facility or unit and its procedures, documentation may be done in the patient’s computerized medical record, on a paper chart, on a flow sheet, or on another tool. The point is that data from the assessment must be documented, accessible to other members of the health care team, and able to be retrieved as needed.

Analysis and Reporting

The second step of the nursing process for the RN is analysis and reporting. The RN is expected to identify, organize, assimilate, and interpret relevant data; establish, accept, or modify a nursing diagnosis to be used as a basis for nursing interventions; and report collected data as necessary to other members of the health care team. It is important to note that this step in the nursing process is unique to the role of the registered nurse; the LPN nursing process steps do not include analysis.

Step one in the process is assessment, but assessment data is not helpful unless it is analyzed to determine the relevant pieces of data, how the pieces of data connect with one another, and what the data mean in relation to the individual patient. Identification, organization, and interpretation of data help the RN determine the significance of the data, who needs information about the data, and how the plan of care will be developed based on that data.

Nursing diagnoses are different from medical diagnoses. Nursing diagnosis, as defined in rule (4723-4-01(B)(8) OAC), means “the identification of a patient’s needs or problems which are amenable to nursing intervention”. There is no requirement in rule as to what format is used for stating a nursing diagnosis or where the nursing diagnosis is documented. A registered nurse who assesses an elderly patient with dementia and realizes that he is not aware he is in a hospital might note a risk for fall related to confusion. This is a nursing diagnosis, from which a plan can be developed to prevent falls and their associated injuries. Note that this diagnosis, because it stipulates the reason for the risk, will lead to a plan of care that is specific to this patient. Another patient might be at risk for falls related to dizziness with his low blood pressure; another might have a fall risk related to recent administration of narcotic analgesia. In each case, the plan of care will be different because the cause of the risk is different.

Reporting of health assessment data to other members of the healthcare team is the final part of the “analysis” section of the nursing process for RNs. Again, it is up to the discretion of the RN to determine what information should be shared, and with whom. A word of caution is important here – HIPAA specifically stipulates that healthcare providers have the responsibility to share information relevant to the provision of safe care. It is not the nurse’s job to withhold information or to arbitrarily decide what information to share and what to keep confidential. As long as the purpose of the sharing of information is to facilitate care of the patient, that sharing is consistent with both HIPAA regulations and Ohio Board of Nursing rules.

Planning

Rule 4723-4-07(A)(3) OAC states that the registered nurse, will, in an accurate and timely manner, (a) develop, establish, maintain, or modify the nursing plan of care consistent with current nursing science, including desired patient outcomes and nursing interventions; and (b) communicate the nursing plan of care and all modifications of the plan to members of the health care team.

The phrase “consistent with current nursing science” in (a) above was added to rule language in 2014. It is important that nurses base their decisions about patient care on best available evidence, not just “because we’ve always done it that way” or because “that’s the policy”. All policies should be revised and updated periodically, and nurses have an obligation to remain current in their knowledge of evidence-based practice standards.

Think about the patient described earlier who was identified as a fall risk related to confusion. The desired outcome for this gentleman is that he is free of injuries that might occur as a result of a fall, and interventions to get to that outcome might include frequent reminders to help orient him, leaving a night light on to aid in orientation, arranging for a family member to stay with him during waking hours, and frequent toileting to avoid situations where he tries to get up quickly without assistance. This plan of care can be documented in a medical record, a separate plan of care document, or any other mechanism deemed appropriate by the facility. Ease of access to information by all members of the healthcare team will provide consistency and continuity in the plan of care.

Implementation

Implementation is the fourth step of the OBN-described nursing process for the RN. Once again, the rule begins with a stipulation that the planned actions be implemented in an “accurate and timely manner”. There are a number of actions that could be included within the implementation phase of the process; the OBN rule says that these may include executing the nursing regimen which has been developed in the above steps, carrying out an order which has been received by an authorized individual and providing nursing care consistent with the assessment, analysis, and planning steps of the process which is within the education, knowledge, skills, and abilities of the registered nurse. In other words, even though a nursing action has been determined to be appropriate for a particular patient, if you don’t know how to perform the action, you should not perform it. Your job in that case would be to either find another person who is able to perform the action or to seek appropriate education to enable you to perform the action correctly. Other actions included in the “implementation” section of the nursing process rule are assisting and collaborating with other healthcare providers in the care of the patient and delegating nursing tasks consistent with delegation rules (delegation was defined earlier in this study). Remember that the bottom line, from the Board of Nursing perspective, is that the patient is safe.

Evaluation

The fifth and final step in the nursing process for the RN is evaluation. Rules for evaluation include the facts that the RN will, in an accurate and timely manner, evaluate and document the patient’s response to nursing interventions and progress toward expected outcomes of the plan of care. Sometimes this documentation is completed via a checklist or flowchart, such as results of vital sign or intake and output findings; sometimes a checklist or narrative/free text entry in a medical record is the preferred way to share information. Consider the facts to be shared, who needs access to the information, and the best location for others to get the required information. All of these factors should be congruent with facility policy regarding how, when, and where documentation is completed. It is important to remember that evaluation is a required part of the nursing process. If there is no evidence that an intervention has been determined to be successful, then one might wonder why it was necessary to perform the intervention in the first place. This part of the process “closes the loop” of the nursing process and provides further data for subsequent reassessments or alterations to the plan of care. In fact, the last step in the evaluation process as defined in rule is to reassess the patient’s health status and modify plans and/or interventions as needed.

Nursing Process for the Licensed Practical Nurse

 According to rule 4723-4-08 OAC, the LPN “contributes” to the nursing process. This is consistent with previous information in this study regarding the way the LPN implements the scope of practice under the direction of the RN, physician, or others designated in law and rule. The LPN does not function independently, but does provide a significant and valuable contribution to the work of the health care team in providing safe care to patients. Similar to the rule statement for the RN, the LPN is expected to use the steps of the nursing process as part of a cyclical process rather than a linear one and is expected to collaborate with others in applying the process steps. Additionally, and also consistent with requirements for RNs, the LPN is expected to carry out all steps of the nursing process in an accurate and timely manner. The steps delineated in rule for the LPN are:

Assessment

The LPN contributes to the nursing assessment of a client by collecting and documenting subjective and objective data related to the patient’s current health status and reporting that data as appropriate to other members of the healthcare team. This part of the nursing process is consistent with the scope of practice requirement in law that the LPN conducts “observations” of patients in a diversity of healthcare settings.

Planning

The LPN’s contribution to planning includes involvement with the person providing direction of the care for the patient in developing, maintaining, and/or modifying the nursing component of the plan of care and communicating that plan and any associated changes with those needing the information. The LPN might discuss with the RN the data that have been collected in the assessment phase of the process. The two of them together determine what plan should be put into place based on that assessment data.

Implementation

The LPN again contributes to the care of the patient by providing nursing interventions, administering authorized medications and treatments, giving direct basic nursing care under rules regarding direction, and collaborating with others in providing care of the patient. Note that the rule specifies that the LPN gives “basic nursing care” under direction. It is the RN’s responsibility to determine what aspects of care the LPN can and should participate in, based on that RN’s knowledge of both the capabilities of the LPN and the needs of the patient. The implementation rule also specifies that the LPN can delegate performance of nursing tasks to unlicensed assistive personnel, under RN direction and consistent with the separate chapter of rules on delegation (4723-13 OAC).

Evaluation

The evaluation component of the nursing process for the LPN indicates that the LPN is expected to contribute to evaluating the patient’s response to nursing interventions, document those observations, communicate information to other members of the health care team, and contribute to revision of the nursing plan of care, as needed. It is clear throughout each phase of the nursing process that the LPN is considered to have an important role to play in providing safe patient care in those settings where LPNs are employed.

Clinical Judgment

The nursing process rules for RNs begin with the requirement that the RN will use “clinical judgment” in its application. Clinical judgment is defined as “the application of the nurse’s knowledge and reasoning within the context of the clinical environment in making decisions about patient care” (4723-4-01(B)(4) OAC). This is consistent with expected use of evidence-based practice and best available evidence, and also supports the statement in the implementation phase of the nursing process that the nurse base decisions and actions on “current nursing science” (4723-4-07(A)(3)(a) OAC).

Use of clinical judgment implies that the nurse uses good judgment and critical thinking, applies previously-learned knowledge to current situations, seeks guidance and support as needed, and references evidence-based practice standards rather than tradition as support for nursing actions. (Benner, Hughes, & Sutphen, 2008). Other entire studies are devoted to the topics of critical thinking and clinical judgment. For the purpose of this study, however, it is important to note that all steps of the nursing process require application of clinical judgment skills. Here are some examples, followed by potential clinical scenarios. Remember that these are example only, and the prudent nurse and good critical thinker will reflect on other relevant situations involving use of critical thinking and clinical judgment skills to protect patient safety.

• The nurse seeks information from various sources as part of assessment
  • These may include people from other health care professions such as medicine, pharmacy, social work, respiratory therapy, and others.
  • They may include the patient, family, and other significant resources, such as religious or cultural informants.
  • Additional sources of data may be written/computerized records – previous medical records from admissions to this facility, transfer information from a nursing home or home health agency, or written data from internal sources such as laboratory reports or provider consultations
• The nurse validates information with the patient, the family, or other members of the healthcare team rather than making unilateral decisions.
  • This means that the nurse seeks to understand information, rather than leaping to conclusions based on “assumptions” about information. Validating means asking for clarification, requesting input from those who can provide perspective, and considering different angles of a situation.
  • An example may be a situation where a prescriber has written an order for a medication to be given in a dose of 25 mg. The nurse does not regularly give the medication, but does remember having given it in the past in a dose of 2.5 mg. The nurse who is not a strong critical thinker and is operating on “auto pilot” may proceed with the higher dose, thinking that the prescriber must have known what dose to prescribe when the order was written. On the other hand, a good critical thinker will be mindful and focused, realizing that the prescribed dose is different than usual. This nurse will display good clinical judgment by contacting the prescriber to clarify the order and seek additional information. Ohio Board of Nursing rules specify the actions to be taken when clarifying an order, but the decision to do so rests with the clinical judgment ability of the nurse.
• The nurse keeps an open mind and seeks to learn more about unfamiliar situations, such as patients with different cultural or religious backgrounds
  • Consider the nurse who has a patient from another country, or a patient who is Muslim, Jewish, or Amish. What values and beliefs does this person hold? Who is the primary decision-maker in the family? What does this culture or religious group believe about pain? About death and dying? About male nurses caring for female patients? Seeking to understand the frame of reference and value system of the patient and family will help the nurse in providing patient-centric care.
  • Think about a patient who wants to be admitted to hospice, but requests to be a full code. Why would a patient and/or family make this decision? What values support this perspective? How can the patient’s wishes be honored within the context of the hospice care environment?

The nurse acknowledges when he/she does not have all the answers and needs assistance from someone else.

• • A patient is admitted to a medical-surgical unit with chronic obstructive pulmonary disease. He has a co-morbidity of severe depression and is on antidepressant medication. The nurse is unfamiliar with the medication and treatment plan specific to the depression diagnosis, so a colleague who works on the inpatient psychiatric unit is consulted to assist in assessing the patient and developing a comprehensive plan of care.
  • A patient is admitted to the medical-surgical unit for hip replacement surgery tomorrow. He brings with him the equipment he uses at home for his sleep apnea. The nurse is unfamiliar with this equipment, so takes the opportunity to learn from the patient and his family how it is set up and how it works. The patient is given the autonomy to use the equipment per his usual standard, but knows that the nurse is interested, willing to learn, and available to provide assistance as needed. The nurse also discusses with the patient the availability of a respiratory therapist, should additional assistance be needed.
• The nurse continually assesses the patient’s situation, making modifications in the plan of care as needed, rather than at prescribed intervals or according to a linear progression of steps.
  • Recognizing that the nursing process is cyclical in nature, the nurse is always alert to new assessment data that will potentially alter the plan of care. The critically thinking registered nurse will carefully consider new data, analyze new facts in relation to what is already known and what is not yet known, will consider “what if” scenarios to project possible outcomes, and will modify the plan of care as needed, based on best-available evidence.
  • The registered nurse carefully considers assignment of personnel, directing provision of care by the licensed practical nurse or performance of tasks by unlicensed assistive personnel, to meet the needs of the patient. Changes in assignment are made as needed, based on nursing assessment of changing patient needs, rather than “static” factors such as number of hours worked or “equal” workloads of staff.
• The nurse recognizes situations where patients are at risk and seeks appropriate assistance from other nurses or other members of the healthcare team
  • A nurse recognizes that a patient’s condition is deteriorating and considers the implications of calling the rapid response team for assistance. One thought is that calling for assistance may make the nurse look “weak” and unable to handle the situation. Another perspective is that the nurse trusts good clinical judgment in assessing the patient’s condition and realizes that failure to intervene at this point may well lead to cardiac and/or respiratory arrest and the need to have a full code. Knowing that judgments are sound, and that help is available, plus knowing that patient outcomes from rapid response interventions are significantly better than code outcomes, the nurse makes the decision to request assistance from the rapid response team.
  • The nurse regularly assesses fall risk of patients upon admission. Rather than making this a “routine” to check the appropriate boxes in the computerized documentation system, she includes questions to assess the patient’s usual activities at home, considering such factors as use of assistive devices, use of medications that could contribute to unsteady gait, blurred vision, or other situations that could compromise safe mobility. Learning that the patient typically uses a walker at home but has not brought it to the hospital, she contacts physical therapy to procure proper equipment to promote safety in the hospital.
• The nurse shares information freely to enhance the team’s ability to provide safe, quality care.
  • The nurse works collaboratively as a member of the healthcare team, recognizing the nurse’s significant role in helping the patient have a successful recovery from his major trauma – a multivehicle accident on the freeway in which a passenger in the patient’s car died. The nurse is sensitive to the fact that the patient’s needs are more than medical treatment, and diligently seeks assistance and support from social work, the hospital chaplain, and the patient’s family to meet his comprehensive care needs.
  • The nurse recognizes the need to maintain balance between appropriate sharing of information and the need to safeguard the patient’s personal medical information. The nurse is also aware of situations, such as suspected elder abuse, where mandatory reporting is required, and knows how to adhere to such requirements.
• The nurse implements a plan of care based on unique factors relevant to an individual patient rather than using a “cook-book” care plan.
  • The nurse uses evidence-based practice standards to provide care based on the best available evidence, recognizing that evidence-based practice consists of more than research data. Several relevant sources of evidence are considered, including the past experience of the nurse and the lived experiences of the patient and his family.
  • The nurse is aware of ways to access information and is savvy in using computer search engines, hospital librarians, and other sources of information to get current data to guide practice. The nurse knows not to rely on information that is dated or comes from questionable sources.
• The nurse recognizes and values the opportunity to question other members of the healthcare team when unsure about a proposed plan of care or when concerned that the proposed plan of care may not be in the best interest of the patient.
  • The nurse sees herself as a key player in the health care of the patient, rather than a task-performer who carries out a prescriber’s “orders”. Using standardized communication tools such as SBAR (situation, background, assessment, recommendation), the nurse assertively shares information to assist the team in providing comprehensive care.
  • The nurse seeks to understand scopes of practice of other healthcare professions and values the collaboration that can ensue, rather than engaging in “turf wars” to protect artificial boundaries.
• The nurse is familiar with standards of practice for his practice area and implements appropriate standards to promote patient safety and wellbeing.
  • While law and rules from Ohio’s and other states’ boards of nursing are written in general, to apply to practice in any setting, standards of practice specific to various clinical areas are available from professional associations. There are standards, for example, for critical care nursing, emergency department nursing, oncology nursing, parish nursing, and nursing professional development practice. The good critical thinker will review these standards periodically and reflect on his/her practice in relation to them, using appropriate clinical judgment to make decisions.
  • The good critical thinker knows sources of information and is not afraid to ask questions. He recognizes that questioning is a way to clarify and verify information to aid in providing quality care, rather than a process of challenging another team member’s decision-making. Using effective communication skills, the good critical thinker clearly conveys the concept of respectful collaboration in practice with his colleagues by his verbal and non-verbal behaviors.
• The nurse uses appropriate sources of data to learn about patients, their needs, and their care.
  • Sources of personal data include patients, families, significant others, and members of the healthcare team.
  • Sources of clinical data include reputable web sites, evidence-based practice standards, research findings, and up-to-date resource books/manuals.
  • Sources of facility specific data can include policy/procedure manuals, ethics guidelines and committees, and administrative directives.
  • The critically-thinking nurse is able to locate appropriate data, or go to the right people to get this data, in order to provide safe, timely patient care.

Numerous additional examples could be provided, but the bottom line is that providing nursing care is both an expectation and a privilege. Nurses are expected to use good thinking and clinical judgment to plan, implement, and evaluate appropriate care, not just be “robots” performing jobs. It is the ability to use clinical judgment that makes the nurse so valuable!

Summary

Ohio Board of Nursing rules guide use of the nursing process by both registered and licensed practical nurses. For the RN, steps of the nursing process include assessment, analysis, planning, implementation, and evaluation. For the LPN, steps of the nursing process include contributing to assessment, planning, implementation, and evaluation. Clinical judgment and current nursing science are expected to be used to carry out the steps of the nursing process in a way that provides safe, appropriate care to patients.

References

Benner, P., Hughes, R., and Sutphen, M. (2008) Clinical reasoning, decision making, and action: thinking critically and clinically. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Volume 1. Rockville MD: Agency for Healthcare Research and Quality.

Hawkins R, Silvester JA, Passiment M, Riordan L, Weiss KB for the National Collaborative for Improving the Clinical Learning Environment IP-CLE Planning Group. (2018) Envisioning the Optimal Interprofessional Clinical Learning Environment: Initial findings from an October 2017 NCICLE Symposium. http://ncicle.org.

Institute of Medicine (2003). Health professions education: A bridge to quality. Washington DC: National Academies Press.

Interprofessional Education Collaborative. (2016).  Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative.

Ohio Board of Nursing: www.nursing.ohio.gov

Ohio Board of Nursing Rules, Chapter 4: Standards of Practice Relative to Registered Nurse or Licensed Practical Nurse: http://codes.ohio.gov/oac/4723-4