problem solving approach in community health nursing definition

What is Problem-Solving in Nursing? (With Examples, Importance, & Tips to Improve)

Whether you have been a nurse for many years or you are just beginning your nursing career, chances are, you know that problem-solving skills are essential to your success. With all the skills you are expected to develop and hone as a nurse, you may wonder, “Exactly what is problem solving in nursing?” or “Why is it so important?” In this article, I will share some insight into problem-solving in nursing from my experience as a nurse. I will also tell you why I believe problem-solving skills are important and share some tips on how to improve your problem-solving skills.

What Exactly is Problem-Solving in Nursing?

5 reasons why problem-solving is important in nursing, reason #1: good problem-solving skills reflect effective clinical judgement and critical thinking skills, reason #2: improved patient outcomes, reason #3: problem-solving skills are essential for interdisciplinary collaboration, reason #4: problem-solving skills help promote preventative care measures, reason #5: fosters opportunities for improvement, 5 steps to effective problem-solving in nursing, step #1: gather information (assessment), step #2: identify the problem (diagnosis), step #3: collaborate with your team (planning), step #4: putting your plan into action (implementation), step #5: decide if your plan was effective (evaluation), what are the most common examples of problem-solving in nursing, example #1: what to do when a medication error occurs, how to solve:, example #2: delegating tasks when shifts are short-staffed, example #3: resolving conflicts between team members, example #4: dealing with communication barriers/lack of communication, example #5: lack of essential supplies, example #6: prioritizing care to facilitate time management, example #7: preventing ethical dilemmas from hindering patient care, example #8: finding ways to reduce risks to patient safety, bonus 7 tips to improve your problem-solving skills in nursing, tip #1: enhance your clinical knowledge by becoming a lifelong learner, tip #2: practice effective communication, tip #3: encourage creative thinking and team participation, tip #4: be open-minded, tip #5: utilize your critical thinking skills, tip #6: use evidence-based practices to guide decision-making, tip #7: set a good example for other nurses to follow, my final thoughts, list of sources used for this article.

ANA Nursing Resources Hub

Search Resources Hub

Problem Solving in Nursing: Strategies for Your Staff

4 min read • September, 15 2023

Problem solving is in a nurse manager’s DNA. As leaders, nurse managers solve problems every day on an individual level and with their teams. Effective leaders find innovative solutions to problems and encourage their staff to nurture their own critical thinking skills and see problems as opportunities rather than obstacles.

Health care constantly evolves, so problem solving and ingenuity are skills often used out of necessity. Tackling a problem requires considering multiple options to develop a solution. Problem solving in nursing requires a solid strategy.

Nurse problem solving

Nurse managers face challenges ranging from patient care matters to maintaining staff satisfaction. Encourage your staff to develop problem-solving nursing skills to cultivate new methods of improving patient care and to promote  nurse-led innovation .

Critical thinking skills are fostered throughout a nurse’s education, training, and career. These skills help nurses make informed decisions based on facts, data, and evidence to determine the best solution to a problem.

Problem-Solving Examples in Nursing

To solve a problem, begin by identifying it. Then analyze the problem, formulate possible solutions, and determine the best course of action. Remind staff that nurses have been solving problems since Florence Nightingale invented the nurse call system.

Nurses can implement the  original nursing process  to guide patient care for problem solving in nursing. These steps include:

• Assessment . Use critical thinking skills to brainstorm and gather information.
• Diagnosis . Identify the problem and any triggers or obstacles.
• Planning . Collaborate to formulate the desired outcome based on proven methods and resources.
• Implementation . Carry out the actions identified to resolve the problem.
• Evaluation . Reflect on the results and determine if the issue was resolved.

How to Develop Problem-Solving Strategies

Staff look to nurse managers to solve a problem, even when there’s not always an obvious solution. Leaders focused on problem solving encourage their team to work collaboratively to find an answer. Core leadership skills are a good way to nurture a health care environment that supports sharing concerns and  innovation .

Here are some essentials for building a culture of innovation that encourages problem solving:

• Present problems as opportunities instead of obstacles.
• Strive to be a positive role model. Support creative thinking and staff collaboration.
• Encourage feedback and embrace new ideas.
• Respect staff knowledge and abilities.
• Match competencies with specific needs and inspire effective decision-making.
• Offer opportunities for  continual learning and career growth.
• Promote research and analysis opportunities.
• Provide support and necessary resources.
• Recognize contributions and reward efforts .

Embrace Innovation to Find Solutions

Try this exercise:

Consider an ongoing departmental issue and encourage everyone to participate in brainstorming a solution. The team will:

• Define the problem, including triggers or obstacles.
• Determine methods that worked in the past to resolve similar issues.
• Explore innovative solutions.
• Develop a plan to implement a solution and monitor and evaluate results.

Problems arise unexpectedly in the fast-paced health care environment. Nurses must be able to react using critical thinking and quick decision-making skills to implement practical solutions. By employing problem-solving strategies, nurse leaders and their staff can  improve patient outcomes  and refine their nursing skills.

Images sourced from Getty Images

Related Resources

Item(s) added to cart

16.3 Applying the Nursing Process to Community Health

Community health nurses apply the nursing process to address needs of individuals, families, vulnerable populations, and entire communities. See Figure 16.7 [1] for an illustration of the nursing process in community health nursing.

The community health nurse typically begins a community health needs assessment by determining what data is already available. [2] As previously discussed in the “ Community Health Concepts ” section, national, state, county, and local health needs assessments are widely available. Secondary analysis refers to analyzing previously collected data to determine community needs.

Community health nurses may also engage in primary data collection to better understand the community needs and/or study who may be affected by actions taken as a result of the assessment. [3]   Primary data collection includes tools such as public forums, focus groups, interviews, windshield surveys, surveys, and participant observation.

Public Forums

Public forums are gatherings where large groups of citizens discuss important issues at well-publicized locations and times. Forums give people of diverse backgrounds a chance to express their views and enhance understanding of the community’s specific needs and resources. Forums should be planned in a convenient location with accessibility to public transportation and child care. They should also be scheduled at convenient times for working families to gain participation from a wide range of populations.

Focus Groups

Focus groups are a systematic method of data collection through small-group discussions led by a facilitator. Participants in focus groups are selected to represent a larger group of people. Groups of 6-10 people with similar backgrounds or interests are interviewed in an informal or formal setting. Focus groups should be scheduled at several dates and times to ensure a broad participation from members of the community. Here are advantages of focus groups:

• Community member involvement in assessing and planning community initiatives is encouraged.
• Different perceptions, values, and beliefs by community members are explored.
• Input can be obtained from specific subpopulations of the community. Example of subpopulations include young mothers caring for infants, individuals receiving home hospice care, individuals struggling to find housing, residents of the prison system, individuals coping with mental health disorders, or residents in group homes.

Interviews are structured conversations with individuals who have experience, knowledge, or understanding about a particular topic or issue. Key informant interviews are conducted with people in key positions in the community and have specific areas of knowledge and experience. These interviews can be useful for exploring specific community problems and/or assessing a community’s readiness to address those problems. [4]

Advantages of interviews include the following [5] :

• They can be conducted in a variety of settings (e.g., homes, schools, churches, stores, or community centers).
• They are low cost and generally have low dropout rates.
• Respondents define what is important from their perspective.
• It is possible to explore issues in depth, and there is an opportunity to clarify responses.
• They can provide leads to other data sources and key informants.
• They provide an opportunity to build partnerships with community members.
• Data can be compared among local government officials, citizens, and non-government leaders.

Interviews can have these disadvantages:

• Interviews can be time-consuming to schedule and perform.
• They require trained interviewers.
• There is a potential for interviewer bias to affect the data collected during the interview.
• Rapport must be established before sensitive information is shared.
• It is more time-consuming to summarize and analyze findings.

Windshield Surveys

A windshield survey is a type of direct observation of community needs while driving and literally looking through the windshield. It can be used to observe characteristics of a community that impact health needs such as housing, pollution, parks and recreation areas, transportation, health and social services agencies, industries, grocery stores, schools, and religious institutions.

View the following YouTube video of a windshield survey [6] : Windshield Survey Nursing .

Surveys use standardized questions that are relatively easy to analyze. They are beneficial for collecting information across a large geographic area, obtaining input from as many people as possible, and exploring sensitive topics. [7] Surveys can be conducted face to face, via the telephone, mailed, or shared on a website. Responses are typically anonymous but demographic information is often collected to focus on the needs of specific populations. Disadvantages of surveys can include the following [8] :

• Surveys can be time-consuming to design, implement, and analyze the results.
• The accuracy of survey results depends on who is surveyed and the size of the sample.
• Mailed surveys may have low response rates with higher costs due to postage.
• They offer little opportunity to explore issues in depth, and questions cannot be clarified.
• There is no opportunity to build rapport with respondents.

Participant Observation

Participant observation refers to nurses informally collecting data as a member of the community in which they live and work. This is considered a subjective observation because it is from the nurse’s perspective. Informal observations are made, or discussions are elicited among peers and neighbors within the community.

Sociocultural Considerations

When analyzing community health needs, it is essential to do so through a sociocultural lens. Just as an individual’s health can be influenced by a wide variety of causes, community health problems are affected by various factors in the community. For example, a high rate of cancer in one community could be related to environmental factors such as pollution from local industry, but in another community, it may be related to the overall aging of the population. Both communities have a high rate of cancer, but the public health response would be very different. Another example related to mental health is related to various situational factors affecting depression. A high rate of depression in one community may be related to socioeconomic factors such as low-paying jobs, lack of support systems, and poor access to basic needs like grocery stores, whereas in another community it may be related to lack of community resources during frequent weather disasters. The public health response would be different for these two communities.

Nurses must also recognize and value cultural differences such as health beliefs, practices, and linguistic needs of diverse populations. They must take steps to identify subpopulations who are vulnerable to health disparities and further investigate the causes and potential interventions for these disparities. For example, mental health disparities pose a significant threat to vulnerable populations in our society, such as high rates of suicide among LGBTQ+ youth, reduced access to prevention services among people living in rural areas, and elevated rates of substance misuse among Native Americans. These disparities threaten the health and wellness of these populations. [9]

Key points to consider when assessing a community using a sociocultural lens include the following:

• Have the trends of assessment data changed over time? What are the potential causes for these changes in this community?
• How does the community’s needs assessment data compare to similar communities at local, county, state, and national levels? What target goals and health initiatives have been successfully implemented in other communities?
• What vulnerable subpopulations are part of this community, and what health disparities are they experiencing? What are potential causes and solutions for these health disparities?
• Input from members of vulnerable subpopulations must be solicited regarding their perspectives on health disparities, as well as barriers they are experiencing in accessing health care.

Similar to how nurses individualize nursing diagnoses for clients based on priority nursing problems identified during a head-to-toe assessment, community health nurses use community health needs assessment data to develop community health diagnoses. These diagnoses are broad, apply to larger groups of individuals, and address the priority health needs of the community. Resources such as Healthy People 2030 can be used to determine current public health priorities.

A community diagnosis is a summary statement resulting from analysis of the data collected from a community health needs assessment. [10] A clear statement of the problem, as well as causes of the problem, should be included. A detailed community diagnosis helps guide community health initiatives that include nursing interventions.

A community diagnosis can address health deficits or services that support health in the community. A community diagnosis may also address a need for increased wellness in the community. Community diagnoses should include these four parts:

• The problem
• The population or vulnerable group
• The effects of the problem on the population/vulnerable group
• The indicators of the problem in this community

Here are some examples of community health diagnoses based on community health needs assessments:

• Community Scenario A
• Assessment data: The local high school has had a 50% increase in the number of teen pregnancies in the past year, causing high school graduation rates to decrease due to pregnant students dropping out of high school.
• Community diagnosis: Increased need for additional birth control and resources for prevention of pregnancy due to lack of current resources, as evidenced by 50% increase in teen pregnancies in the last year and a decrease in graduation rates.
• Community Scenario B
• Assessment data: Fifty percent of residents of an assisted living facility were found to have blood pressure readings higher than 130/80 mmHg during a health fair last week at the facility.
• Community diagnosis: Increased need for education about exercise and diet and referrals to primary care doctors for residents of an assisted living facility due to increased risk for mortality related to high blood pressure, as evidenced by a high number of residents with high blood pressure during a health fair.
• Community Scenario C
• Assessment data: The local high school has had two cases of suicide in the past year.
• Diagnosis: Increased need for community education regarding suicide prevention and crisis hotlines, as evidenced by an increase in adolescent suicide over the past twelve months.

Outcomes Identification

Outcomes refer to the changes in communities that nursing interventions and prevention strategies are intended to produce. Outcomes include broad overall goals for the community, as well as specific outcomes referred to as “SMART” outcomes that are specific, measurable, achievable, realistic, and with a timeline established.

Broad goals for communities can be tied to national objectives established by Healthy People 2030, as previously discussed in the “ Community Health Concepts ” section.

Healthy People objectives are classified by these five categories [11] :

• Health Conditions
• Health Behaviors
• Populations
• Settings and Systems
• Social Determinants of Health

SMART outcomes can be created based on the objectives listed under each category. For example, if an overall community goal is related to “Drug and Alcohol Use” under the “Health Behaviors” category, a SMART outcome could be based on the Healthy People objective, “Increase the proportion of people with a substance use disorder who got treatment in the past year.” [12] Based on this Healthy People objective, an example of a SMART outcome could be the following:

• The proportion of people treated for a substance disorder in Smith County will increase to 14% within the next year.

View the Healthy People 2030 Objectives and Community Objectives .

Planning Interventions

Nursing interventions for the community can be planned based on the related Healthy People category and objective. For example, based on the sample SMART outcome previously discussed, a planned nursing intervention could be the following:

•  The nurse will provide education and materials regarding evidence-based screening practices for substance use disorder in local clinics.

Community health nursing interventions typically focus on prevention of illness with health promotion interventions. After performing a community health needs assessment, identifying priority problems, and establishing health goals and SMART outcomes, the nurse integrates knowledge of health disorders (e.g., diabetes, cancer, obesity, or mental health disorders) and current health risks in a community to plan prevention interventions.

There are two common public health frameworks used to plan prevention interventions. A traditional preventive framework is based on primary, secondary, or tertiary prevention interventions. A second framework, often referred to as the Continuum of Care Prevention Model, was established by the Institute of Medicine (IOM) and includes universal, selected, and indicated prevention interventions. Both frameworks are further discussed in the following sections. [13]

Primordial, Primary, Secondary, Tertiary, and Quaternary Interventions

Preventive health interventions may include primordial, primary, secondary, tertiary, and quaternary prevention interventions. These strategies attempt to prevent the onset of disease, reduce complications of disease that develops, and promote quality of life. [14]

Primordial Prevention

Primordial prevention consists of risk factor reduction strategies focused on social and environmental conditions that affect vulnerable populations. In other words, primordial prevention interventions target underlying social determinants of health that can cause disease. These measures are typically promoted through laws and national policy. An example of a primordial prevention strategy is improving access to urban neighborhood playgrounds to promote physical activity in children and reduce their risk for developing obesity, diabetes, and cardiovascular disease. [15] See Figure 16.8 [16] for an image of a neighborhood playground.

Primary Prevention

Primary prevention consists of interventions aimed at susceptible populations or individuals to prevent disease from occurring. An example of primary prevention is immunizations. [17] Nursing primary prevention interventions also include public education and promotion of healthy behaviors. [18] See Figure 16.9 [19] for an image of an immunization clinic sponsored by a student nurses’ association.

Secondary Prevention

Secondary prevention emphasizes early detection of disease and targets healthy-appearing individuals with subclinical forms of disease. Subclinical disease refers to pathologic changes with no observable signs or symptoms. Secondary prevention includes screenings such as annual mammograms, routine colonoscopies, Papanicolaou (Pap) smears, as well as screening for depression and substance use disorders. [20] Nurses provide education to community members about the importance of these screenings. See Figure 16.10 [21] for an image of a mammogram.

Tertiary Prevention

Tertiary prevention is implemented for symptomatic clients to reduce the severity of the disease and potential long-term complications. While secondary prevention seeks to prevent the onset of illness, tertiary prevention aims to reduce the effects of the disease after it is diagnosed in an individual. [22] For example, rehabilitation therapy after an individual experiences a cerebrovascular accident (i.e., stroke) is an example of tertiary prevention. See Figure 16.11 [23] for an image of a client receiving rehabilitation after experiencing a stroke.

The goals of tertiary prevention interventions are to reduce disability, promote curative therapy for a disease or injury, and prevent death. Nurses may be involved in providing ongoing home health services in clients’ homes as a component of interprofessional tertiary prevention efforts. Health education to prevent the worsening or recurrence of disease is also provided by nurses.

Quaternary Prevention

Quaternary prevention refers to actions taken to protect individuals from medical interventions that are likely to cause more harm than good and to suggest interventions that are ethically acceptable. Targeted populations are those at risk of overmedicalization. [24] An example of quaternary prevention is encouraging clients with terminal illness who are approaching end of life to seek focus on comfort and quality of life and consider hospice care rather than undergo invasive procedures that will likely have no impact on recovery from disease.

See additional examples of primordial, primary, secondary, tertiary, and quaternary prevention strategies in Table 16.3a.

Table 16.3a Examples of Prevention Interventions [25] , [26]

In the United States, several governing bodies make prevention recommendations. For example, the United States Preventive Services Task Force (USPSTF) makes recommendations for primary and secondary prevention strategies, and the Women’s Preventive Services Initiative (WPSI) makes recommendations specifically for females. The Advisory Committee on Immunizations Practices (ACIP) makes recommendations for vaccinations, and various specialty organizations such as the American College of Obstetrics and Gynecology (ACOG) and the American Cancer Society (ACS) make preventative care recommendations. Preventive services have been proven to be an essential aspect of health care but are consistently underutilized in the United States. [27] Nurses can help advocate for the adoption of evidence-based prevention strategies in their communities and places of employment.

Continuum of Care Prevention Model

A second framework for prevention interventions, referred to as the “Continuum of Care Prevention Model,” was originally proposed by the Institute of Medicine (IOM) in 1994 and has been adopted by the Substance Abuse and Mental Health Services Administration (SAMHSA). [28] See Figure 16.12 [29] for an illustration of the Continuum of Care Prevention Model.

The Continuum of Care Prevention Model can be used to illustrate a continuum of mental health services for community members that includes prevention, treatment, and maintenance care:

• Universal prevention : Interventions designed to reach entire groups, such as those in schools, workplaces, or entire communities. [30] , [31] For example, wellness sessions regarding substance misuse can be planned and implemented at a local high school.
• Selected prevention : Interventions that target individuals or groups with greater risk factors (and perhaps fewer protective factors) than the broader population. [32] , [33] For example, a research study showed that wellness programs implemented for adolescents who were already using alcohol or drugs reduced the quantity and frequency of their alcohol use and reduced episodes of binge drinking. [34]
• Indicated prevention : Interventions that target individuals who have a high probability of developing disease. [35] For example, interventions may be planned for adolescents who show early signs of substance misuse but have not yet been diagnosed with a substance use disorder. Interventions may include referrals to community support services for adolescents who have violated school alcohol or drug policies. [36]
• Treatment refers to identification of a mental health disorder and standard treatment for the known disorder. Treatment also includes interventions to reduce the likelihood of future co-occurring disorders. [37]
• Maintenance refers to long-term treatment to reduce relapse and recurrence, as well as provision of after-care services such as rehabilitation. [38]

See additional examples of prevention strategies using the Continuum of Care Prevention Model in Table 16.3b.

Table 16.3b Examples of Continuum of Care Prevention Strategies

Read  A Guide to SAMHSA’s Strategic Prevention Framework PDF for more about planning prevention strategies for substance misuse and related mental health problems.

Culturally Competent Interventions

To overcome systemic barriers that can contribute to health disparities, nurses must recognize and value cultural differences of diverse populations and develop prevention programs and interventions in ways that ensure members of these populations benefit from their efforts. [39]

SAMHSA identified the following cultural competence principles for planning prevention interventions [40] :

• Include the targeted population in needs assessments and prevention planning
• Use a population-based definition of community (i.e., let the community define itself)
• Stress the importance of relevant, culturally appropriate prevention approaches
• Promote cultural competence among program staff

Review additional concepts related to culturally responsive care in the “ Diverse Patients ” chapter of Open RN Nursing Fundamentals .

Evidence-Based Practice

It is essential to incorporate evidence-based practice when planning community health interventions. SAMHSA provides an evidence-based practice resource center for preventive practices related to mental health and substance abuse. See these resources, as well as examples of evidence-based programs and practices in the following box.

Examples of Evidence Based Prevention Practices related to Mental Health and Substance Misuse [41]

• Blueprints for Healthy Youth Development : Youth violence, delinquency, and drug prevention and intervention programs that meet a strict scientific standard of program effectiveness
• Evidence-Based Behavioral Practice (EBBP) : A project that creates training resources to help bridge the gap between behavioral health research and practice
• SAMHSA’s Suicide Prevention Research Center (SPRC) : A best practices registry that identifies, reviews, and disseminates information about best practices that address specific objectives of the National Strategy for Suicide Prevention
• The Athena Forum: Prevention 101 : Substance misuse prevention programs and strategies with evidence of success from the Washington State Department of Social and Health Services
• National Institute on Drug Abuse: Preventing Drug Use Among Children and Adolescents : Research-based drug abuse prevention principles and an overview of program planning, including universal, selected, and indicated interventions

View the SAMHSA Evidence-Based Practice Resource Center .

Implementation

Community health nurses collaborate with individuals, community organizations, health facilities, and local governments for successful implementation of community health initiatives. Depending on the established community health needs, goals, outcomes, and target group, the implementation of nursing interventions can be categorized as clinical, behavioral, or environmental prevention:

• Clinical prevention : Interventions are delivered one-on-one to individuals in a direct care setting. Examples of clinical prevention interventions include vaccine clinics, blood pressure monitoring, and screening for disease.
• Behavioral prevention : Interventions are implemented to encourage individuals to change habits or behaviors by using health promotion strategies. Examples of behavioral prevention interventions include community exercise programs, smoking cessation campaigns, or promotion of responsible alcohol drinking by adults.
• Environmental prevention : Interventions are implemented for the entire community when laws, policies, physical environments, or community structures influence a community’s health. Examples of environmental prevention strategies include improving clean water systems, establishing no-smoking ordinances, or developing community parks and green spaces.

When evaluating the effectiveness of community health initiatives, nurses refer to the established goals and SMART outcomes to determine if they were met by the timeline indicated. In general, the following questions are asked during the evaluation stage:

• Did the health of the community improve through the interventions put into place?
• Are additional adaptations or changes to the interventions needed to improve outcomes in the community?
• What additional changes are needed to improve the health of the community?
• Have additional priority problems been identified?
• “ Nursing Process in Community Health Nursing ” by Open RN project is licensed under CC BY 4.0 ↵
• Community Tool Box by Center for Community Health and Development at the University of Kansas is licensed under CC BY NC SA 3.0 ↵
• A Guide to SAMHSA’s Strategic Prevention Framework by Substance Abuse and Mental Health Services Administration is available in the Public Domain . ↵
• Medrea, R. (2014, July 20). Windshield survey nursing [Video]. YouTube. All rights reserved. https://youtu.be/aAzW1bW_Dbw ↵
• McDonald, L. (2006). Florence Nightingale and public health policy: Theory, activism and public administration. University of Guelph. https://cwfn.uoguelph.ca/nursing-health-care/fn-and-public-health-policy/ ↵
• Office of Disease Prevention and Health Promotion. Healthy People 2030: Building a healthier future for all. U.S. Department of Health and Human Services. https://health.gov/healthypeople ↵
• Savage, C. L. (2020). Public/community health and nursing practice: Caring for populations (2nd ed.). FA Davis. ↵
• This work is a derivative of StatPearls by Kisling and Das and is licensed under CC BY 4.0 ↵
• “ Playground_at_Hudson_Springs_Park.jpg ” by Kevin Payravi is licensed under CC BY-SA 3.0 ↵
• “ 10442934136_1f910af332_b ” by Lower Columbia College (LCC) is licensed under CC BY_NC-ND 2.0 ↵
• “ US_Navy_021025-N-6498N-001_Mammogram_technician,_aids_a_patient_in_completing_her_annual_mammogram_evaluation.jpg ” by U.S. Navy photo by Ensign Ann-Marie Al Noad is in the Public Domain . ↵
• “ tech_zerog.jpg ” by unknown author at Gaylord.org is included on the basis of Fair Use ↵
• National Research Council (US); Institute of Medicine (US) Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults; and Research Advances and Promising Interventions. Defining the scope of prevention. (2009). In M. E. O’Connell & Warner B. T. (Eds). Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. In Research advances and promising interventions. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK32789/ ↵
• This image is a derivative of the “IOM protractor” by unknown author and is included on the basis of Fair Use. Access for free at http://www.ca-sdfsc.org/docs/resources/SDFSC_IOM_Policy.pdf ↵
• A Guide to SAMHSA’s Strategic Prevention Framework by Substance Abuse and Mental Health Services Administration is available in the Public Domain. ↵
• Werch, C., Moore, M. J., DiClemente, C. C., Bledsoe, R., & Jobli, E. (2005). A multihealth behavior intervention integrating physical activity and substance use prevention for adolescents. Prevention Science, 6 (213). https://doi.org/10.1007/s11121-005-0012-3 ↵
• Substance Abuse and Mental Health Services Administration. (2019, July 19). Finding evidence-based programs and practices. https://www.samhsa.gov/sites/default/files/20190719-samhsa-finding_evidence-based-programs-practices.pdf ↵

Analyzing previously collected data to determine community needs.

Data collection that occurs through public forums, focus groups, interviews, windshield surveys, surveys, and participant observation.

Gatherings where large groups of citizens discuss important issues at well-publicized locations and times.

Systematic method of data collection through small-group discussions led by a facilitator.

Structured conversations with individuals who have experience, knowledge, or understanding about a particular topic or issue.

Interviews conducted with people in key positions in the community and have specific areas of knowledge and experience.

Type of direct observation of community needs while driving and literally looking through the windshield.

Standardized questions that are relatively easy to analyze.

A summary statement resulting from analysis of the data collected from a community health needs assessment.

Risk factor reduction strategies focused on social and environmental conditions that affect vulnerable populations.

Interventions aimed at susceptible populations or individuals to prevent disease from occurring.

The early detection of disease and targets healthy-appearing individuals with subclinical forms of disease.

Implemented for symptomatic clients to reduce the severity of the disease and potential long-term complications.

Actions taken to protect individuals from medical interventions that are likely to cause more harm than good and to suggest interventions that are ethically acceptable.

Interventions designed to reach entire groups, such as those in schools, workplaces, or entire communities.

Interventions that target individuals or groups with greater risk factors (and perhaps fewer protective factors) than the broader population.

Interventions that target individuals who have a high probability of developing disease.

Interventions are delivered one-on-one to individuals in a direct care setting.

Interventions are implemented to encourage individuals to change habits or behaviors by using health promotion strategies.

Interventions are implemented for the entire community when laws, policies, physical environments, or community structures influence a community’s health.

Nursing: Mental Health and Community Concepts Copyright © 2022 by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

• Subscribe to journal Subscribe
• Get new issue alerts Get alerts

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

Nurse leaders as problem-solvers

Addressing lateral and horizontal violence.

Anthony, Michelle R. PhD, RN; Brett, Anne Liners PhD, RN

Michelle R. Anthony is a program coordinator at Columbia (S.C.) VA Health Care System. Anne Liners Brett is doctoral faculty at the University of Phoenix in Tempe, Ariz.

Acknowledgment: The authors acknowledge the support of the University of Phoenix Center for Educational and Instructional Technology Research.

The contents of this article do not represent the views of the US Department of Veterans Affairs or the United States Government.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

For more than 126 additional continuing-education articles related to management topics, go to NursingCenter.com/CE .

Earn CE credit online: Go to http://nursing.ceconnection.com and receive a certificate within minutes .

Read about a qualitative, grounded theory study that looked to gain a deeper understanding of nurse leaders' perceptions of their role in addressing lateral and horizontal violence, and the substantive theory developed from the results.

The issue of lateral and horizontal violence (LHV) has plagued the nursing profession for more than 3 decades, yet solutions remain elusive. The significance of LHV isn't lost on nurse leaders because it creates an unhealthy work environment. Research literature worldwide has continued to report the prevalence of disruptive behaviors experienced by nursing students, novice nurses, and seasoned nurses in the workforce. The World Health Organization, International Council of Nurses, and Public Services International have recognized this issue as a major global public health priority. 1

LHV, also called nurse-on-nurse aggression, disruptive behavior, or incivility, undermines a culture of safety and negatively impacts patient care. 2,3 This experience, known to nurses as “eating their young,” isn't only intimidating and disruptive, it's also costly and demoralizing to the nursing profession and healthcare organizations. 4,5 Although the impact of LHV can be dreadful for both the institution and its staff, little is known about the reasons for these behaviors among nursing professionals. 2

LHV encompasses all acts of meanness, hostility, disruption, discourtesy, backbiting, divisiveness, criticism, lack of unison, verbal or mental abuse, and scapegoating. 6 The sole intent of bullying behaviors is to purposefully humiliate and demean victims. Bullying behaviors also taint healthcare organizations; cause irreparable harm to workplace culture; breakdown team communication; and severely impact the quality of the care provided, thereby jeopardizing patient safety. 7,8 Researchers have reported that acts of LHV are used to demonstrate power, domination, or aggression; for retribution; to control others; and to enhance self-image. 9-12

Previous studies have shown that the frequency of LHV in healthcare organizations is quite severe, with about 90% of new nurses surveyed reporting acts of incivility by their coworkers. 13 Sixty-five percent of nurses in one survey reported witnessing incidents of despicable acts, whereas another 46% of coworkers in the same survey reported the issue as “very serious” and “somewhat serious.” 13

LHV poses a significant challenge for nurse leaders who are legally and morally responsible for providing a safe working environment. 2,6 The purpose of this qualitative, grounded theory study was to gain a deeper understanding of nurse leaders' perceptions of their role in addressing LHV and develop a substantive theory from the results.

Literature review

A paucity of evidence exists in the literature regarding how nurse leaders perceive their role in addressing LHV. 14 Studies have shown that this phenomenon is attributed to heavy workloads, a stressful work environment, and lack of workgroup cohesiveness, as well as organizational factors such as misuse of authority and the lack of organizational policies and procedures for addressing LHV behaviors. 15

In one study, one-third of the nurses reported that they had observed emotional abuse during several of their work shifts. 16 Another study indicated that 30% of survey respondents (n = 2,100) stated LHV occurs weekly. 17 A third study revealed that 25% of participants noted LHV happened monthly, and a fourth study of ED nurses reported that about 27.3% of the nurses had experienced LHV perpetrated by nursing leadership (managers, supervisors, charge nurses, and directors), physicians, or peers in the last 6 months. 18

In a survey completed by members of the Washington State Emergency Nurses Association, 27% of respondents experienced acts of bullying in the past 6 months. 19 Another study reported that 27% to 85% of nurse respondents had experienced some form of uncivil behavior. 20 Other data have shown that those more vulnerable to violent, disruptive, and intimidating behaviors are newly licensed nurses beginning their careers. 21

Although nurse leaders can be perpetrators of LHV, they play an essential role in addressing LHV behaviors and creating a safe work environment. 22 The literature suggests that, in many cases, a lack of awareness and response by nurse leaders adds to the prevalence of LHV. 23 This may be due, in part, to nurse leaders being aligned with the perpetrators who are creating the toxic work environment. 6 The literature suggests that an environment where staff members feel safe to practice results in a culture that decreases burnout and promotes nurse retention and quality outcomes. 24,25

This qualitative, grounded theory study focused on nurse leaders' perception of their role in breaking the cycle of LHV for staff members whom they supervise. Two research questions guided the study: 1. How do nurse leaders perceive their role in addressing LHV among nursing staff members under their supervision? 2. What substantive theory may emerge from the data collected during interviews with nurse leaders?

A grounded theory methodology was used to explore the nurse leader's role in addressing LHV with the intent of developing a substantive theory through the meaningful organization of data themes to provide a framework to address the phenomenon of LHV. Purposive sampling was used to recruit a total of 14 participants for this study from a large healthcare system in the Southeastern US. The participants were chosen because of their experience with LHV and their ability to discuss and reflect on those experiences. Informed consent was obtained before the start of the study, which included explaining the reason for the study and what to expect. In addition, permission was obtained from the Institutional Review Board.

Data collection and analysis

Demographic data collected to describe the sample included gender, age range, number of years holding a management position, supervisory responsibility, and highest degree obtained. (See Table 1 .)

Semistructured, in-depth interviews were the primary mode of data collection. The recorded interviews were conducted face-to-face and lasted about 60 minutes. Data collection continued until saturation was achieved. Data saturation occurred when no new descriptive codes, categories, or themes were emerging from the analyzed data. The interviews were transcribed verbatim and verified through a member check process.

During the data analysis process, themes and patterns were identified. Data from each participant's interview were examined to determine if the responses were aligned with the identified themes. Analysis of the data included coding at increasingly abstract levels and constant comparison. Qualitative software assisted in coding the information and uncovering subtle trends.

Four themes emerged from core categories developed during the qualitative data coding process.

Theme 1: Understanding/addressing LHV . In question one, participants were asked to describe their understanding of LHV. Five subthemes emerged from the data collected with this question. (See Table 2 .)

Theme 2: Experience addressing LHV . In the second question, participants were asked about their experience with addressing incidents of LHV. Six subthemes were identified. (See Table 3 .)

Theme 3: Role perception in addressing LHV . In the third question, participants were asked what they perceive their role to be in addressing LHV. Six subthemes resulted from this question. (See Table 4 .)

Theme 4: Organizational impediment to addressing LHV . In question four, participants were asked to describe the factors within the organization that influence or impede their role in addressing LHV. This question yielded nine subthemes. (See Table 5 .)

Substantive theory

As a result of the themes that emerged from the data, a substantive theory was developed. This is especially important for the nursing profession to develop as a scientifically based practice. Theories help guide research and provide the expansion, generation, and validation of the science of nursing knowledge. 26 The substantive theory will help nurse leaders become more cognizant of the role that effective leadership plays in preventing or intervening in incidents of LHV in the workplace. The analysis revealed that nurse leaders are aware that the quality of patient care and staff well-being can be adversely affected by the impact of LHV.

Data themes were used to formulate the following theory: Nurse leaders address LHV affecting their staff members by solving problems, creating a safe work environment, and reducing institutional barriers that impede addressing LHV in a timely fashion. Nurse leaders perceive their role as a problem-solver, which is a necessary step in advocacy. 27 Problem-solving is a process that contains the elements of decision-making and critical thinking. 28

The theory that emerged from the core categories explicitly focused on the central phenomenon of LHV in the nursing work environment. Figure 1 shows the interrelatedness of the themes to the resultant substantive theory.

Discussion and implications

The study results have several implications for both the nursing profession and nurse leaders. The nursing profession requires decisive and robust leadership, and the role of the nurse leader is to be a combination of nurturer, investigator, and judge to examine incidents of LHV. 26,29-32 Nurse leaders are responsible for setting the tone and expectations for a safe work environment. This includes modeling the expected ethical behaviors; for example, doing the right things for the right reasons, being collegial toward each other, and being respectful of other's differences. One participant remarked, “This is a different world based on how I was raised. I was raised to be respectful to people.”

In addition, nurse leaders are responsible for enforcing policies created to address disruptive behaviors and working with the administration as soon as an incident occurs. Past research indicates that a healthy and collaborative work environment fosters nurse engagement and patient safety. 25,30 Staff members and patients need a leader to protect them when necessary; thus, the nurse leader needs to “walk the walk” in providing a safe environment for all. Nurse leaders engaged in these kinds of behaviors are providing strong leadership and practicing strong decision-making, thus ensuring the continued robustness of their organizations.

Recommendations and limitations

Future research could replicate this study in a different geographic region to explore the causes of LHV by soliciting the views of nursing students, new graduate nurses, and nurse educators from unionized and nonunionized hospital systems and comparing the results to further understand this phenomenon. Additionally, developing a tool to test the substantive theory could substantiate the nurse leader's role as a problem-solver to address incidence of LHV in the workplace.

The decision to conduct this study in one type of healthcare organization limits the ability to compare the interviewed nurse leaders' experiences with nurse leaders in other healthcare organizations. The experiences of nurses in other healthcare organizations may be different; thus, overall generalizability of the study may be limited.

Say “no” to the status quo

The results of this study support the findings of previous researchers. 23,31,33,34 Accepting the status quo is unacceptable and can cause irreparable harm to organizational well-being if LHV isn't addressed. Collaboration between nurse leaders and administrators is essential to successfully reduce institutional obstacles that prevent the timely handling of LHV incidents. The role of the nurse leader as a problem-solver should be clear, defined, and well supported to seek resolutions to toxic behaviors that are hurting the work environment. But we must remember that creating a policy doesn't equal change. Every employee from the lowest level in the organization to the highest ranks of administration must model civil behaviors.

INSTRUCTIONS Nurse leaders as problem-solvers: Addressing lateral and horizontal violence

Test instructions.

• Read the article. The test for this CE activity is to be taken online at http://nursing.ceconnection.com .
• You'll need to create (it's free!) and login to your personal CE Planner account before taking online tests. Your planner will keep track of all your Lippincott Professional Development online CE activities for you.
• There's only one correct answer for each question. A passing score for this test is 14 correct answers. If you pass, you can print your certificate of earned contact hours and access the answer key. If you fail, you have the option of taking the test again at no additional cost.
• For questions, contact Lippincott Professional Development: 1-800-787-8985 .
• Registration deadline is June 3, 2022 .

PROVIDER ACCREDITATION

Lippincott Professional Development will award 1.5 contact hours for this continuing nursing education activity.

Lippincott Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 1.5 contact hours, and the District of Columbia, Georgia, and Florida CE Broker #50-1223.

Payment: The registration fee for this test is $17.95.

• + Favorites
• View in Gallery

Readers Of this Article Also Read

Leadership strategies to promote frontline nursing staff engagement, nurse leader competencies: a toolkit for success, keeping the peace: conflict management strategies for nurse managers, principles for sustaining shared/professional governance in nursing, workplace incivility: nurse leaders as change agents.

• français
• español
• português

Related Links

Community health management: a problem-solving approach.

View Statistics

Description, document number, other identifiers, collections.

• EMRO Publications

Show Statistical Information

• 4. Regional Office for the Eastern Mediterranean

• Search Menu

Sign in through your institution

• Browse content in Arts and Humanities
• Browse content in Archaeology
• Anglo-Saxon and Medieval Archaeology
• Archaeological Methodology and Techniques
• Archaeology by Region
• Archaeology of Religion
• Archaeology of Trade and Exchange
• Biblical Archaeology
• Contemporary and Public Archaeology
• Environmental Archaeology
• Historical Archaeology
• History and Theory of Archaeology
• Industrial Archaeology
• Landscape Archaeology
• Mortuary Archaeology
• Prehistoric Archaeology
• Underwater Archaeology
• Zooarchaeology
• Browse content in Architecture
• Architectural Structure and Design
• History of Architecture
• Residential and Domestic Buildings
• Theory of Architecture
• Browse content in Art
• Art Subjects and Themes
• History of Art
• Industrial and Commercial Art
• Theory of Art
• Biographical Studies
• Byzantine Studies
• Browse content in Classical Studies
• Classical History
• Classical Philosophy
• Classical Mythology
• Classical Numismatics
• Classical Literature
• Classical Reception
• Classical Art and Architecture
• Classical Oratory and Rhetoric
• Greek and Roman Papyrology
• Greek and Roman Epigraphy
• Greek and Roman Law
• Greek and Roman Archaeology
• Late Antiquity
• Religion in the Ancient World
• Social History
• Digital Humanities
• Browse content in History
• Colonialism and Imperialism
• Diplomatic History
• Environmental History
• Genealogy, Heraldry, Names, and Honours
• Genocide and Ethnic Cleansing
• Historical Geography
• History by Period
• History of Emotions
• History of Agriculture
• History of Education
• History of Gender and Sexuality
• Industrial History
• Intellectual History
• International History
• Labour History
• Legal and Constitutional History
• Local and Family History
• Maritime History
• Military History
• National Liberation and Post-Colonialism
• Oral History
• Political History
• Public History
• Regional and National History
• Revolutions and Rebellions
• Slavery and Abolition of Slavery
• Social and Cultural History
• Theory, Methods, and Historiography
• Urban History
• World History
• Browse content in Language Teaching and Learning
• Language Learning (Specific Skills)
• Language Teaching Theory and Methods
• Browse content in Linguistics
• Applied Linguistics
• Cognitive Linguistics
• Computational Linguistics
• Forensic Linguistics
• Grammar, Syntax and Morphology
• Historical and Diachronic Linguistics
• History of English
• Language Evolution
• Language Reference
• Language Acquisition
• Language Variation
• Language Families
• Lexicography
• Linguistic Anthropology
• Linguistic Theories
• Linguistic Typology
• Phonetics and Phonology
• Psycholinguistics
• Sociolinguistics
• Translation and Interpretation
• Writing Systems
• Browse content in Literature
• Bibliography
• Children's Literature Studies
• Literary Studies (Romanticism)
• Literary Studies (American)
• Literary Studies (Asian)
• Literary Studies (European)
• Literary Studies (Eco-criticism)
• Literary Studies (Modernism)
• Literary Studies - World
• Literary Studies (1500 to 1800)
• Literary Studies (19th Century)
• Literary Studies (20th Century onwards)
• Literary Studies (African American Literature)
• Literary Studies (British and Irish)
• Literary Studies (Early and Medieval)
• Literary Studies (Fiction, Novelists, and Prose Writers)
• Literary Studies (Gender Studies)
• Literary Studies (Graphic Novels)
• Literary Studies (History of the Book)
• Literary Studies (Plays and Playwrights)
• Literary Studies (Poetry and Poets)
• Literary Studies (Postcolonial Literature)
• Literary Studies (Queer Studies)
• Literary Studies (Science Fiction)
• Literary Studies (Travel Literature)
• Literary Studies (War Literature)
• Literary Studies (Women's Writing)
• Literary Theory and Cultural Studies
• Mythology and Folklore
• Shakespeare Studies and Criticism
• Browse content in Media Studies
• Browse content in Music
• Applied Music
• Dance and Music
• Ethics in Music
• Ethnomusicology
• Gender and Sexuality in Music
• Medicine and Music
• Music Cultures
• Music and Media
• Music and Religion
• Music and Culture
• Music Education and Pedagogy
• Music Theory and Analysis
• Musical Scores, Lyrics, and Libretti
• Musical Structures, Styles, and Techniques
• Musicology and Music History
• Performance Practice and Studies
• Race and Ethnicity in Music
• Sound Studies
• Browse content in Performing Arts
• Browse content in Philosophy
• Aesthetics and Philosophy of Art
• Epistemology
• Feminist Philosophy
• History of Western Philosophy
• Metaphysics
• Moral Philosophy
• Non-Western Philosophy
• Philosophy of Language
• Philosophy of Mind
• Philosophy of Perception
• Philosophy of Science
• Philosophy of Action
• Philosophy of Law
• Philosophy of Religion
• Philosophy of Mathematics and Logic
• Practical Ethics
• Social and Political Philosophy
• Browse content in Religion
• Biblical Studies
• Christianity
• East Asian Religions
• History of Religion
• Judaism and Jewish Studies
• Qumran Studies
• Religion and Education
• Religion and Health
• Religion and Politics
• Religion and Science
• Religion and Law
• Religion and Art, Literature, and Music
• Religious Studies
• Browse content in Society and Culture
• Cookery, Food, and Drink
• Cultural Studies
• Customs and Traditions
• Ethical Issues and Debates
• Hobbies, Games, Arts and Crafts
• Natural world, Country Life, and Pets
• Popular Beliefs and Controversial Knowledge
• Sports and Outdoor Recreation
• Technology and Society
• Travel and Holiday
• Visual Culture
• Browse content in Law
• Arbitration
• Browse content in Company and Commercial Law
• Commercial Law
• Company Law
• Browse content in Comparative Law
• Systems of Law
• Competition Law
• Browse content in Constitutional and Administrative Law
• Government Powers
• Judicial Review
• Local Government Law
• Military and Defence Law
• Parliamentary and Legislative Practice
• Construction Law
• Contract Law
• Browse content in Criminal Law
• Criminal Procedure
• Criminal Evidence Law
• Sentencing and Punishment
• Employment and Labour Law
• Environment and Energy Law
• Browse content in Financial Law
• Banking Law
• Insolvency Law
• History of Law
• Human Rights and Immigration
• Intellectual Property Law
• Browse content in International Law
• Private International Law and Conflict of Laws
• Public International Law
• IT and Communications Law
• Jurisprudence and Philosophy of Law
• Law and Politics
• Law and Society
• Browse content in Legal System and Practice
• Courts and Procedure
• Legal Skills and Practice
• Legal System - Costs and Funding
• Primary Sources of Law
• Regulation of Legal Profession
• Medical and Healthcare Law
• Browse content in Policing
• Criminal Investigation and Detection
• Police and Security Services
• Police Procedure and Law
• Police Regional Planning
• Browse content in Property Law
• Personal Property Law
• Restitution
• Study and Revision
• Terrorism and National Security Law
• Browse content in Trusts Law
• Wills and Probate or Succession
• Browse content in Medicine and Health
• Browse content in Allied Health Professions
• Arts Therapies
• Clinical Science
• Dietetics and Nutrition
• Occupational Therapy
• Operating Department Practice
• Physiotherapy
• Radiography
• Speech and Language Therapy
• Browse content in Anaesthetics
• General Anaesthesia
• Clinical Neuroscience
• Browse content in Clinical Medicine
• Acute Medicine
• Cardiovascular Medicine
• Clinical Genetics
• Clinical Pharmacology and Therapeutics
• Dermatology
• Endocrinology and Diabetes
• Gastroenterology
• Genito-urinary Medicine
• Geriatric Medicine
• Infectious Diseases
• Medical Toxicology
• Medical Oncology
• Pain Medicine
• Palliative Medicine
• Rehabilitation Medicine
• Respiratory Medicine and Pulmonology
• Rheumatology
• Sleep Medicine
• Sports and Exercise Medicine
• Community Medical Services
• Critical Care
• Emergency Medicine
• Forensic Medicine
• Haematology
• History of Medicine
• Browse content in Medical Skills
• Clinical Skills
• Communication Skills
• Nursing Skills
• Surgical Skills
• Browse content in Medical Dentistry
• Oral and Maxillofacial Surgery
• Paediatric Dentistry
• Restorative Dentistry and Orthodontics
• Surgical Dentistry
• Medical Ethics
• Medical Statistics and Methodology
• Browse content in Neurology
• Clinical Neurophysiology
• Neuropathology
• Nursing Studies
• Browse content in Obstetrics and Gynaecology
• Gynaecology
• Occupational Medicine
• Ophthalmology
• Otolaryngology (ENT)
• Browse content in Paediatrics
• Neonatology
• Browse content in Pathology
• Chemical Pathology
• Clinical Cytogenetics and Molecular Genetics
• Histopathology
• Medical Microbiology and Virology
• Patient Education and Information
• Browse content in Pharmacology
• Psychopharmacology
• Browse content in Popular Health
• Caring for Others
• Complementary and Alternative Medicine
• Self-help and Personal Development
• Browse content in Preclinical Medicine
• Cell Biology
• Molecular Biology and Genetics
• Reproduction, Growth and Development
• Primary Care
• Professional Development in Medicine
• Browse content in Psychiatry
• Addiction Medicine
• Child and Adolescent Psychiatry
• Forensic Psychiatry
• Learning Disabilities
• Old Age Psychiatry
• Psychotherapy
• Browse content in Public Health and Epidemiology
• Epidemiology
• Public Health
• Browse content in Radiology
• Clinical Radiology
• Interventional Radiology
• Nuclear Medicine
• Radiation Oncology
• Reproductive Medicine
• Browse content in Surgery
• Cardiothoracic Surgery
• Gastro-intestinal and Colorectal Surgery
• General Surgery
• Neurosurgery
• Paediatric Surgery
• Peri-operative Care
• Plastic and Reconstructive Surgery
• Surgical Oncology
• Transplant Surgery
• Trauma and Orthopaedic Surgery
• Vascular Surgery
• Browse content in Science and Mathematics
• Browse content in Biological Sciences
• Aquatic Biology
• Biochemistry
• Bioinformatics and Computational Biology
• Developmental Biology
• Ecology and Conservation
• Evolutionary Biology
• Genetics and Genomics
• Microbiology
• Molecular and Cell Biology
• Natural History
• Plant Sciences and Forestry
• Research Methods in Life Sciences
• Structural Biology
• Systems Biology
• Zoology and Animal Sciences
• Browse content in Chemistry
• Analytical Chemistry
• Computational Chemistry
• Crystallography
• Environmental Chemistry
• Industrial Chemistry
• Inorganic Chemistry
• Materials Chemistry
• Medicinal Chemistry
• Mineralogy and Gems
• Organic Chemistry
• Physical Chemistry
• Polymer Chemistry
• Study and Communication Skills in Chemistry
• Theoretical Chemistry
• Browse content in Computer Science
• Artificial Intelligence
• Computer Architecture and Logic Design
• Game Studies
• Human-Computer Interaction
• Mathematical Theory of Computation
• Programming Languages
• Software Engineering
• Systems Analysis and Design
• Virtual Reality
• Browse content in Computing
• Business Applications
• Computer Security
• Computer Games
• Computer Networking and Communications
• Digital Lifestyle
• Graphical and Digital Media Applications
• Operating Systems
• Browse content in Earth Sciences and Geography
• Atmospheric Sciences
• Environmental Geography
• Geology and the Lithosphere
• Maps and Map-making
• Meteorology and Climatology
• Oceanography and Hydrology
• Palaeontology
• Physical Geography and Topography
• Regional Geography
• Soil Science
• Urban Geography
• Browse content in Engineering and Technology
• Agriculture and Farming
• Biological Engineering
• Civil Engineering, Surveying, and Building
• Electronics and Communications Engineering
• Energy Technology
• Engineering (General)
• Environmental Science, Engineering, and Technology
• History of Engineering and Technology
• Mechanical Engineering and Materials
• Technology of Industrial Chemistry
• Transport Technology and Trades
• Browse content in Environmental Science
• Applied Ecology (Environmental Science)
• Conservation of the Environment (Environmental Science)
• Environmental Sustainability
• Environmentalist Thought and Ideology (Environmental Science)
• Management of Land and Natural Resources (Environmental Science)
• Natural Disasters (Environmental Science)
• Nuclear Issues (Environmental Science)
• Pollution and Threats to the Environment (Environmental Science)
• Social Impact of Environmental Issues (Environmental Science)
• History of Science and Technology
• Browse content in Materials Science
• Ceramics and Glasses
• Composite Materials
• Metals, Alloying, and Corrosion
• Nanotechnology
• Browse content in Mathematics
• Applied Mathematics
• Biomathematics and Statistics
• History of Mathematics
• Mathematical Education
• Mathematical Finance
• Mathematical Analysis
• Numerical and Computational Mathematics
• Probability and Statistics
• Pure Mathematics
• Browse content in Neuroscience
• Cognition and Behavioural Neuroscience
• Development of the Nervous System
• Disorders of the Nervous System
• History of Neuroscience
• Invertebrate Neurobiology
• Molecular and Cellular Systems
• Neuroendocrinology and Autonomic Nervous System
• Neuroscientific Techniques
• Sensory and Motor Systems
• Browse content in Physics
• Astronomy and Astrophysics
• Atomic, Molecular, and Optical Physics
• Biological and Medical Physics
• Classical Mechanics
• Computational Physics
• Condensed Matter Physics
• Electromagnetism, Optics, and Acoustics
• History of Physics
• Mathematical and Statistical Physics
• Measurement Science
• Nuclear Physics
• Particles and Fields
• Plasma Physics
• Quantum Physics
• Relativity and Gravitation
• Semiconductor and Mesoscopic Physics
• Browse content in Psychology
• Affective Sciences
• Clinical Psychology
• Cognitive Psychology
• Cognitive Neuroscience
• Criminal and Forensic Psychology
• Developmental Psychology
• Educational Psychology
• Evolutionary Psychology
• Health Psychology
• History and Systems in Psychology
• Music Psychology
• Neuropsychology
• Organizational Psychology
• Psychological Assessment and Testing
• Psychology of Human-Technology Interaction
• Psychology Professional Development and Training
• Research Methods in Psychology
• Social Psychology
• Browse content in Social Sciences
• Browse content in Anthropology
• Anthropology of Religion
• Human Evolution
• Medical Anthropology
• Physical Anthropology
• Regional Anthropology
• Social and Cultural Anthropology
• Theory and Practice of Anthropology
• Browse content in Business and Management
• Business Ethics
• Business Strategy
• Business History
• Business and Technology
• Business and Government
• Business and the Environment
• Comparative Management
• Corporate Governance
• Corporate Social Responsibility
• Entrepreneurship
• Health Management
• Human Resource Management
• Industrial and Employment Relations
• Industry Studies
• Information and Communication Technologies
• International Business
• Knowledge Management
• Management and Management Techniques
• Operations Management
• Organizational Theory and Behaviour
• Pensions and Pension Management
• Public and Nonprofit Management
• Social Issues in Business and Management
• Strategic Management
• Supply Chain Management
• Browse content in Criminology and Criminal Justice
• Criminal Justice
• Criminology
• Forms of Crime
• International and Comparative Criminology
• Youth Violence and Juvenile Justice
• Development Studies
• Browse content in Economics
• Agricultural, Environmental, and Natural Resource Economics
• Asian Economics
• Behavioural Finance
• Behavioural Economics and Neuroeconomics
• Econometrics and Mathematical Economics
• Economic History
• Economic Systems
• Economic Methodology
• Economic Development and Growth
• Financial Markets
• Financial Institutions and Services
• General Economics and Teaching
• Health, Education, and Welfare
• History of Economic Thought
• International Economics
• Labour and Demographic Economics
• Law and Economics
• Macroeconomics and Monetary Economics
• Microeconomics
• Public Economics
• Urban, Rural, and Regional Economics
• Welfare Economics
• Browse content in Education
• Adult Education and Continuous Learning
• Care and Counselling of Students
• Early Childhood and Elementary Education
• Educational Equipment and Technology
• Educational Strategies and Policy
• Higher and Further Education
• Organization and Management of Education
• Philosophy and Theory of Education
• Schools Studies
• Secondary Education
• Teaching of a Specific Subject
• Teaching of Specific Groups and Special Educational Needs
• Teaching Skills and Techniques
• Browse content in Environment
• Applied Ecology (Social Science)
• Climate Change
• Conservation of the Environment (Social Science)
• Environmentalist Thought and Ideology (Social Science)
• Management of Land and Natural Resources (Social Science)
• Natural Disasters (Environment)
• Pollution and Threats to the Environment (Social Science)
• Social Impact of Environmental Issues (Social Science)
• Sustainability
• Browse content in Human Geography
• Cultural Geography
• Economic Geography
• Political Geography
• Browse content in Interdisciplinary Studies
• Communication Studies
• Museums, Libraries, and Information Sciences
• Browse content in Politics
• African Politics
• Asian Politics
• Chinese Politics
• Comparative Politics
• Conflict Politics
• Elections and Electoral Studies
• Environmental Politics
• Ethnic Politics
• European Union
• Foreign Policy
• Gender and Politics
• Human Rights and Politics
• Indian Politics
• International Relations
• International Organization (Politics)
• Irish Politics
• Latin American Politics
• Middle Eastern Politics
• Political Behaviour
• Political Economy
• Political Institutions
• Political Methodology
• Political Communication
• Political Philosophy
• Political Sociology
• Political Theory
• Politics and Law
• Politics of Development
• Public Policy
• Public Administration
• Qualitative Political Methodology
• Quantitative Political Methodology
• Regional Political Studies
• Russian Politics
• Security Studies
• State and Local Government
• UK Politics
• US Politics
• Browse content in Regional and Area Studies
• African Studies
• Asian Studies
• East Asian Studies
• Japanese Studies
• Latin American Studies
• Middle Eastern Studies
• Native American Studies
• Scottish Studies
• Browse content in Research and Information
• Research Methods
• Browse content in Social Work
• Addictions and Substance Misuse
• Adoption and Fostering
• Care of the Elderly
• Child and Adolescent Social Work
• Couple and Family Social Work
• Direct Practice and Clinical Social Work
• Emergency Services
• Human Behaviour and the Social Environment
• International and Global Issues in Social Work
• Mental and Behavioural Health
• Social Justice and Human Rights
• Social Policy and Advocacy
• Social Work and Crime and Justice
• Social Work Macro Practice
• Social Work Practice Settings
• Social Work Research and Evidence-based Practice
• Welfare and Benefit Systems
• Browse content in Sociology
• Childhood Studies
• Community Development
• Comparative and Historical Sociology
• Disability Studies
• Economic Sociology
• Gender and Sexuality
• Gerontology and Ageing
• Health, Illness, and Medicine
• Marriage and the Family
• Migration Studies
• Occupations, Professions, and Work
• Organizations
• Population and Demography
• Race and Ethnicity
• Social Theory
• Social Movements and Social Change
• Social Research and Statistics
• Social Stratification, Inequality, and Mobility
• Sociology of Religion
• Sociology of Education
• Sport and Leisure
• Urban and Rural Studies
• Browse content in Warfare and Defence
• Defence Strategy, Planning, and Research
• Land Forces and Warfare
• Military Administration
• Military Life and Institutions
• Naval Forces and Warfare
• Other Warfare and Defence Issues
• Peace Studies and Conflict Resolution
• Weapons and Equipment

• < Previous chapter
• Next chapter >

9 Problem-Solving and Decision-Making Skills for Public Health Practice

• Published: October 2023
• Cite Icon Cite
• Permissions Icon Permissions

This chapter provides an initial definition of problem-solving and the components of the problem-solving process. It identifies common mistakes early in the process and their implications. It explains that the first step toward successful problem-solving is thoroughly and accurately defining the problem and acknowledging that multiple solutions must be considered. It explores multiple approaches to problem-solving, such as rational problem-solving and organic problem-solving, as well as a type of organic problem-solving called appreciative inquiry. The chapter also explores seven decision-making styles and elaborates on common mistakes made during the process, as well as how to overcome them.

Personal account

• Sign in with email/username & password
• Get email alerts
• Save searches
• Purchase content
• Activate your purchase/trial code
• Add your ORCID iD

Institutional access

Sign in with a library card.

• Sign in with username/password
• Recommend to your librarian
• Institutional account management
• Get help with access

Access to content on Oxford Academic is often provided through institutional subscriptions and purchases. If you are a member of an institution with an active account, you may be able to access content in one of the following ways:

IP based access

Typically, access is provided across an institutional network to a range of IP addresses. This authentication occurs automatically, and it is not possible to sign out of an IP authenticated account.

Choose this option to get remote access when outside your institution. Shibboleth/Open Athens technology is used to provide single sign-on between your institution’s website and Oxford Academic.

• Click Sign in through your institution.
• Select your institution from the list provided, which will take you to your institution's website to sign in.
• When on the institution site, please use the credentials provided by your institution. Do not use an Oxford Academic personal account.
• Following successful sign in, you will be returned to Oxford Academic.

If your institution is not listed or you cannot sign in to your institution’s website, please contact your librarian or administrator.

Enter your library card number to sign in. If you cannot sign in, please contact your librarian.

Society Members

Society member access to a journal is achieved in one of the following ways:

Sign in through society site

Many societies offer single sign-on between the society website and Oxford Academic. If you see ‘Sign in through society site’ in the sign in pane within a journal:

• Click Sign in through society site.
• When on the society site, please use the credentials provided by that society. Do not use an Oxford Academic personal account.

If you do not have a society account or have forgotten your username or password, please contact your society.

Sign in using a personal account

Some societies use Oxford Academic personal accounts to provide access to their members. See below.

A personal account can be used to get email alerts, save searches, purchase content, and activate subscriptions.

Some societies use Oxford Academic personal accounts to provide access to their members.

Viewing your signed in accounts

Click the account icon in the top right to:

• View your signed in personal account and access account management features.
• View the institutional accounts that are providing access.

Signed in but can't access content

Oxford Academic is home to a wide variety of products. The institutional subscription may not cover the content that you are trying to access. If you believe you should have access to that content, please contact your librarian.

For librarians and administrators, your personal account also provides access to institutional account management. Here you will find options to view and activate subscriptions, manage institutional settings and access options, access usage statistics, and more.

Our books are available by subscription or purchase to libraries and institutions.

• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Rights and permissions
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

• Faye Abdellah: 21 Nursing Problems Theory

Faye Abdellah is a celebrated nurse theorist, military nurse, and leader in nursing research. Get to know the major concepts of her “ 21 Nursing Problems ” nursing theory, its application, and its impact on nursing.

Table of Contents

Early life of faye abdellah, as an educator, as a researcher, established nursing standards, military nursing service, abdellah’s typology of 21 nursing problems, awards and honors, assumptions, nursing problems, problem solving, basic needs, sustenal care needs, remedial care needs, restorative care needs, patient-centered approaches to nursing, 21 nursing problems and the nursing process, recommended resources, external links, biography of faye glenn abdellah.

Faye Glenn Abdellah (March 13, 1919 – present) is a nursing research pioneer who developed the “Twenty-One Nursing Problems.” Her nursing model was progressive for the time in that it refers to a nursing diagnosis during a time in which nurses were taught that diagnoses were not part of their role in health care.

She was the first nurse officer to rank a two-star rear admiral, the first nurse, and the first woman to serve as a Deputy Surgeon General.

On March 13, 1919, Faye Abdellah was born in New York to a father of Algerian heritage and a Scottish mother. Her family subsequently moved to New Jersey, where she attended high school.

Years later, on May 6, 1937, the German hydrogen-fueled airship Hindenburg exploded over Lakehurst.

Abdellah and her brother witnessed the explosion, destruction, and fire after the ignited hydrogen killed many people. That incident became the turning point in Abdellah’s life. It was that time when she realized that she would never again be powerless to assist when people were in such a dire need of assistance. It was at that moment she vowed that she would learn to nurse and become a professional nurse.

Faye Abdellah earned a nursing diploma from Fitkin Memorial Hospital’s School of Nursing, now known as Ann May School of Nursing.

It was sufficient to practice nursing during her time in the 1940s, but she believed that nursing care should be based on research, not hours of care.

Abdellah went on to earn three degrees from Columbia University: a bachelor of science degree in nursing in 1945, a master of arts degree in physiology in 1947, and a doctor of education degree in 1955.

With her advanced education, Abdellah could have chosen to become a doctor. However, as she explained in one of her interviews that she wanted to be an M.D. because she could do all she wanted to do in nursing, which is a caring profession.

Career and Appointments

In her early twenties, Faye Abdellah worked as a health nurse at a private school, and her first administrative position was on the faculty of Yale University from 1945-1949. At that time, she was required to teach a class called “120 Principles of Nursing Practice,” using a standard nursing textbook published by the National League for Nursing. The book included guidelines that had no scientific basis, which challenged Abdellah to explain everything she called the “brilliant” students.

After a year, Abdellah became so frustrated that she gathered her colleagues in the Yale courtyard and burned the textbooks. The next morning the school’s dean told her she would have to pay for the destroyed texts. It took a year for Abdellah to settle the debt, but she never regretted her actions because it started her on the long road to pursue the scientific basis of the nursing practice .

In 1949, she met Lucile Petry Leone, the first Nurse Officer, and decided to join the Public Health Service. Her first assignment was with the division of nursing that focused on research and studies. They performed studies with numerous hospitals to improve nursing practice .

Abdellah was an advocate of degree programs for nursing. Diploma programs, she believes, were never meant to prepare nurses at the professional level. Nursing education, she argued, should be based on research; she herself became among the first in her role as an educator to focus on theory and research. Her first studies were qualitative; they simply described situations. As her career progressed, her research evolved to include physiology, chemistry, and behavioral sciences.

In 1957, Abdellah spearheaded a research team in Manchester, Connecticut, that established the groundwork for what became known as progressive patient care . In this framework, critical care patients were treated in an intensive care unit, followed by a transition to immediate care and then home care. The first two segments of the care program proved very popular within the caregiver profession. Abdellah is also credited with developing the first nationally tested coronary care unit as an outgrowth of her work in Manchester.

Home care, which is the third phase of the progressive patient care equation, was not widely accepted in the mid-twentieth century. Abdellah explained that people at the time kept saying home care would mean having a maid or a nurse in everyone’s home. They could not figure out that home care with nurses teaching self-care would help patients regain independent function. Forty years later, home care had become an essential part of long-term health care.

In another innovation within her field, Abdellah developed the Patient Assessment of Care Evaluation (PACE), a system of standards used to measure the relative quality of individual health-care facilities that were still used in the healthcare industry into the 21st century. She was also one of the first people in the healthcare industry to develop a classification system for patient care and patient-oriented records.

Classification systems have evolved in different ways within the health-care industry, and Abdellah’s work was foundational in developing the most widely used form: Diagnostic related groups, or DRGs. DRGs, which became the standard coding system used by Medicare, categorize patients according to particular primary and secondary diagnoses. This system keeps health-care costs down because each DRG code includes the maximum amount Medicare will payout for a specific diagnosis or procedure while also taking into account patient age and length of stay in a healthcare facility. Providers are given an incentive to keep costs down because they only realize a profit if costs are less than the amount specified by the relevant DRG category.

During her 40-year career as a Commissioned Officer in the U.S. Public Health Service from 1949 to 1989, Abdellah was assigned to work with the Korean people during the Korean War. As a senior officer, she was alternatively assigned to Japan, China , Russia, Australia, and the Scandinavian countries to identify the Public Health Service’s role in dealing with various health problems. She was able to assist and initiate, in an advisory role, numerous studies in those countries.

She served as Chief Nurse Officer from 1970 to 1987 and was the first nurse to achieve the rank of a two-star Flag Officer named by U.S. Surgeon General C. Everett Koop as the first woman and nurse Deputy Surgeon General from 1982 to 1989. After retirement, Abdellah founded and served as the first dean in the Graduate School of Nursing, GSN, Uniformed Services University of the Health Sciences (USUHS).

Faye Abdellah is well known for developing the “Twenty-One Nursing Problems Theory” that has interrelated the concepts of health, nursing problems, and problem-solving.

She views nursing as an art and a science that molds the attitude, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help individuals cope with their health needs, whether they are ill or well.

She used Henderson’s 14 basic human needs and nursing research to establish the classification of nursing problems.

Faye Abdellah’s theory is further discussed below.

As a consultant and educator, Faye Abdellah shared her nursing theories with caregivers around the world. She led seminars in France, Portugal, Israel, Japan, China, New Zealand, Australia, and the former Soviet Union. She also served as a research consultant to the World Health Organization. From her global perspective, Abdellah learned to appreciate nontraditional and complementary medical treatments and developed the belief such non-Western treatments deserved scientific research.

Also, she has been active in professional nursing associations and is a prolific author, with more than 150 publications. Her publications include Better Nursing Care Through Nursing Research and Patient-Centered Approaches to Nursing . She also developed educational materials in many areas of public health, including AIDS , hospice care , and drug addiction.

Abdellah considers her greatest accomplishment being able to “play a role in establishing a foundation for nursing research as a science.” Her book, Patient-Centered Approaches to Nursing , emphasizes nursing science and has elicited changes throughout nursing curricula. Her work, which is based on the problem-solving method, serves as a vehicle for delineating nursing (patient) problems as the patient moves toward a healthy outcome.

Faye Abdellah is recognized as a leader in nursing research and nursing as a profession within the Public Health Service (PHS) and as an international expert on health problems. She was named a “living legend” by the American Academy of Nursing in 1994 and was inducted into the National Women’s Hall of Fame in 2000 for a lifetime spent establishing and leading essential health care programs for the United States. In 2012, Abdellah was inducted into the American Nurses Association Hall of Fame for a lifetime of contributions to nursing.

Her contributions to nursing and public health have been recognized with almost 90 professional and academic honors, such as the Allied Signal Achievement Award for pioneering research in aging and Sigma Theta Tau’s Lifetime Achievement Award.

Abdellah’s leadership , her publications, and her lifelong contributions have set a new standard for nursing and health care. Her legacy of more than 60 years of extraordinary accomplishments lives nationally and globally.

Aside from being the first nurse and the first woman to serve as a Deputy Surgeon General, Faye Glenn Abdellah also made a name in the nursing profession to formulate her “21 Nursing Problems Theory.” Her theory changed the focus of nursing from disease-centered to patient-centered and began to include the care of families and the elderly in nursing care. The Patient Assessment of Care Evaluation developed by Abdellah is now the standard used in the United States.

Abdellah’s 21 Nursing Problems Theory

According to Faye Glenn Abdellah’s theory, “Nursing is based on an art and science that molds the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people, sick or well, cope with their health needs.”

The patient-centered approach to nursing was developed from Abdellah’s practice, and the theory is considered a human needs theory. It was formulated to be an instrument for nursing education , so it most suitable and useful in that field. The nursing model is intended to guide care in hospital institutions but can also be applied to community health nursing, as well.

The assumptions Abdellah’s “21 Nursing Problems Theory” relate to change and anticipated changes that affect nursing; the need to appreciate the interconnectedness of social enterprises and social problems; the impact of problems such as poverty, racism, pollution, education, and so forth on health and health care delivery; changing nursing education ; continuing education for professional nurses; and development of nursing leaders from underserved groups.

• Learn to know the patient.
• Sort out relevant and significant data.
• Make generalizations about available data concerning similar nursing problems presented by other patients.
• Identify the therapeutic plan.
• Test generalizations with the patient and make additional generalizations.
• Validate the patient’s conclusions about his nursing problems.
• Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting this behavior.
• Explore the patient’s and family’s reaction to the therapeutic plan and involve them in the plan.
• Identify how the nurse feels about the patient’s nursing problems.
• Discuss and develop a comprehensive nursing care plan .

Major Concepts of 21 Nursing Problems Theory

The model has interrelated concepts of health and nursing problems and problem-solving, which is inherently logical in nature.

She describes nursing recipients as individuals (and families), although she does not delineate her beliefs or assumptions about the nature of human beings.

Health, or the achieving of it, is the purpose of nursing services. Although Abdellah does not define health, she speaks to “total health needs” and “a healthy state of mind and body.”

Health may be defined as the dynamic pattern of functioning whereby there is a continued interaction with internal and external forces that results in the optimal use of necessary resources to minimize vulnerabilities.

Society is included in “ planning for optimum health on local, state, and international levels.” However, as Abdellah further delineates her ideas, the focus of nursing service is clearly the individual.

The client’s health needs can be viewed as problems, overt as an apparent condition, or covert as a hidden or concealed one.

Because covert problems can be emotional, sociological, and interpersonal in nature, they are often missed or misunderstood. Yet, in many instances, solving the covert problems may solve the overt problems as well.

Quality professional nursing care requires that nurses be able to identify and solve overt and covert nursing problems. The problem-solving process can meet these requirements by identifying the problem, selecting pertinent data, formulating hypotheses, testing hypotheses through collecting data, and revising hypotheses when necessary based on conclusions obtained from the data.

Subconcepts

The following are the subconcepts of Faye Abdellah’s “21 Nursing Problems” theory and their definitions.

The 21 nursing problems fall into three categories: physical, sociological, and emotional needs of patients; types of interpersonal relationships between the patient and nurse; and common elements of patient care . She used Henderson’s 14 basic human needs and nursing research to establish the classification of nursing problems. Abdellah’s 21 Nursing Problems are the following:

• To maintain good hygiene and physical comfort .
• To promote optimal activity: exercise, rest, sleep
• To promote safety by preventing accidents, injuries, or other trauma and preventing the spread of infection .
• To maintain good body mechanics and prevent and correct the deformity.
• To facilitate the maintenance of a supply of oxygen to all body cells.
• To facilitate the maintenance of nutrition for all body cells.
• To facilitate the maintenance of elimination.
• To facilitate the maintenance of fluid and electrolyte balance.
• To recognize the physiologic responses of the body to disease conditions—pathologic, physiologic, and compensatory.
• To facilitate the maintenance of regulatory mechanisms and functions.
• To facilitate the maintenance of sensory function.
• To identify and accept positive and negative expressions, feelings, and reactions.
• To identify and accept interrelatedness of emotions and organic illness.
• To facilitate the maintenance of effective verbal and nonverbal communication .
• To promote the development of productive interpersonal relationships.
• To facilitate progress toward achievement and personal spiritual goals.
• To create or maintain a therapeutic environment.
• To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs.
• To accept the optimum possible goals in the light of limitations, physical and emotional.
• To use community resources as an aid in resolving problems that arise from an illness.
• To understand the role of social problems as influencing factors in the cause of illness.

Moreover, patients’ needs are further divided into four categories: basic to all patients , sustenance care needs , remedial care needs , and restorative care needs .

The basic needs of an individual patient are to maintain good hygiene and physical comfort ; promote optimal health through healthy activities, such as exercise, rest, and sleep ; promote safety through the prevention of health hazards like accidents, injury , or other trauma and the prevention of the spread of infection; and maintain good body mechanics and prevent or correct deformity.

Sustenal care needs to facilitate the maintenance of a supply of oxygen to all body cells; facilitate the maintenance of nutrition of all body cells; facilitate the maintenance of elimination; facilitate the maintenance of fluid and electrolyte balance; recognize the physiological responses of the body to disease conditions; facilitate the maintenance of regulatory mechanisms and functions, and facilitate the maintenance of sensory function.

Remedial care needs to identify and accept positive and negative expressions, feelings, and reactions; identify and accept the interrelatedness of emotions and organic illness; facilitate the maintenance of effective verbal and non- verbal communication ; promote the development of productive interpersonal relationships; facilitate progress toward achievement of personal spiritual goals; create and maintain a therapeutic environment; and facilitate awareness of the self as an individual with varying physical, emotional, and developmental needs.

Restorative care needs include the acceptance of the optimum possible goals in light of limitations, both physical and emotional; the use of community resources as an aid to resolving problems that arise from an illness; and the understanding of the role of social problems as influential factors in the case of illness.

Abdellah’s work, based on the problem-solving method, serves as a vehicle for delineating nursing (patient) problems as the patient moves toward a healthy outcome. The theory identifies ten steps to identify the patient’s problem and 11 nursing skills to develop a treatment typology.

The ten steps are:

• Validate the patient’s conclusions about his nursing problems.
• Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his or her behavior.
• Explore the patient and their family’s reactions to the therapeutic plan and involve them in the plan.
• Identify how the nurses feel about the patient’s nursing problems.

The 11 nursing skills are:

• observation of health status
• skills of communication
• application of knowledge
• the teaching of patients and families
• planning and organization of work
• use of resource materials
• use of personnel resources
• problem-solving
• the direction of work of others
• therapeutic uses of the self
• nursing procedure

Abdellah also explained nursing as a comprehensive service, which includes:

• Recognizing the nursing problems of the patient
• Deciding the appropriate course of action to take in terms of relevant nursing principles
• Providing continuous care of the individual’s total needs
• Providing continuous care to relieve pain and discomfort and provide immediate security for the individual
• Adjusting the total nursing care plan to meet the patient’s individual needs
• Helping the individual to become more self- directing in attaining or maintaining a healthy state of body and mind
• Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations
• Helping the individual to adjust to his limitations and emotional problems
• Working with allied health professions in planning for optimum health on local, state, national, and international levels
• Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet people’s health needs

Faye Abdellah’s work is a set of problems formulated in terms of nursing-centered services used to determine the patient’s needs. The nursing-centered orientation to client care appears to be contradicting the client-centered approach that Abdellah professes to support. This can be observed by her desire to move away from a disease-centered orientation.

In her attempt to bring the nursing practice to its proper relationship with restorative and preventive measures for meeting total client needs, she seems to swing the pendulum to the opposite pole, from the disease orientation to nursing orientation, while leaving the client somewhere in the middle.

The nursing process in Abdellah’s theory includes assessment , nursing diagnosis , planning, implementation , and evaluation.

In the assessment phase , the nursing problems implement a standard procedure for data collection . A principle underlying the problem-solving approach is that for each identified problem, pertinent data is collected. The overt or covert nature of problems necessitates a direct or indirect approach, respectively.

The outcome of the collection of data in the first phase concludes the patient’s possible problems, which can be grouped under one or more of the broader nursing problems. This will further lead to the nursing diagnosis .

After formulating the diagnosis, a nursing care plan is developed, and appropriate nursing interventions are determined. The nurse now sets those interventions in action, which complete the implementation phase of the nursing process .

The evaluation takes place after the interventions have been carried out. The most convenient evaluation would be the nurse’s progress or lack of progress toward achieving the goals established in the planning phase.

With Faye Abdellah’s aim in formulating a clear categorization of patient’s problems as health needs, she rather conceptualized nurses’ actions in nursing care, which is contrary to her aim. Nurses’ roles were defined to alleviate the problems assessed through the proposed problem-solving approach.

The problem-solving approach introduced by Abdellah has the advantage of increasing the nurse’s critical and analytical thinking skills since the care to be provided would be based on sound assessment and validation of findings.

One can identify that the framework is strongly applied to individuals as the focus of nursing care. The inclusion of an aggregate of people such as the community or society would make the theory of Abdellah more generalizable since nurses do not only provide one-person service, especially now that the community healthcare level is sought to have higher importance than curative efforts in the hospital.

The following are the strengths of Faye Abdellah’s “21 Nursing Problems” theory.

• The problem-solving approach is readily generalizable to the client with specific health needs and specific nursing problems.
• With the model’s nature, healthcare providers and practitioners can use Abdellah’s problem-solving approach to guide various activities within the clinical setting. This is true when considering a nursing practice that deals with clients with specific needs and specific nursing problems.
• The language of Faye Abdellah’s framework is simple and easy to comprehend.
• The theoretical statement greatly focuses on problem-solving, an activity that is inherently logical in nature.

The following are the limitations of Faye Abdellah’s “21 Nursing Problems” theory.

• The major limitation to Abdellah’s theory and the 21 nursing problems is their robust nurse-centered orientation. She rather conceptualized nurses’ actions in nursing care which is contrary to her aim.
• Another point is the lack of emphasis on what the client is to achieve was given in client care.
• The framework seems to focus quite heavily on nursing practice and individuals. This somewhat limits the generalizing ability, although the problem-solving approach is readily generalizable to clients with specific health needs and specific nursing.
• Also, Abdellah’s framework is inconsistent with the concept of holism. The nature of the 21 nursing problems attests to this. As a result, the client may be diagnosed with numerous problems leading to fractionalized care efforts. Potential problems might be overlooked because the client is not deemed to be in a particular illness stage.

Abdellah’s typology of 21 nursing problems is a conceptual model mainly concerned with patient’s needs and nurses’ role in problem identification using a problem analysis approach.

According to the model, patients are described as having physical, emotional, and sociological needs. People are also the only justification for the existence of nursing. Without people, nursing would not be a profession since they are the recipients of nursing.

Patient-centered approaches to nursing health are described as a state mutually exclusive of illness. Abdellah does not define health but speaks to “total health needs” and “a healthy state of mind and body” in her nursing description.

However, Abdellah rather conceptualized nurses’ actions in nursing care, contrary to her aim of formulating a clear categorization of patients’ problems as health needs. Nurses’ roles were defined to alleviate the problems assessed through the proposed problem-solving approach.

As a whole, the theory is intended to guide care not just in the hospital setting but can also be applied to community nursing, as well. The model has interrelated concepts of health and nursing problems and problem-solving, which is inherently logical in nature.

Furthermore, the 21 nursing problems progressed to a second-generation development referred to as patient problems and patient outcomes . Abdellah educated the public on AIDS , drug addiction, violence, smoking, and alcoholism. Her work is a problem-centered approach or philosophy of nursing.

Recommended books and resources to learn more about nursing theory:

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

• Nursing Theorists and Their Work (10th Edition) by Alligood Nursing Theorists and Their Work, 10th Edition provides a clear, in-depth look at nursing theories of historical and international significance. Each chapter presents a key nursing theory or philosophy, showing how systematic theoretical evidence can enhance decision making, professionalism, and quality of care.
• Knowledge Development in Nursing: Theory and Process (11th Edition) Use the five patterns of knowing to help you develop sound clinical judgment. This edition reflects the latest thinking in nursing knowledge development and adds emphasis to real-world application. The content in this edition aligns with the new 2021 AACN Essentials for Nursing Education.
• Nursing Knowledge and Theory Innovation, Second Edition: Advancing the Science of Practice (2nd Edition) This text for graduate-level nursing students focuses on the science and philosophy of nursing knowledge development. It is distinguished by its focus on practical applications of theory for scholarly, evidence-based approaches. The second edition features important updates and a reorganization of information to better highlight the roles of theory and major philosophical perspectives.
• Nursing Theories and Nursing Practice (5th Edition) The only nursing research and theory book with primary works by the original theorists. Explore the historical and contemporary theories that are the foundation of nursing practice today. The 5th Edition, continues to meet the needs of today’s students with an expanded focus on the middle range theories and practice models.
• Strategies for Theory Construction in Nursing (6th Edition) The clearest, most useful introduction to theory development methods. Reflecting vast changes in nursing practice, it covers advances both in theory development and in strategies for concept, statement, and theory development. It also builds further connections between nursing theory and evidence-based practice.
• Middle Range Theory for Nursing (4th Edition) This nursing book’s ability to break down complex ideas is part of what made this book a three-time recipient of the AJN Book of the Year award. This edition includes five completely new chapters of content essential for nursing books. New exemplars linking middle range theory to advanced nursing practice make it even more useful and expand the content to make it better.
• Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice This book offers balanced coverage of both qualitative and quantitative research methodologies. This edition features new content on trending topics, including the Next-Generation NCLEX® Exam (NGN).
• Nursing Research (11th Edition) AJN award-winning authors Denise Polit and Cheryl Beck detail the latest methodologic innovations in nursing, medicine, and the social sciences. The updated 11th Edition adds two new chapters designed to help students ensure the accuracy and effectiveness of research methods. Extensively revised content throughout strengthens students’ ability to locate and rank clinical evidence.

Recommended site resources related to nursing theory:

• Nursing Theories and Theorists: The Definitive Guide for Nurses MUST READ! In this guide for nursing theories, we aim to help you understand what comprises a nursing theory and its importance, purpose, history, types or classifications, and give you an overview through summaries of selected nursing theories.

Other resources related to nursing theory:

• Betty Neuman: Neuman Systems Model
• Dorothea Orem: Self-Care Deficit Theory
• Dorothy Johnson: Behavioral System Model
• Florence Nightingale: Environmental Theory
• Hildegard Peplau: Interpersonal Relations Theory
• Ida Jean Orlando: Deliberative Nursing Process Theory
• Imogene King: Theory of Goal Attainment
• Jean Watson: Theory of Human Caring
• Lydia Hall: Care, Cure, Core Nursing Theory
• Madeleine Leininger: Transcultural Nursing Theory
• Martha Rogers: Science of Unitary Human Beings
• Myra Estrin Levine: The Conservation Model of Nursing
• Nola Pender: Health Promotion Model
• Sister Callista Roy: Adaptation Model of Nursing
• Virginia Henderson: Nursing Need Theory
• Abdellah, F.G. The federal role in nursing education. Nursing outlook. 1987, 35(5),224-225.
• Abdellah, F.G. Public policy impacting on nursing care of older adults. In E.M. Baines (Ed.), perspectives on gerontological nursing. Newbury, CA: Sage publications. 1991.
• Abdellah, F.G., & Levine, E. Preparing nursing research for the 21st century. New York: Springer. 1994.
• Abdellah, F.G., Beland, I.L., Martin, A., & Matheney, R.V. Patient-centered approaches to nursing (2nd ed.). New York: Mac Millan. 1968.
• Abdellah, F.G. Evolution of nursing as a profession: perspective on manpower development. International Nursing Review, 1972); 19, 3..
• Abdellah, F.G.). The nature of nursing science. In L.H. Nicholl (Ed.), perspectives on nursing theory. Boston: Little, Brown, 1986.
• Craddock, J. (2013). Encyclopedia of world biography supplement. Detroit, Mich.: Gale. https://www.encyclopedia.com/doc/1G2-3435000010.html
• Better Patient Care Through Nursing Research
• Preparing Nursing Research for the 21st Century: Evolution, Methodologies, Challenges

With contributions by Wayne, G. (for Biography), Vera, M. 

6 thoughts on “Faye Abdellah: 21 Nursing Problems Theory”

Thank you for sharing Angelo

I mean no disrespect to RADM Abdellah’s service to our nation, but the USPHS is not part of the military. It is part of the Uniformed Services, but not in the Dept of Defense.

Oh! Good to know! Thanks for clarifying :)

An insightful information 👌

I was a brand new lieutenant US Army and just graduated from college to become a nurse. I had used Faye Abdellah’s Theories as the rationale for nursing care plans in school papers, so I was very familiar. A big professional regret was I had the opportunity to meet Faye at a nursing conference in Germany. I was a timid young nurse and somewhat shy and saw her in one of the conference sessions sitting by herself. I wish I introduced myself and talked to her. I really respected her as a pioneer in nursing theory.

thanks for sharing.

Leave a Comment Cancel reply

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

3.2 Community Health Concepts

Open Resources for Nursing (Open RN)

Community Health Nursing

Nurses working in a community setting include public health nurses, school nurses, and parish nurses, to name a few.

Public health nurses work across various settings in the community such as government agencies, community-based centers, shelters, and vaccine distribution sites. They provide disease prevention and health promotion services, such as working with mothers and children to improve nutrition, operating immunization clinics, and leading public health education initiatives such as smoking cessation campaigns. Public health nurses also prepare to respond quickly to public health emergencies such as natural disasters or epidemics. [1] , [2] Emergency preparedness is further discussed in the “ Environmental Health and Emergency Preparedness ” chapter. See Figure 16.2 [3] for an image of a community health nurse providing health screenings in a maternal and child health clinic.

School nurses work with over 56 million school-age children and adolescents. They provide direct care for chronic health problems and administer medications prescribed during school hours. They also provide mental health care, a need that has grown during the COVID-pandemic. Their work also affects the larger community. For example, school nurses may help develop disaster plans that coordinate activities in the school with the larger neighborhood. [4] , [5]

Parish nurses use their nursing skills for church or parish members in paid or volunteer positions. They provide health education, screening, advocacy, and referrals to other services in the community. [6]

Barriers for Community Health Nurses

Community health nurses serve important roles in identifying priority health needs of a community, as well as planning and implementing preventative health initiatives. However, community health nurses may face unique barriers when providing care to individuals, families, and community members. Three barriers are referred to as gaining entry, role negotiation, and confidentiality:

• Gaining Entry: Community health nurses may be considered “outsiders” as representatives of the established health care system and may not necessarily be trusted by community members. It is vital for community health nurses to build trust and supportive relationships. When working with individuals and families, nurses should assess specific community issues affecting that individual’s health or their access to health care and then address those issues in their nursing care plan. Nurses can also investigate if there are community resources available to refer the client and/or their family members for additional services. See Figure 16.3 [7] for an image of Red Cross volunteers working with caregivers of clients receiving palliative care.
• Role Negotiation and Confidentiality: Community health nurses must separate their roles as data collectors, health professionals, and neighbors. These roles can be difficult to differentiate when the nurse is assessing community health needs and providing nursing interventions for a population of individuals within their own home community. These individuals may include family members, friends, neighbors, or peers. Trust must be established and confidentiality assured according to legal and ethical parameters of nursing practice. Nurses should also establish a sense of partnership and encourage clients to participate in planning preventative health strategies for themselves and their families.

Community Health

Community health nursing is based on several underlying concepts such as encouraging healthy living, preventing illness, promoting rehabilitation, evaluating the effectiveness of community resources, and advocating for improved overall community health. [8] , [9] In this manner, community health nurses pursue health equity. Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing potential obstacles to obtaining and maintaining optimal health such as lack of access to health care services, good jobs with fair pay, quality education and housing, and safe environments. [10] Community health nurses address these conditions that are also known as social determinants of health.

Social determinants of health (SDOH) are the conditions in which people are born, grow, work, live, and age. Research shows that the SDOH can be more important than health care or lifestyle choices in influencing health and account for 30-55% of health outcomes. [11] See an illustration of SDOH in Figure 16.4. [12]  SDOH can contribute to health inequities , defined as avoidable differences in health status seen within and between communities. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health. According to the World Health Organization, SDOH can influence health equity in positive and negative ways [13] :

• Income and social protection
• Unemployment and job insecurity
• Working life conditions
• Food insecurity
• Housing, basic amenities, and the environment
• Early childhood development
• Social inclusion and nondiscrimination
• Structural conflict
• Access to affordable health services of decent quality

Health disparities are health differences that are linked with social, economic, and/or environmental disadvantages. Health disparities adversely affect groups of people who often experience greater obstacles to health based on individual characteristics such as socioeconomic status, age, gender, culture, religion, mental illness, disability, sexual orientation, or gender identity. [14] These groups are often referred to as “vulnerable groups,” and their care is further discussed in the “ Vulnerable Populations ” chapter.

As community health nurses strive to promote health equity, they assess SDOH, health disparities, and health inequities that are present in communities. They often begin by analyzing the context of the community because these characteristics can affect how community members respond to public health initiatives. The context of a community includes the following factors:

• For example, is this a rural community that requires long-distance transportation to health care services?
• For example, are there buses or ride share services available for members to reach health care services?
• For example, is there an area of the community located next to a factory contributing to air pollution?
• For example, is there an area where it is common for several multi-generation family members to live together in one residence?
• For example, do public parks commemorate war veterans?
• For example, what relationships do the school board members have with community members?
• For example, does the community have a tradition of celebrating Memorial Day with a parade and public tributes at a local cemetery?
• For example, is there a YMCA or other services in the community that promote physical activities for youth and other members of the community?
• For example, is there an urgent care clinic in this community that can be accessed by bus service?
• For example, is this a working class community whose members primarily work in a few local factories?
• For example, how does the mayor of this city communicate with members of the community?
• For example, is there a town board that meets regularly and collaboratively makes decisions affecting planning and zoning of the community?
• For example, is it assumed in this community that neighbors will help clean up the neighborhood after storm damage occurs to several homes?

According to the CDC, a healthy community is one in which local groups from all parts of the community work together to prevent disease and make healthy living options accessible. Working at the community level to promote healthy living brings the greatest health benefits to the greatest number of people. It also helps to reduce health gaps caused by differences in income, education, race and ethnicity, location, and other factors that can affect health. [15]

Community Health Needs Assessment

Community health needs assessment is a systematic process to identify and analyze community health needs and assets in order to prioritize these needs, plan, and act upon significant unmet community health needs. [16] A community health assessment gives nurses and community organizations comprehensive information about the community’s current health status, needs, and issues. This information can be used to develop a community health improvement plan by justifying how and where resources should be allocated to best meet community needs. [17] Community health needs assessments are performed and reported at national, state, county, and local levels.

National Health Needs Assessments

Healthy People 2030 addresses the most current national public health priorities. It is published by the United States Department of Health and Human Services Office of Disease Prevention and Promotion. See Figure 16.5 [18] for an illustration related to using Healthy People 2030 objectives and leading health indicators to assess community needs data, plan, and evaluate community health interventions.

A set of evidence-based Healthy People objectives are published every ten years based on current national data. Objectives are classified by categories [19] :

• Health Conditions
• Health Behaviors
• Populations
• Settings and Systems
• Social Determinants of Health

Examples of Healthy People 2030 community objectives include the following [20] :

• Increase the number of community organizations that provide preventative services
• Increase the rate of bystander CPR and AED use for nontraumatic cardiac arrests in public places
• Increase the proportion of adult stroke survivors who participate in rehabilitation services

Leading Health Indicators (LHIs) are a subset of high-priority Healthy People 2030 objectives to drive action toward improving health and well-being. Most LHIs address important factors that impact major causes of death and disease in the United States. They help organizations, communities, and community health nurses focus their resources and efforts to improve the health and well-being of all people. There are 23 LHIs that cover the life span from infants, children, adolescents, adults, and older adults. See a list of LHIs in Table 16.2.

Table 16.2 Leading Health Indicators Across the Life Span

Healthy People 2030 Resources

View Healthy People 2030 Objectives , Community Objectives , and Leading Health Indicators .

State Needs Assessments

States perform health needs assessments to develop state funding and program priorities for community health. For example, the Wisconsin Department of Health Services (DHS) performs a mental health and substance abuse needs assessment every other year. Data in this report includes the following:

• Prevalence of Needs: The prevalence of disorders, conditions, and associated problems for the entire population and subpopulations
• Access to Services: Determination of which and how many services are received by individuals and exploration of barriers to access
• Service Workforce and Capacity: Examination of the mental health and substance use services workforce, including the number of providers of these services and the geographic dispersion of the workforce across the state

Another example of a state needs assessment related to mental health is the Behavioral Health Gaps Study funded by the Wisconsin DHS to assess gaps and needs in the behavioral health service system for individuals with mental health and substance use disorders. Key gaps documented in this study included shortages in child and geriatric psychiatrists; shortages in mental health inpatient beds and residential facilities for treating substance use; inadequacies of the medical transportation system; a need for improving crisis stabilization services in the community that focus on reducing contact with police officers; shortages in medication-assisted treatment providers and clinics; long waitlists across the service array; shortages in competent translation services; and the need to provide wraparound services, particularly for consumers with families. [21]

Explore your state’s health needs assessments. Examples of health needs assessments in the state of Wisconsin are as follows:

Department of Health Service’s Mental Health and Substance Abuse Needs Assessment PDF

The Behavioral Health Gaps Report for the State of Wisconsin PDF completed by University of Wisconsin-Madison Population Health Institute

County Health Rankings

County health rankings are created annually by the University of Wisconsin Population Health Institute for counties across the country. [22] These rankings provide a snapshot of a community’s health and can be used as a starting point for implementing change to promote health equity in communities. See the following box to explore the health ranking for your community.

Visit the Explore Health Rankings web page from the University of Wisconsin Population Health Institute to view the health ranking of your community.

Local Needs Assessments

Local communities perform health needs assessments and develop specific health initiatives for their community members. For example, the Eau Claire County Health Department Needs Assessment was used to create a county health plan. In 2021 the top health priorities were documented as drug use, mental health, alcohol misuse, obesity, and healthy nutrition. See Figure 16.6 [23] with an image related to data from a county mental health needs assessment.

Explore your community’s health initiatives. View the example of Eau Claire City-County Health Department Needs Assessment .

Hospitals’ Community Health Needs Assessments

Tax-exempt hospitals are required to conduct community health needs assessments according to the Patient Protection and Affordable Care Act (i.e., the Affordable Care Act). Hospitals are required to adopt implementation strategies to meet the community health needs identified through their needs assessment. This collaboration among hospitals and community partners expands the community’s capacity to address health needs through a shared vision and creates a foundation for coordinated efforts to improve community health. [24]

View examples of hospitals’ community health needs assessments:

Mayo Clinic’s Community Health Needs Assessment PDF

Community Health Needs Assessments by HSHS Affiliated Hospitals in Wisconsin and Illinois

• Greenwood, B. (2018, June 29). What are the primary roles of the community nurse? CHRON. https://work.chron.com/primary-roles-community-nurse-15144.html ↵
• National Academy of Medicine. (2021, May). The future of nursing 2020-2030: Charting a path to achieve health equity [Report]. https://www.phnurse.org/assets/docs/FON%20Valuing%20Community%20and%20Public%20Health%20Nursing.pdf ↵
• “ PIXNIO-45563-3000x2000 ” by USAID on Pixnio is licensed under CC0 ↵
• “ 10716898813_74292ef548_k ” by Department of Foreign Affairs and Trade is licensed under CC BY 2.0 ↵
• Braveman, P., Arkin, E., Orleans, T., Proctor, D., & Plough, A. (2017, May 1). What is health equity? Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html ↵
• World Health Organization. (n.d.). Social determinants of health. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 ↵
• “Healthy People 2030 SDOH Graphic.png” by U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion is in the Public Domain . Access for free at https://health.gov/healthypeople/objectives-and-data/social-determinants-health ↵
• HealthyPeople.gov. (2022, February 6). Disparities. Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities ↵
• Centers for Disease Control and Prevention. (2015, September 18). A healthy community is a prepared community. [Blog]. https://blogs.cdc.gov/publichealthmatters/2015/09/a-healthy-community-is-a-prepared-community / ↵
• Vigna, A. J. (2020). The 2019 behavioral health gaps report for the state of Wisconsin. University of Wisconsin Population Health Institute. https://uwphi.pophealth.wisc.edu/publications-2/evaluation-reports-2/. ↵
• VHA Inc., & Healthy Communities Institute. (2013) . Assessing & addressing community health needs. Catholic Heart Association of the United States. https://www.chausa.org/docs/default-source/general-files/cb_assessingaddressing-pdf.pdf?sfvrsn=4 ↵
• “HP2030_HowtoUse_Screen1_2020-03-24.png” by unknown author for U.S. Department of Health and Human Services is in the Public Domain . Access for free at https://health.gov/our-work/national-health-initiatives/healthy-people/healthy-people-2030/promoting-healthy-people-2030 . ↵
• Office of Disease Prevention and Health Promotion. Healthy People 2030: Building a healthier future for all. U.S. Department of Health and Human Services. https://health.gov/healthypeople ↵
• This image is derived from 2021 Eau Claire County Community Health Assessment by Community Health Assessment Planning Partnership Committee and is in the Public Domain ↵
• VHA Inc., & Healthy Communities Institute. (2013). Assessing & addressing community health needs . Catholic Heart Association of the United States. https://www.chausa.org/docs/default-source/general-files/cb_assessingaddressing-pdf.pdf?sfvrsn=4 ↵

Nurses who work across various settings in the community such as government agencies, community-based centers, shelters, and vaccine distribution sites.

Nurses who provide direct care for children with chronic health problems and administer medications prescribed during school hours.

Nurses who use their skills for church or parish members in paid or volunteer positions.

Everyone has a fair and just opportunity to be as healthy as possible.

Conditions in which people are born, grow, work, live, and age.

Avoidable differences in health status seen within and between communities.

Health differences that are linked with social, economic, and/or environmental disadvantages.

Local groups from all parts of the community work together to prevent disease and make healthy living options accessible.

Systematic process to identify and analyze community health needs and assets in order to prioritize these needs, plan, and act upon significant unmet community health needs.

3.2 Community Health Concepts Copyright © 2024 by Open Resources for Nursing (Open RN) is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

Share This Book

• Open access
• Published: 12 October 2023

Community-based nursing: a concept analysis with Walker and Avant’s approach

• Arezoo Zeydani   ORCID: orcid.org/0000-0001-5019-7161 1 ,
• Foroozan Atashzadeh-Shoorideh   ORCID: orcid.org/0000-0002-6144-6001 2 ,
• Meimanat Hosseini   ORCID: orcid.org/0000-0002-3458-0491 3 &
• Sima Zohari-Anboohi   ORCID: orcid.org/0000-0003-3422-9420 4  

BMC Medical Education volume  23 , Article number:  762 ( 2023 ) Cite this article

5691 Accesses

6 Citations

Metrics details

Community-based nursing in recent years has received much attention from nursing schools in different countries as a suitable solution in response to existing and future problems and challenges, but there is yet no comprehensive and correct understanding of this concept and considering its importance, the present study was conducted to the aim of analyzing the concept of community-based nursing.

Concept analysis was done using Walker and Avant's 8-step approach. Nursing dictionary, Persian dictionary, research articles, journals and conferences articles, dissertations, thesis, books, and other sources related to the concept of research were investigated through search engines and available databases using the keywords of nursing, community-based, concept analysis and Walker and Avant from 1990 to 2023. Finally, 54 articles related to the concept were reviewed and analyzed.

The results showed that community-based nursing has attributes such as individual-oriented/ family-oriented/ community-oriented, social partnership with the communities and stakeholders, social justice, and group and interprofessional cooperation, the community as the main activity setting, providing services based on cultural diversity, providing services according to the context, conditions and community needs, caring for individuals and families with health problems throughout life, responding to the community needs, community-based experiences and facing real-life issues in the context of community, using a problem-based and service-based approach, providing context-based care and considering factors affecting health. In this regard, borderline and related cases (community health nursing, community-oriented nursing, population-based nursing, and public health nursing) were also presented to clarify the concept. Antecedents of community-based nursing included: determining the position of community-based nursing, making infrastructure and structure, the partnership between university, hospital and community, identifying all settings, the presence of educators proficient in education, survey of community needs, having knowledge, communication and community-based skills, expanding the role of the nurse, stakeholders' attitude towards community-oriented nursing and management and financial support. Consequences of community-based nursing included: competence development in nurses, solving community-based nursing challenges, meeting the health needs of individuals, families and communities, social justice, and increasing access to health care services.

The results of this study can provide an objective and understandable image of the use of community-based nurses and their education in practice. Conducting more quantitative and qualitative studies about community-based nursing is also recommended.

Peer Review reports

The term community-based has different meanings, but the common and main point of all of them is the community, which is the focus of service delivery and where community participation is very important [ 1 ]. Changes in health care services have led to changes in nursing. The practice of nursing has changed from providing services in the hospital to the community level [ 2 ].

Community-based nursing provides nursing care to individuals, families, and groups wherever they are, such as where they live and work [ 3 ]. Community-based nursing in recent years has received much attention and empowers nurses to work at the community level [ 4 , 5 , 6 ].

Due to the extensive changes, including the increase in urbanization and the increase in the elderly population, changes in the geographical epidemiology of diseases, and the inability to control them by the health team has been highlighted the need to pay attention to community-based nursing as a suitable solution in response to the problems and challenges ahead. In Iran, a study showed that community-based nursing provides direct access to health and treatment services through home visits and home care and accurate identification of the patients’ needs [ 7 ].

Community-based nursing as a new field in education and a new role of nurses in the community has attracted the attention of many nursing schools in different countries in recent years. Still, due to the attention to this concept in recent years, there is no comprehensive and correct understanding. Many people have confused this concept with community-oriented nursing, community health nursing, population-based nursing, and public health nursing, or use these concepts interchangeably. In contrast, these concepts have different meanings and applications, and there is a limited understanding of this concept [ 3 , 8 , 9 ]. As a result, clarifying the concept of community-based nursing and the elements and attributes of this concept increases understanding and the need to pay attention to it.

Also, considering that every community has different context and characteristics, therefore specifying the definition, features, and constituent elements of this concept by examining the concept in other communities helps us in developing knowledge and a comprehensive understanding of the concept [ 10 ].

“In fact, without a clear understanding of the concept of community-based nursing, one cannot reasonably anticipate its effective execution and appropriate training. A comprehensive grasp of the concept and its constituent elements is essential for the proper implementation of community-based nursing care, enabling nurses to embody the role of a community-based nurse. Furthermore, such comprehension serves to garner increased attention from policymakers and raise public awareness.“ [ 2 , 3 ].

In the field of “community-based nursing education” conceptualization has been done by Mtshali [ 9 , 11 ], but “community-based nursing” has not been conceptually analyzed so far. Therefore, the main aim of this research is to explore the concept of community-based nursing to reach a comprehensive and common understanding of this phenomenon.

Methodological framework

Concept analysis has been widely considered and supported as a fundamental research approach to expanding and developing nursing knowledge. Concept analysis is a process of examining the main elements of the concept that the researcher wants to better understand the concept by reviewing its components. It’s a way to deconstruct a term to understand it better and create a correct definition that provides the possibility of measuring the concept and a great insight into the phenomenon of interest [ 12 ]. The purpose of concept analysis is to examine the structure and function of the concept. The concepts within themselves have attributes that make them unique from other concepts. Therefore, concepts are a group of information with defining characteristics. The understanding of the concept changes over time, which is one of the reasons why concept analysis should not be considered a final product. The aim is to understand it in the present moment in time [ 13 ]. Walker and Avant’s concept analysis method is a modified and simplified version of Wilson’s (1963) classic concept analysis, which has eight steps instead of 11 steps and is easier for beginner researchers to understand and do it. This logical positivist approach can clarify a concept by simplifying it [ 14 ].

Data sources

This study is a systematic analytical approach; it aims to clarify the concept of community-based nursing and determine its dimensions using the approach of Walker and Avant (2019). To find meanings related to the concept, an extensive search of the literature of 1990–2023 in search engines and available databases such as Iran Doc, Google Scholar, SID, OVID, CINAHL, Scopus, PubMed, Magiran with keywords of Community-based, nursing, Walker & Avant, concept analysis was done.

Data analysis

In the current research, based on the approach of Walker and Avant (2019), the following steps were carried out, including selecting the concept, determining the aims of the analysis, identifying the uses of the analyzed concept, determining the defined attributes of the concept, identifying a model case, identifying borderline and related issues, identification of the antecedents and consequences of the concept and defining the empirical referents [ 14 ].

Data collection

In this way, in the beginning, a search was conducted to find what existed under the title of community-based nursing in related articles and sources. Then the articles were included in the study based on the inclusion criteria (English language, relevance to the concept of community-based nursing and similar concepts, access to the full text of the article, and non-repetition). The exclusion criteria included the focus of the study on hospital nursing. The procedure for selecting studies using PRISMA diagrams is shown in Fig.  1 . Initially, 123 studies were identified, after removing 40 duplicates, 12 studies based on inclusion and exclusion criteria, 17 studies based on eligibility criteria, finally, 54 studies related to the review concept and defining attributes were extracted from them ( Supplementary file ).

PRISMA diagram of search strategy

Selection of a concept

In this analysis, the concept of “community-based nursing” is considered the main concept of the present research due to its wide application in response to the challenges and health problems of the community, the ever-increasing changes in the way of providing services and the health care system and its importance in education. This concept has received a lot of attention due to its importance in promoting the health of society in the healthcare system. Still, this concept has no proper understanding and clarity, and the boundaries that separate it from other concepts have not been defined. Therefore, it seems that the clarification of this concept can help to understand the performance of community-based nursing and how to train nurses in this field [ 10 , 15 , 16 ].

Determine the aims or purposes of analysis

Considering that the concept of community-based nursing is one of the concepts that is confused with many other concepts and is sometimes used instead of other concepts, while these concepts are different from each other [ 15 ] and it is necessary to clarify the boundaries and its difference to the other similar concepts, that this issue increases the understanding of this concept and its better application in nursing, the concept analysis of the “community-based nursing” was done.

Determine the defining attributes

To identify the characteristics of community-based nursing, a wide range of old to new literature (1995–2023) was reviewed, and the characteristics of community-based nursing were determined as follows:

(1) Individual-oriented/family-oriented/ community-oriented, (2) Social partnership with the communities and stakeholders, (3) Social justice, (4) Group and interprofessional cooperation, (5) The community as the main activity setting, (6) Providing services based on cultural diversity, (7) Providing services according to the context, conditions and community needs, (8) Caring for individuals and families with health problems throughout life, (9) Responding to the community needs, (10) Community-based experiences and facing the fundamental issues of life in the context of community, 11. Using a problem-based and service-based approach, 12. Providing context-based care and considering factors affecting health (physical, psychological, political, economic, social, and cultural conditions).

Identifying all uses of the concept

The concept of co

Identify antecedents and consequences

lowing cases: (1) Managing acute and chronic conditions and providing acute or chronic care in health care centers, homes, schools, primary care clinics, outpatient services, and community centers [ 2 , 3 ], (2) Disease prevention and community health promotion [ 17 ], (3) Focusing on caring for the illness of individuals and families throughout life and promoting self-care in them [ 2 , 3 ], (4) Serving in underdeveloped and under-resourced conditions [ 9 ], serving at-risk populations (including agricultural workers, industrial workers, pregnant women, people with disabilities, mothers who have recently given birth, etc.), establishing fairness and justice in health, and working to the policymakers to change policy and make the environment healthy [ 17 ], (5) Identifying the target population’s needs and meeting the community’s health needs and responding to them, symptoms, and medication management [ 16 , 18 ].

Identify a model case

A nurse has gone to their home to take care of a family that has an elderly father with diabetes and a diabetic foot ulcer who needs to change the dressing (attributes including community-oriented, the community is the main activity setting, caring for individuals and families with health problems throughout life). First, the nurse evaluates the condition of the patient’s family in terms of economic, cultural, social, physical and psychological aspects (attributes including providing context-based care and considering factors affecting health) and realizes that their children are all married and they live alone and economically, they are at an average level, as a result, to the patient’s consent, the nurse prepares and uses a suitable dressing for his leg wound (attributes including providing services according to the context, conditions and community needs), and then the nurse teaches the father of the family how to take care of the dressing and the leg wound (individual-oriented) and meanwhile, the nurse asks about his diet, the client does not like some foods and on the contrary eats some foods that are not suitable for him and says that he cannot have a regular meal plan (using a problem-based and service-based approach), also, he does not use some foods at all due to the prohibition in their culture and religion (attribute of cultural diversity). Based on this, the nurse prepares the best meal plan in consultation with the treatment team and nutrition consultant and then implements it with the approval of the specialist doctor and other members of the treatment team, as well as with the client’s consent (attributes including group and interprofessional cooperation and participation). The nurse also teaches his wife about diet and asks her to cooperate with her husband to implement this plan. While talking to the mother of the family, the nurse notices her respiratory distress, asks her questions, examines the mother, and realizes that she has asthma and does not use her respiratory aid sprays properly. As a result, the nurse helps her to use the spray correctly and teaches her. The mother of the family states that she is depressed due to her difficult situation, the nurse talked to the mental health consultant of the care team about this issue, and an appointment was made to examine the mother of the family and help her (attributes including group and interprofessional cooperation and participation). In the end, the nurse explained the risk factors of diabetes and asked them that if their children have these attributes, they must be evaluated and referred to the health care center of their region (details including family-oriented, community-based experiences and facing real problems of life in the context of the community). Finally, the nurse determines the time of the next visit, advises on social services that can help the family, and ensures that the patient and his family have received all the needed care (attributes including social justice and responding to the community needs).

Identify borderline and related cases

In this study, borderline and related cases of community-based nursing based on the literature review included the following:

Community health nursing: In community-based nursing, the nurse may meet an acute need, but the goal is to strengthen the capacity of the individual and family to take care of themselves. The main goal of community health nursing is to maintain the community’s health, and its secondary goal is to promote self-care among individuals and families. It also provides care, especially for high-risk people and those with infectious diseases. Community-based nursing care is family-oriented, even if it is for an individual. Community health nursing combines nursing theory and public health sciences. It assigns the priorities of prevention, protection, and health promotion, and its responsibility goes beyond the client, individual and family. In community-based nursing, the nurse cares for individuals and families who have health problems, while in community health nursing, the nurse works with people who are generally well and have no symptoms. The roles of community-based nurses and community health nurses are both client-centered and service-centered. They include providing care, education, counseling, client advocacy and support, and case management, which are similar. Still, the main difference between the two is in the group-oriented roles. In community health nursing, the nurse has more group roles, such as the community advocate, who knows what the community wants and needs and solves it with the available resources. In community-based nursing, nurses spend most of their time (85%) in case management, patient education, individual and family counseling, and interdisciplinary practice, while in community health nursing, nurses spend most of their time in finding case and patient education, while both emphasize cultural sensitivity [ 3 , 19 ].

Community-oriented nursing: Many attributes of community-based nursing are shared with community-oriented nursing, but they are different. The purpose of community-oriented nursing is to prevent illness and disability, maintain and promote health, focus on health care for individuals, families and groups in the community, provide medical services to improve the quality of life, provide community diagnosis, health monitoring and assessment and school nursing, while the goal of community-based nursing is to manage acute and chronic conditions, focus on caring for the illness of individuals and families throughout life, determining special care in the community where they are located, home care, disease prevention, and health promotion [ 9 ].

Population-based nursing: Population-based nursing is a systems approach to a problem for a specific population, but in community-based nursing, the target population may be located anywhere. In population-focused nursing evaluation, the target population and the environment in which the population is located should be examined. These assessments focus on epidemiological, environmental, psychological, cultural, spiritual, technological factors and the availability of community support systems [ 8 , 20 ].

Public health nursing: Public health nurses serve poor people instead of working with the whole people, and this is under cover of community health nursing, which occurs in every field. Public health nursing aims to prevent disease and disability and support the community, with a broad focus on community health and investigating the impact of the health status of the community (resources) on the health of individuals, families, and groups [ 8 ].

Antecedents of community-based nursing based on extensive literature review included the following: (1) Determining the position of community-based nursing, its duties and organizational level in the Ministry of Health and achieving the position of the nurse at all levels of health from prevention to rehabilitation [ 21 ] and creating job opportunities [ 7 ], (2) Making infrastructure and providing structure (political and legal, security, cultural, communications, transportation, facilities, equipment and resources) [ 7 , 16 , 18 , 22 , 23 , 24 , 25 ], (3) The partnership between university, hospital, community and community health service providers [ 16 , 23 , 26 ], (4) Identifying all areas and capabilities of providing health services and accessing them [ 27 , 28 ], (5) The presence of educators proficient in community-based nurse education [ 28 , 29 ], (6) Survey of community needs [ 29 , 30 ], 6. Survey of community needs [ 31 , 32 ], (7) Knowledge, communication and community-based skills [ 33 ], (8) Expanding the role of the nurse [ 10 , 34 , 35 ], 9.Stakeholders’ attitude towards community-oriented nursing [ 16 , 36 ], 10. Management and financial support for the provision of community-based nursing services [ 18 , 24 , 30 , 37 ].

Based on an extensive literature review, community-based nursing consequences included: 1. Competence development in nurses, such as improving professional, practical, communication skills, critical thinking, teamwork, experience, and deep knowledge about health and social issues in the community [ 33 ],

2. Solving community-based nursing challenges such as hospital-oriented and treatment-oriented in the health system, defects in the position and role of community-based nurses, flaws in community-based education infrastructure, deficiencies in trust, awareness, and acceptance of nurses in the community by the people [ 7 , 38 , 39 ], 3. Meeting the health needs of individuals, families, groups, communities and populations, developing community capacity for health, social justice, and eliminating health inequality [ 11 , 12 , 16 , 23 , 30 , 40 , 41 , 42 , 43 , 44 ], 4. Increasing access to health care services [ 7 , 11 ].

Define empirical referents

According to the extensive literature review, community-based nursing is a vital approach that delivers essential care across the lifespan with a central focus on enhancing overall health, primary care, and rehabilitation. This approach thrives on interdisciplinary collaboration to cater to diverse client groups within their natural environments. It is firmly rooted in the principle that healthcare decision-making primarily rests with the individual, their family, and the community. The nurse plays a pivotal role in devising nursing interventions for the client, their family, and the healthcare team, aligning these interventions with the values held by the client, their family, and the broader community. Community-based nursing places a strong emphasis on prevention, striving to avert the onset of diseases, promptly identify health issues, and provide early intervention and rehabilitation following illness or injury [ 3 ].

In the present study, the concept of community-based nursing was analyzed using Walker and Avant’s approach. Since the concept analysis causes objectification of a specific concept and its operationalization [ 14 ], it seems that expressing experimental interpretations of community-based nursing can be applied more quickly in the hospital, community, and education. Many studies provide positive evidence of community-based nursing practice [ 2 , 17 , 24 , 33 , 40 ]. As it was mentioned, based on a review of studies, community-based nursing has several attributes that are mentioned below.

Community-based nursing is characterized by individual-centered, family-centered, and community-centered orientation. It provides nursing care for individuals, families, and groups wherever they are, including their place of residence, workplace, school, etc. Many studies have considered this attribute important in community-based nursing [ 3 , 16 , 18 ]. In such a way, even if the individual is a client of the community-based nurse, nursing care should be family-oriented and consider the needs of the individual and the family. Being family-oriented means that the nurse believes in improving families’ competence and designs care based on the family’s needs and decisions; this increases the independence of the individual, family and their participation. Such care is necessary for the community because most clients live in their homes despite their health problems [ 3 ].

Social participation is defined as a person’s participation in activities that interact with others in community, also, this concept is defined as groups that work with common goals, responsibilities and power for the betterment of community and it includes the participation of community members, governmental and non-governmental organizations, universities, health center staff and other stakeholders and pays attention to the populations it is supposed to serve, many studies have mentioned social participation as an essential characteristic of community-based nursing [ 3 , 9 , 11 , 12 , 16 , 18 , 22 , 23 , 24 , 29 , 37 , 40 , 41 , 45 , 46 , 47 , 48 , 49 ] and the success of community-based nursing performance depends to a large extent on this factor, because it will not be possible to achieve the goals without involving individuals, families and community, also, providing care by a community-based nurse should be focused on the values, preferences of the individual and the family, Therefore, it is necessary to involve them in order to succeed in reaching the goals and supporting the individual and the family [ 18 ]. Community participation provides an opportunity for all community members to participate actively and effectively in the process of development and exploitation, and health promotion programs seek the participation of the community and stakeholders as active partners. Hence the category of participation is considered one of the crucial characteristics of community-based nursing [ 50 ].

The meaning of social justice is the fair and equitable benefit of the people of a community from health care based on need, which is at the heart of community-based health promotion measures to achieve health equality and is another essential attribute of community-based nursing [ 51 ].

Community-based nursing requires group and interprofessional cooperation, and the nurse collaborates with different teams, including doctors, pharmacists, specialists, and assistants. Interdisciplinary collaboration is an essential element in the role of community-based nurses because nurses cannot achieve patient support goals without collaboration with other healthcare team members. Nurses provide the necessary care throughout the patient’s life, focusing on improving health and primary rehabilitation care through interdisciplinary cooperation for different community Sects. [ 2 , 10 ]. In fact, in community-based nursing, to provide comprehensive support and integrated services, it is necessary for medical, administrative, human services, and related professionals to cooperate. It requires extensive cooperation of the government organization with other related institutions such as the welfare organization, municipalities, radio, and television. Many studies have emphasized collaboration as an essential attribute of community-based nursing [ 10 , 12 , 16 , 18 , 22 , 24 , 29 , 37 , 40 , 45 , 49 , 52 ].

The community is considered the main setting for the activity of community-based nurses. It is used to such an extent that the percentage of community-based experiences is higher than other clinical experiences. Most studies have emphasized this issue [ 8 , 9 , 11 , 16 , 23 ]. Another issue is that the hospital is considered a part of the community. Still, nurses perform most of their activities at the community level and provide services according to the prevention levels of healthy people in their natural living environments, from hospital to rehabilitation [ 16 ].

Another essential attribute of community-based nursing is attention to cultural diversity. Cultural diversity exists within and between countries, and nurses are morally committed to providing care appropriate to the culture. To provide adequate care to a client with a different culture or ethnic background, the nurse tries to understand the other person’s point of view regarding their cultural framework. When the nurses are not successful in this field, the consequence will be inequality in care; considering ethnic diversity in Iran, understanding the beliefs of clients, patients, and families, and paying attention to their needs deepens the relationship between nurses and clients [ 53 ]. The nurse must be aware of cultural differences, value the patient’s culture, include it in care plans, and communicate one-by-one with people and families with diverse ethnic or cultural backgrounds in such a way that shows respect for their culture. This brings mutual satisfaction between nurse and client [ 3 , 17 ]. The emphasis is that community is inextricably linked with cultural values. Many studies have considered cultural diversity as one of the essential pillars of community-based nursing [ 16 , 17 , 18 , 29 ].

Providing nursing care considering the background, conditions, and community needs is one of the attributes of community-based nursing since the community is the primary activity setting, taking into account the local, regional, and global community conditions, demographic and epidemiological developments, the prevalence of mental diseases, severe changes and the burden of diseases and developing a care plan based on that importance has many and different studies have emphasized this issue [ 26 , 34 , 41 , 49 ].

The philosophy of community-based nursing is to guide nursing care for individuals, families with health problems, and other groups throughout life, wherever they are, including where they live, work and go to school, etc. According to this definition, community-based nursing is not a specialty but a philosophy that guides all nursing care [ 3 ] and have been mentioned in different studies [ 3 , 54 ].

Community-based nurses are responsible for the health needs of the community. They must be able to provide the necessary care for individuals and families and investigate, plan, intervene, and evaluate the community’s needs. Since nursing services are mainly offered in hospitals in Iran, the activities of nurses do not meet the community’s needs, and it is one of the essential things mentioned in many studies [ 11 , 16 , 18 , 34 , 45 , 49 , 55 , 56 ]. The results of Baqhaei et al.‘s study also showed that the need to train capable and competent nurses who respond to the changing needs of the community has increased, for example, with the increase of the elderly population, palliative care, prevention, and acute care are more important [ 57 ].

Community-based experiences and facing real-life problems in the context of the community are integral parts of community-based nursing. Nurses need a wide range of experiences to provide care to individuals, families, and communities, from preventive care to acute care and rehabilitation. This means that they need direct access to population groups to work with and communicate with over time and help improve their health status, and many studies have emphasized this issue [ 16 , 22 , 23 , 37 , 40 , 42 , 58 ].

Using a problem-based and service-based approach to solve problems is one of the attributes of community-based nursing. Solving problems and dealing with real-life issues requires using such an approach, and by focusing on the situation, nurses look for different solutions. With critical thinking and using evidence, they provide the best available resolution to meet the needs of the client and the family [ 11 , 16 , 49 ] and serve the community, especially under-resourced communities. Different studies have considered and emphasized the importance of these approaches in community-based nursing [ 11 , 16 , 49 , 55 ].

Due to being exposed to the conditions and realities of the lives of individuals and families, nurses need to be aware of the target community’s values. This issue makes them aware of social and cultural issues, injustices, and other factors affecting health [ 9 ].

Proper care of individuals and families in social environments requires careful attention to social risks such as poverty, mental illness, unsafe housing, history or current injury, malnutrition, transportation problems, low literacy, etc. The nursing care team should comprehensively assess these areas and cooperate with social partners and colleagues (such as welfare, nursing home, etc.) to deal with them and follow the needs of the individual, family, and community over time. In community-based nursing, nurses are exposed to social, economic, political, cultural and other factors affecting the health of individuals, families, and communities. It is believed that such exposure facilitates a better understanding of social issues and equips nurses with the skills to deal with them. More importantly, it provides a comprehensive and complete view of health and disease because when the nurse encounters the patient only in the hospital setting, such opportunities are lost [ 2 , 3 , 9 , 16 , 18 , 30 , 37 ].

To ensure the continued provision of essential services, community-based nurses must hold a well-defined position within the healthcare infrastructure [ 22 , 39 , 59 ]. Their roles and responsibilities should be clearly delineated, and the settings for their activities must be precisely defined. Equally important is the need for these nurses to acquire the necessary skills through expert-led training programs, thus enabling them to deliver effective services [ 39 , 45 ]. It is imperative that policymakers adopt a community-oriented perspective, as their support is pivotal for the realization of these goals [ 36 ].

Being in different situations and solving problems in community increases the competence of nurses [ 33 ]. The positive result of the presence of nurses in the community creates trust in the community and by increasing access to health and treatment services, the needs of the community are met. Increasing access to health for all helps to eliminate health inequalities [ 10 , 12 , 26 ]. As a result, more people turn to this type of service and visits to hospitals decrease. Such a thing reduces many costs and as a result, policy makers pay attention to the needs of the community and they try to solve the problems and challenges in this field [ 44 , 60 ].

Concept analysis of community-based nursing focused only on theoretical analysis without empirical verification from the nurse educators; this indicates the limitation of the study. Verification of the concept from the nurse educators could have helped the researcher obtain additional data to expand further or clarify the concept.

Proper care of individuals and families in social environments requires careful attention to social risks such as poverty, mental illness, unsafe housing, history or current injury, malnutrition, transportation problems, low literacy, etc. The nursing care team should comprehensively assess these areas and cooperate with social partners and colleagues (such as welfare, nursing home, etc.) to deal with them and follow the needs of the individual, family, and community over time. In community-based nursing, nurses are exposed to social, economic, political, cultural and other factors affecting the health of individuals, families, and communities. It is believed that such exposure facilitates a better understanding of social issues and equips nurses with the skills to deal with them. More importantly, it provides a comprehensive and complete view of health and disease because when the nurse encounters the patient only in the hospital setting, such opportunities are lost. Based on the literature review, it can be said that community-based nursing, in facing the fundamental problems of life, using a problem-oriented and service-oriented approach, provides the necessary health care for individuals and families to the health problems during life and based on the context and community needs (cultural, political, social, economic, health status of the client) provides from the first level of the prevention to the third level and it does this through group and interdisciplinary cooperation and taking into account cultural diversity, factors affecting health and social justice for different strata of community in the natural environment of life and places in the community and it is based on the principle that community-based nursing is a collaborative work, the individual, family, and community have primary responsibility for health care decisions and the nurse mainly determines the nursing interventions with the client, the family and the health care team based on the values of the client, the family and the community and tries to respond to the community needs. The main goal of community-based nursing is to strengthen the capacity of the individual and family to take care of themselves and improve the community’s health. To achieve such a goal, it is necessary to provide infrastructure and structures such as the position of a community-based nurse, essential resources, and facilities and conditions for the nurse to enter the community. In line with the present study, it is proposed to investigate the challenges of community-based nursing education in Iran and introduce a solution to improve it.

Availability of data and materials

All data generated or analyzed during this study have been incorporated into this manuscript.

McLeroy KR, Norton BL, Kegler MC, Burdine JN, Sumaya CV. Community-based interventions. Am J Public Health. 2003;93(4):529–33. 

Article   Google Scholar  

Hunt R. Introduction to community-based nursing. Edition t. editor: Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Wilkins; 2009.

Google Scholar  

Zotti ME, Brown P, Stotts RC. Community-based nursing versus community health nursing: what does it all mean? Nurs Outlook. 1996;44(5):211–7.

Lubbers J, Rossman C. Satisfaction and self-confidence with nursing clinical simulation: novice learners, medium-fidelity, and community settings. Nurse Educ Today. 2017;48:140–4.

Higgins K, Hawkins J, Horvath E. Improving oral health: integrating oral health content in advanced practice registered nurse education. J Nurse Practitioners. 2020;16(5):394–7.

Cheng Y-C, Huang L-C, Yang C-H, Chang H-C. Experiential learning program to strengthen self-reflection and critical thinking in freshmen nursing students during COVID-19: a quasi-experimental study. Int J Environ Res Public Health. 2020;17(15): 5442.

Heydari H, Rahnavard Z, Ghaffari F. Exploring the position of community-based nursing in Iran: a qualitative study. Int J Community Based Nurs Midwifery. 2017;5(4):386–96.

Baldwin JH, O’Neill Conger C, Abegglen JC, Hill EM. Population-focused and community‐based nursing—moving toward clarification of concepts. Public Health Nurs. 1998;15(1):12–8.

Mtshali G. Conceptualisation of community-based basic nursing education in South Africa: a grounded theory analysis. Curationis. 2005;28(2):5–12.

Whitehead D. The role of community-based nurses in health promotion. Br J Community Nurs. 2000;5(12):604–9.

Mtshali NG, Gwele NS. Community-based nursing education in South Africa: a grounded-middle range theory. J Nurs Educ Pract. 2016;6(2):55–67.

Shin HY, Kim KY, Kang P. Concept analysis of community health outreach. BMC Health Serv Res. 2020;20(1):1–9.

Tsimane TA, Downing C. Transformative learning in nursing education: a concept analysis. Int J Nurs Sci. 2020;7(1):91–8.

Walker LO, Avant KC. Strategies for Theory Construction in Nursing. 6th edition. Boston: Pearson; 2019.

Harvey C, Hegney D, Sobolewska A, Chamberlain D, Wood E, Wirihana L, et al. Developing a community-based nursing and midwifery career pathway–A narrative systematic review. J PloS One. 2019;14(3): e0211160.

Uys L, Gwele N. Curriculum Development in Nursing: Process and Innovation. 1st ed. London: Routledge; 2005.

Flynn BC. Communicating with the public: community-based nursing research and practice. Public Health Nurs. 1998;15(3):165–70.

Cohn J, Corrigan J, Lynn J, Meier D, Miller J, Shega J et al. Community-based models of care delivery for people with serious illness. NAM Perspectives. Discussion Paper. Washington: National Academy of Medicine; https://doi.org/10.31478/201704b2017:1–13 .

Allender JA, Rector CL, Warner KD. Community Health Nursing, Promoting and Protecting the Public’s Health. 7th edition. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010.

Ariosto DA, Harper EM, Wilson ML, Hull SC, Nahm E-S, Sylvia ML. Population health: a nursing action plan. J Am Med Inf Association Open. 2018;1(1):7–10.

Rahnavard Z. The position and function of community based nursing in Iranian health system. The first regional conference on the development of community-based nursing and midwifery sciences; Islamic Azad University of Isfahan Najaf Abad unit. 2018:32–41.

Nuuyoma V, Munangatire T, Nghiweni N. Nursing students’ experiences of community-based learning in an undergraduate programme at a namibian university. Int J Afr Nurs Sci. 2022;17:100458.

Amalba A, Van Mook W, Mogre V, Scherpbier A. The perceived usefulness of community based education and service (COBES) regarding students’ rural workplace choices. BMC Med Educ. 2016;16(1):1–11.

Feenstra C, Gordon B, Hansen D, Zandee G. Managing community and neighborhood partnerships in a community-based nursing curriculum. J Prof Nurs. 2006;22(4):236–41.

Mwanika A, Okullo I, Kaye D, Muhwezi W, Atuyambe L, Nabirye R, et al. Perception and valuations of community-based education and service by alumni at Makerere university college of health sciences. BMC Int Health Hum Rights. 2011;11(1):1–8.

Mtshali N. Implementing community-based education in basic nursing education programs in South Africa. Curationis. 2009;32(1):25–32.

Lohr AM, Ingram M, Nuñez AV, Reinschmidt KM, Carvajal SC. Community–clinical linkages with community health workers in the United States: a scoping review. Health Promot Pract. 2018;19(3):349–60.

Huang W, Long H, Li J, Tao S, Zheng P, Tang S, et al. Delivery of public health services by community health workers (CHWs) in primary health care settings in China: a systematic review (1996–2016). Global Health Research and Policy. 2018;3(1):1–29.

Fauziddin M, Suryanti S, Wiryanto W. Community-based education and regional culture, has it been put into practice? AL-ISHLAH. Jurnal Pendidikan. 2022;14(2):1069–78.

Claramita M, Setiawati EP, Kristina TN, Emilia O, Van Der Vleuten C. Community-based educational design for undergraduate medical education: a grounded theory study. BMC Med Educ. 2019;19(1):1–10.

Talebi E, Nobahar M, Babamohamadi H. A comparative study of the nursing undergraduate program in Iran and Alice Lee university in Singapore. J Nurs Educ. 2021;9(6):60–72.

Radrazm L, Babamohamadi H, Nobahar M. Comparison of undergraduate nursing curriculum in Iran and UBC Canada: a comparative study. J Nurs Educ. 2021;10(5):32–41.

Zeydani A, Atashzadeh-Shoorideh F, Abdi F, Hosseini M, Zohari-Anboohi S, Skerrett V. Effect of community-based education on undergraduate nursing students’ skills: a systematic review. BMC Nurs. 2021;20(1):1–12.

Barasteh S, Rassouli M, Karimirad MR, Ebadi A. Future challenges of nursing in health system of Iran. Front Public Health. 2021;9:1052.

Irajpour A, Khorasani P, Bagheri M, Eshaghian A, Ziaee ES, Saberi Z, et al. The framework for developing nursing specialist roles in the health care system of Iran. Nurs Outlook. 2020;68(1):45–54.

Nagata C, Tsutsumi M, Kiyonaga A, Nogaki H. Evaluation of a training program for community-based end-of-life care of older people toward aging in place: a mixed methods study. Nurse Educ Pract. 2021;54: 103091.

Ohta R, Ryu Y, Sano C. The contribution of citizens to community-based medical education in Japan: a systematic review. Int J Environ Res Public Health. 2021;18(4): 1575.

Hosseinnejad A, Rassouli M, Jahani S, Elahi N, Molavynejad S. Community health nursing in Iran: a review of challenges and solutions (an integrative review). Front Public Health. 2022;10: 899211.

Heidary A, Mazlom R, Ildarabadi E. Nursing’s position in health care delivery system in Iran. Iran J Nurs Res. 2012;7(25):37–44.

Edwards JB, Alley NM. Transition to community-based nursing curriculum: processes and outcomes. J Prof Nurs. 2002;18(2):78–84.

Fichardt A, Viljoen M, Botma Y, Du Rand P. Adapting to and implementing a problem-and community-based approach to nursing education. Curationis. 2000:23(3)86–92. https://doi.org/10.4102/curationis.v23i3.717 .

Steffy ML. Community health learning experiences that influence RN to BSN students interests in community/public health nursing. Public Health Nurs. 2019;36(6):863–71.

Kerrigan V, Kelly A, Lee A, Mungatopi V, Mitchell A, Wyber R, et al. A community-based program to reduce acute rheumatic fever and rheumatic heart disease in northern Australia. BMC Health Serv Res. 2021;21(1):1–5.

Massimi A, De Vito C, Brufola I, Corsaro A, Marzuillo C, Migliara G, et al. Are community-based nurse-led self-management support interventions effective in chronic patients? Results of a systematic review and meta-analysis. PLoS ONE. 2017;12(3): e0173617.

Beauchesne MA, Meservey PM. An interdisciplinary community-based educational model. J Prof Nurs. 1999;15(1):38–43.

Kaye DK, Muhwezi WW, Kasozi AN, Kijjambu S, Mbalinda SN, Okullo I, et al. Lessons learnt from comprehensive evaluation of community-based education in Uganda: a proposal for an ideal model community-based education for health professional training institutions. BMC Med Educ. 2011;11(1):1–9.

Hall B, Tandon R. Socially Responsible Higher Education. Leiden, Netherland: 1st edition. Brill Publisher; 2021.

Ng JAI. A look back: assessment of the learning outcomes of the community-based research experiences of the senior high school students of a higher education institution in Batangas. Int J Learn Teach Educational Res. 2022;21(3):342–58.

De Villiers J, Joubert A, Bester C. Evaluation of clinical teaching and professional development in a problem and community-based nursing module. Curationis. 2004;27(1):82–93.

Mohamadi NK, Bahreini F. A review on the role of community participation in health promotion programs. Depiction of Health. 2019;10(4):310–8.

Ruger JP. Health and social justice. The Lancet. 2004;364(9439):1075–80.

Asakawa T, Kawabata H, Kisa K, Terashita T, Murakami M, Otaki J. Establishing community-based integrated care for elderly patients through interprofessional teamwork: a qualitative analysis. J Multidisciplinary Healthc. 2017;10:399–407.

Heidari M, Anoosheh M, Armaki T, Mohammadi E. Communication strategies for nurses facing culturally diverse patients. J Payesh. 2012;11(5):719–24.

Shirvani T, Javadivala Z, Azimi S, Shaghaghi A, Fathifar Z, Devender Bhalla H, et al. Community-based educational interventions for prevention of type II diabetes: a global systematic review and meta-analysis. Syst Reviews. 2021;10(1):1–12.

https:// inside.linfield.edu/_files/portland/student-nursing-manual.pdf . Accessed Sept 6, 2022.

Oros M, Johantgen M, Antol S, Heller BR, Ravella P. Community-based nursing centers: challenges and opportunities in implementation and sustainability. Policy Politics Nursing Practice. 2001;2(4):277–87.

Baghaei R, Mokhtari L, Mihandoost S, Hosseinzadegan F. Comparative study of nursing education in three Middle East countries. J Med Educ Dev. 2021;13(40):30–40.

Stricklin SM. Achieving clinical competencies through community-based clinical experiences. J Am Psychiatr Nurses Assoc. 2016;22(4):291–301.

Atashzadeh-Shoorideh F, Zeydani A, Hosseini M, Zohari-Anboohi S. Explaining of existing challenges of community-based undergraduate nursing education in Iran: a qualitative study. BMC Med Educ. 2023;23(1):1–12.

Heydari H, Shahsavari H, Hazini A, Nasrabadi AN. Exploring the barriers of home care services in Iran: a qualitative study. J Scientifica. 2016;2016:2056470.

Download references

Acknowledgements

Not applicable.

The authors received no financial support for the research, authorship and publication of this article.

Author information

Authors and affiliations.

Student Research Committee, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Arezoo Zeydani

Department of Psychiatric Nursing and Management, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Foroozan Atashzadeh-Shoorideh

Department of Community Health Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Meimanat Hosseini

Department of Medical Surgical-Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Sima Zohari-Anboohi

You can also search for this author in PubMed   Google Scholar

Contributions

AZ: Conceptualization, methodology, investigation, interpretation of data, writing-original draft, validation, review & editing FA: Conceptualization, methodology, investigation, interpretation of data, writing-original draft, validation, review & editing, supervision, project administration MH: Methodology, investigation, validation, review & editing SZ: Methodology, investigation, validation, review & editing.

Corresponding author

Correspondence to Foroozan Atashzadeh-Shoorideh .

Ethics declarations

Ethics approval and consent to participate.

This was a retrospective record review without any direct patient interaction by the study team. The research was performed in accordance with the Declaration of Helsinki and approved by two ethics committees. The ethics boards of the University of the Witwatersrand and Boston University reviewed and approved the study protocols and provided a waiver of informed consent.

Consent for publication

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1: supplementary file..

Overview of all included studies in concept analysis

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Zeydani, A., Atashzadeh-Shoorideh, F., Hosseini, M. et al. Community-based nursing: a concept analysis with Walker and Avant’s approach. BMC Med Educ 23 , 762 (2023). https://doi.org/10.1186/s12909-023-04749-5

Download citation

Received : 11 March 2023

Accepted : 04 October 2023

Published : 12 October 2023

DOI : https://doi.org/10.1186/s12909-023-04749-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Community-based
• Concept analysis
• Walker and avant

BMC Medical Education

ISSN: 1472-6920

• General enquiries: [email protected]

Community Health Nursing Diagnosis and Nursing Care Plan

Last updated on May 18th, 2022 at 06:35 am

Community Health Nursing Care Plans Diagnosis and Interventions

Community health nursing, also known as public health nursing, is one of the various specializations available in this professional field. Nurses who aspire to work in a setting other than a hospital and have greater control over their practice can choose to specialize in community health nursing.

By taking into account the cultural beliefs, surroundings, lifestyle, and socioeconomic considerations, a community nurse should be able to adapt quickly and help people live healthier lives in their own environment.

Importance of Community Health Nursing

Absence of insurance coverage, transport difficulties, inability to physically get to a doctor’s clinic or hospital, and a lack of understanding of where to go for healthcare are the other reasons why community members may not seek medical care.

History of Nursing Involvement in the Community

Lillian Wald and Florence Nightingale were the first individuals to develop a system of health planning based on a study of the health requirements of the community they served. Nurses have also historically been active in putting other disciplines’ plans into action.

Unlike any other healthcare provider, nurses spend more time in close touch with their patients than anybody else. They spend time in the community with clients, learning about their health, habits, needs, and what it’s like to be a member of that community firsthand.

Principles of Community Health Nursing

Community Health Nursing (CHN) is an essential component of public health, and it is guided by a set of 12 principles, which include:

Responsibilities of a Community Health Nurse

Adpie care plan for community health problems.

The majority of nurses in the community are required to design strategies and actions for the entire community’s health needs, not just for the health of a single person. It involves the process of problem-solving which is centered on a certain group of people.

They look at the data to see if it can be utilized to determine a population’s health, resources, or needs. They also look into how a range of community factors affect the health of the people who live there.

The nursing process in a community setting can be illustrated in the following scenarios:

Community Health Nursing Diagnosis

Community health nursing care plan 1.

Nursing Diagnosis: Altered health-seeking behaviors related to insufficient transport services for senior citizens.

Community Health Nursing Care Plan 2

Risk of Cardiovascular Diseases

Nursing Diagnosis: Risk of cardiovascular diseases related to obesity among the residents of ABC County as demonstrated in an obesity rate of 40.1% and record of being the second-highest mortality risk for cardiovascular disease at 203/100,000 in their District.

The community will have at least 5% decrease in statistical numbers of obese individuals, as measured by BMI, and consequently a reduction in deaths from cardiovascular diseases related to obesity at the end of 2025.

Nursing References

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018).  Medical-surgical nursing: Concepts for interprofessional collaborative care . St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

Leave a Comment Cancel reply

Warning: The NCBI web site requires JavaScript to function. more...

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021.

Nursing Fundamentals [Internet].

• About Open RN

Chapter 4 Nursing Process

4.1. nursing process introduction, learning objectives.

• Use the nursing process to provide patient care
• Identify nursing diagnoses from evidence-based sources
• Describe the development of a care plan
• Prioritize patient care
• Describe documentation for each step of the nursing process
• Differentiate between the role of the PN and RN

Have you ever wondered how a nurse can receive a quick handoff report from another nurse and immediately begin providing care for a patient they previously knew nothing about? How do they know what to do? How do they prioritize and make a plan?

Nurses do this activity every shift. They know how to find pertinent information and use the nursing process as a critical thinking model to guide patient care. The nursing process becomes a road map for the actions and interventions that nurses implement to optimize their patients’ well-being and health. This chapter will explain how to use the  nursing process  as standards of professional nursing practice to provide safe, patient-centered care.

4.2. BASIC CONCEPTS

Before learning how to use the nursing process, it is important to understand some basic concepts related to critical thinking and nursing practice. Let’s take a deeper look at how nurses think.

Critical Thinking and Clinical Reasoning

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning.  Critical thinking  is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” [ 1 ] Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research.

“Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

• Independence of thought: Thinking on your own
• Fair-mindedness:  Treating every viewpoint in an unbiased, unprejudiced way
• Insight into egocentricity and sociocentricity:  Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
• Intellectual humility:  Recognizing your intellectual limitations and abilities
• Nonjudgmental:  Using professional ethical standards and not basing your judgments on your own personal or moral standards
• Integrity:  Being honest and demonstrating strong moral principles
• Perseverance:  Persisting in doing something despite it being difficult
• Confidence:  Believing in yourself to complete a task or activity
• Interest in exploring thoughts and feelings:  Wanting to explore different ways of knowing
• Curiosity:  Asking “why” and wanting to know more

Clinical reasoning  is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.” [ 2 ]  To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. [ 3 ]

Inductive and Deductive Reasoning and Clinical Judgment

Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process.

Inductive reasoning  involves noticing cues, making generalizations, and creating hypotheses.  Cues  are data that fall outside of expected findings that give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A  generalization  is a judgment formed from a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes more clear. Based on generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. A  hypothesis  is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored.

No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. A nurse is similar to the detective looking for cues in Figure 4.1 . [ 4 ]  Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to take action quickly, especially in emergency situations. They can see how certain objects or events form a pattern (i.e., generalization) that indicates a common problem (i.e., hypothesis).

Inductive Reasoning Includes Looking for Cues

Example:  A nurse assesses a patient and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Deductive reasoning  is another type of critical thinking that is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Example:  Based on research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. (See Figure 4.2 ). [ 5 ]  The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking because the intervention is applied to all patients regardless if they have difficulty sleeping or not.

Deductive Reasoning Example: Implementing Interventions for a Quiet Zone Policy

Clinical judgment  is the result of critical thinking and clinical reasoning using inductive and deductive reasoning. Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.”  [ 6 ]  The NCSBN administers the national licensure exam (NCLEX) that measures nursing clinical judgment and decision-making ability of prospective entry-level nurses to assure safe and competent nursing care by licensed nurses.

Evidence-based practice (EBP)  is defined by the American Nurses Association (ANA) as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.” [ 7 ]

Nursing Process

The nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently. [ 8 ]  The mnemonic  ADOPIE  is an easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process:  A ssessment,  D iagnosis,  O utcomes Identification,  P lanning,  I mplementation, and  E valuation.

The nursing process is a continuous, cyclic process that is constantly adapting to the patient’s current health status. See Figure 4.3 [ 9 ]  for an illustration of the nursing process.

The Nursing Process

Review Scenario A in the following box for an example of a nurse using the nursing process while providing patient care.

Patient Scenario A: Using the Nursing Process [ 10 ]

A hospitalized patient has a prescription to receive Lasix 80mg IV every morning for a medical diagnosis of heart failure. During the morning assessment, the nurse notes that the patient has a blood pressure of 98/60, heart rate of 100, respirations of 18, and a temperature of 98.7F. The nurse reviews the medical record for the patient’s vital signs baseline and observes the blood pressure trend is around 110/70 and the heart rate in the 80s. The nurse recognizes these cues form a pattern related to fluid imbalance and hypothesizes that the patient may be dehydrated. The nurse gathers additional information and notes the patient’s weight has decreased 4 pounds since yesterday. The nurse talks with the patient and validates the hypothesis when the patient reports that their mouth feels like cotton and they feel light-headed. By using critical thinking and clinical judgment, the nurse diagnoses the patient with the nursing diagnosis Fluid Volume Deficit and establishes outcomes for reestablishing fluid balance. The nurse withholds the administration of IV Lasix and contacts the health care provider to discuss the patient’s current fluid status. After contacting the provider, the nurse initiates additional nursing interventions to promote oral intake and closely monitor hydration status. By the end of the shift, the nurse evaluates the patient status and determines that fluid balance has been restored.

In Scenario A, the nurse is using clinical judgment and not just “following orders” to administer the Lasix as scheduled. The nurse assesses the patient, recognizes cues, creates a generalization and hypothesis regarding the fluid status, plans and implements nursing interventions, and evaluates the outcome. Additionally, the nurse promotes patient safety by contacting the provider before administering a medication that could cause harm to the patient at this time.

The ANA’s Standards of Professional Nursing Practice associated with each component of the nursing process are described below.

The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” [ 11 ]  A registered nurse uses a systematic method to collect and analyze patient data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, a nurse’s assessment of a hospitalized patient in pain includes the patient’s response to pain, such as the inability to get out of bed, refusal to eat, withdrawal from family members, or anger directed at hospital staff. [ 12 ]

The “Assessment” component of the nursing process is further described in the “ Assessment ” section of this chapter.

The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.” [ 13 ]  A nursing diagnosis is the nurse’s clinical judgment about the  client's  response to actual or potential health conditions or needs. Nursing diagnoses are the bases for the nurse’s care plan and are different than medical diagnoses. [ 14 ]

The “Diagnosis” component of the nursing process is further described in the “ Diagnosis ” section of this chapter.

Outcomes Identification

The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” [ 15 ]  The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses.

The “Outcomes Identification” component of the nursing process is further described in the “ Outcomes Identification ” section of this chapter.

The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” [ 16 ]  Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each patient’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the patient’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care. [ 17 ]

The “Planning” component of the nursing process is further described in the “ Planning ” section of this chapter.

NURSING CARE PLANS

Creating nursing care plans is a part of the “Planning” step of the nursing process. A  nursing care plan  is a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific patient using the nursing process. Registered nurses (RNs) create nursing care plans so that the care provided to the patient across shifts is consistent among health care personnel. Some interventions can be delegated to Licensed Practical Nurses (LPNs) or trained Unlicensed Assistive Personnel (UAPs) with the RN’s supervision. Developing nursing care plans and implementing appropriate delegation are further discussed under the “ Planning ” and “ Implementing ” sections of this chapter.

Implementation

The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.” [ 18 ]  Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the patient. Interventions are also documented in the patient’s electronic medical record as they are completed. [ 19 ]

The “Implementation” Standard of Professional Practice also includes the subcategories “Coordination of Care” and “Health Teaching and Health Promotion” to promote health and a safe environment. [ 20 ]

The “Implementation” component of the nursing process is further described in the “ Implementation ” section of this chapter.

The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [ 21 ]  During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed. [ 22 ]

The “Evaluation” component of the nursing process is further described in the “ Evaluation ” section of this chapter.

Benefits of Using the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other members of the health care team. The benefits of using the nursing process include the following:

• Promotes quality patient care
• Decreases omissions and duplications
• Provides a guide for all staff involved to provide consistent and responsive care
• Encourages collaborative management of a patient’s health care problems
• Improves patient safety
• Improves patient satisfaction
• Identifies a patient’s goals and strategies to attain them
• Increases the likelihood of achieving positive patient outcomes
• Saves time, energy, and frustration by creating a care plan or path to follow

By using these components of the nursing process as a critical thinking model, nurses plan interventions customized to the patient’s needs, plan outcomes and interventions, and determine whether those actions are effective in meeting the patient’s needs. In the remaining sections of this chapter, we will take an in-depth look at each of these components of the nursing process. Using the nursing process and implementing evidence-based practices are referred to as the “science of nursing.” Let’s review concepts related to the “art of nursing” while providing holistic care in a caring manner using the nursing process.

Holistic Nursing Care

The American Nurses Association (ANA) recently updated the definition of  nursing  as, “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.” [ 23 ]

The ANA further describes nursing is a learned profession built on a core body of knowledge that integrates both the art and science of nursing. The  art of nursing  is defined as, “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.” [ 24 ]

Nurses care for individuals holistically, including their emotional, spiritual, psychosocial, cultural, and physical needs. They consider problems, issues, and needs that the person experiences as a part of a family and a community as they use the nursing process. Review a scenario illustrating holistic nursing care provided to a patient and their family in the following box.

Holistic Nursing Care Scenario

A single mother brings her child to the emergency room for ear pain and a fever. The physician diagnoses the child with an ear infection and prescribes an antibiotic. The mother is advised to make a follow-up appointment with their primary provider in two weeks. While providing discharge teaching, the nurse discovers that the family is unable to afford the expensive antibiotic prescribed and cannot find a primary care provider in their community they can reach by a bus route. The nurse asks a social worker to speak with the mother about affordable health insurance options and available providers in her community and follows up with the prescribing physician to obtain a prescription for a less expensive generic antibiotic. In this manner, the nurse provides holistic care and advocates for improved health for the child and their family.

Review how to provide culturally responsive care and reduce health disparities in the “ Diverse Patients ” chapter.

Caring and the nursing process.

The American Nurses Association (ANA) states, “The act of caring is foundational to the practice of nursing.” [ 25 ]  Successful use of the nursing process requires the development of a care relationship with the patient. A  care relationship  is a mutual relationship that requires the development of trust between both parties. This trust is often referred to as the development of  rapport  and underlies the art of nursing. While establishing a caring relationship, the whole person is assessed, including the individual’s beliefs, values, and attitudes, while also acknowledging the vulnerability and dignity of the patient and family. Assessing and caring for the whole person takes into account the physical, mental, emotional, and spiritual aspects of being a human being. [ 26 ] Caring interventions can be demonstrated in simple gestures such as active listening, making eye contact, touching, and verbal reassurances while also respecting and being sensitive to the care recipient’s cultural beliefs and meanings associated with caring behaviors. [ 27 ]  See Figure 4.4 [ 28 ]  for an image of a nurse using touch as a therapeutic communication technique to communicate caring.

Touch as a Therapeutic Communication Technique

Review how to communicate with patients using therapeutic communication techniques like active listening in the “ Communication ” chapter.

Dr. Jean Watson is a nurse theorist who has published many works on the art and science of caring in the nursing profession. Her theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and the public. Dr. Watson’s caring philosophy encourages nurses to be authentically present with their patients while creating a healing environment. [ 29 ]

Read more about Dr. Watson’s theory of caring at the  Watson Caring Science Institute .

Now that we have discussed basic concepts related to the nursing process, let’s look more deeply at each component of the nursing process in the following sections.

4.3. ASSESSMENT

Assessment  is the first step of the nursing process (and the first  Standard of Practice  set by the American Nurses Association). This standard is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” This includes collecting “pertinent data related to the health and quality of life in a systematic, ongoing manner, with compassion and respect for the wholeness, inherent dignity, worth, and unique attributes of every person, including but not limited to, demographics, environmental and occupational exposures, social determinants of health, health disparities, physical, functional, psychosocial, emotional, cognitive, spiritual/transpersonal, sexual, sociocultural, age-related, environmental, and lifestyle/economic assessments.” [ 1 ]

Nurses assess patients to gather clues, make generalizations, and diagnose human responses to health conditions and life processes. Patient data is considered either subjective or objective, and it can be collected from multiple sources.

Subjective Assessment Data

Subjective data  is information obtained from the patient and/or family members and offers important cues from their perspectives. When documenting subjective data stated by a patient, it should be in quotation marks and start with verbiage such as,  The patient reports.  It is vital for the nurse to establish rapport with a patient to obtain accurate, valuable subjective data regarding the mental, emotional, and spiritual aspects of their condition.

There are two types of subjective information, primary and secondary.  Primary data  is information provided directly by the patient. Patients are the best source of information about their bodies and feelings, and the nurse who actively listens to a patient will often learn valuable information while also promoting a sense of well-being. Information collected from a family member, chart, or other sources is known as  secondary data . Family members can provide important information, especially for individuals with memory impairments, infants, children, or when patients are unable to speak for themselves.

See Figure 4.5 [ 2 ]  for an illustration of a nurse obtaining subjective data and establishing rapport after obtaining permission from the patient to sit on the bed.

Example.  An example of documented subjective data obtained from a patient assessment is,  “The patient reports, ‘My pain is a level 2 on a 1-10 scale.’”

Objective Assessment Data

Objective data  is anything that you can observe through your sense of hearing, sight, smell, and touch while assessing the patient. Objective data is reproducible, meaning another person can easily obtain the same data. Examples of objective data are vital signs, physical examination findings, and laboratory results. See Figure 4.6 [ 3 ]  for an image of a nurse performing a physical examination.

Physical Examination

Example.  An example of documented objective data is,  “The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.”

Sources of Assessment Data

There are three sources of assessment data: interview, physical examination, and review of laboratory or diagnostic test results.

Interviewing

Interviewing includes asking the patient questions, listening, and observing verbal and nonverbal communication. Reviewing the chart prior to interviewing the patient may eliminate redundancy in the interview process and allows the nurse to hone in on the most significant areas of concern or need for clarification. However, if information in the chart does not make sense or is incomplete, the nurse should use the interview process to verify data with the patient.

After performing patient identification, the best way to initiate a caring relationship is to introduce yourself to the patient and explain your role. Share the purpose of your interview and the approximate time it will take. When beginning an interview, it may be helpful to start with questions related to the patient’s  medical diagnoses  to gather information about how they have affected the patient’s functioning, relationships, and lifestyle. Listen carefully and ask for clarification when something isn’t clear to you. Patients may not volunteer important information because they don’t realize it is important for their care. By using critical thinking and active listening, you may discover valuable cues that are important to provide safe, quality nursing care. Sometimes nursing students can feel uncomfortable having difficult conversations or asking personal questions due to generational or other cultural differences. Don’t shy away from asking about information that is important to know for safe patient care. Most patients will be grateful that you cared enough to ask and listen.

Be alert and attentive to how the patient answers questions, as well as when they do not answer a question. Nonverbal communication and body language can be cues to important information that requires further investigation. A keen sense of observation is important. To avoid making inappropriate  inferences , the nurse should validate any cues. For example, a nurse may make an inference that a patient is depressed when the patient avoids making eye contact during an interview. However, upon further questioning, the nurse may discover that the patient’s cultural background believes direct eye contact to be disrespectful and this is why they are avoiding eye contact. To read more information about communicating with patients, review the “ Communication ” chapter of this book.

A  physical examination  is a systematic data collection method of the body that uses the techniques of inspection, auscultation, palpation, and percussion. Inspection is the observation of a patient’s anatomical structures. Auscultation is listening to sounds, such as heart, lung, and bowel sounds, created by organs using a stethoscope. Palpation is the use of touch to evaluate organs for size, location, or tenderness. Percussion is an advanced physical examination technique typically performed by providers where body parts are tapped with fingers to determine their size and if fluid is present. Detailed physical examination procedures of various body systems can be found in the Open RN  Nursing Skills  textbook with a head-to-toe checklist in  Appendix C . Physical examination also includes the collection and analysis of vital signs.

Registered Nurses (RNs)  complete the initial physical examination and analyze the findings as part of the nursing process. Collection of follow-up physical examination data can be delegated to  Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs) , or measurements such as vital signs and weight may be delegated to trained  Unlicensed Assistive Personnel (UAP)  when appropriate to do so. However, the RN remains responsible for supervising these tasks, analyzing the findings, and ensuring they are documented .

A physical examination can be performed as a comprehensive, head-to-toe assessment or as a focused assessment related to a particular condition or problem. Assessment data is documented in the patient’s  Electronic Medical Record (EMR) , an electronic version of the patient’s medical chart.

Reviewing Laboratory and Diagnostic Test Results

Reviewing laboratory and diagnostic test results provides relevant and useful information related to the needs of the patient. Understanding how normal and abnormal results affect patient care is important when implementing the nursing care plan and administering provider prescriptions. If results cause concern, it is the nurse’s responsibility to notify the provider and verify the appropriateness of prescriptions based on the patient’s current status before implementing them.

Types of Assessments

Several types of nursing assessment are used in clinical practice:

• Primary Survey:  Used during every patient encounter to briefly evaluate level of consciousness, airway, breathing, and circulation and implement emergency care if needed.
• Admission Assessment:  A comprehensive assessment completed when a patient is admitted to a facility that involves assessing a large amount of information using an organized approach.
• Ongoing Assessment:  In acute care agencies such as hospitals, a head-to-toe assessment is completed and documented at least once every shift. Any changes in patient condition are reported to the health care provider.
• Focused Assessment:  Focused assessments are used to reevaluate the status of a previously diagnosed problem.
• Time-lapsed Reassessment:  Time-lapsed reassessments are used in long-term care facilities when three or more months have elapsed since the previous assessment to evaluate progress on previously identified outcomes. [ 4 ]

Putting It Together

Review Scenario C in the following box to apply concepts of assessment to a patient scenario.

Scenario C [5]

Ms. J. is a 74-year-old woman who is admitted directly to the medical unit after visiting her physician because of shortness of breath, increased swelling in her ankles and calves, and fatigue. Her medical history includes hypertension (30 years), coronary artery disease (18 years), heart failure (2 years), and type 2 diabetes (14 years). She takes 81 mg of aspirin every day, metoprolol 50 mg twice a day, furosemide 40 mg every day, and metformin 2,000 mg every day.

Ms. J.’s vital sign values on admission were as follows:

• Blood Pressure: 162/96 mm Hg
• Heart Rate: 88 beats/min
• Oxygen Saturation: 91% on room air
• Respiratory Rate: 28 breaths/minute
• Temperature: 97.8 degrees F orally

Her weight is up 10 pounds since the last office visit three weeks prior. The patient states, “I am so short of breath” and “My ankles are so swollen I have to wear my house slippers.” Ms. J. also shares, “I am so tired and weak that I can’t get out of the house to shop for groceries,” and “Sometimes I’m afraid to get out of bed because I get so dizzy.” She confides, “I would like to learn more about my health so I can take better care of myself.”

The physical assessment findings of Ms. J. are bilateral basilar crackles in the lungs and bilateral 2+ pitting edema of the ankles and feet. Laboratory results indicate a decreased serum potassium level of 3.4 mEq/L.

As the nurse completes the physical assessment, the patient’s daughter enters the room. She confides, “We are so worried about mom living at home by herself when she is so tired all the time!”

Critical Thinking Questions

Identify subjective data.

Identify objective data.

Provide an example of secondary data.

Answers are located in the Answer Key at the end of the book.

4.4. DIAGNOSIS

Diagnosis  is the second step of the nursing process (and the second Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.” The RN “prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the health care consumer across the health–illness continuum and the care continuum.” Diagnoses, problems, strengths, and issues are documented in a manner that facilitates the development of expected outcomes and a collaborative plan. [ 1 ]

Analyzing Assessment Data

After collection of assessment data, the registered nurse analyzes the data to form generalizations and create hypotheses for nursing diagnoses. Steps for analyzing assessment data include performing data analysis, clustering of information, identifying hypotheses for potential nursing diagnosis, performing additional in-depth assessment as needed, and establishing nursing diagnosis statements. The nursing diagnoses are then prioritized and drive the nursing care plan. [ 2 ]

Performing Data Analysis

After nurses collect assessment data from a patient, they use their nursing knowledge to analyze that data to determine if it is “expected” or “unexpected” or “normal” or “abnormal” for that patient according to their age, development, and baseline status. From there, nurses determine what data are “clinically relevant” as they prioritize their nursing care. [ 3 ]

Example.  In Scenario C in the “Assessment” section of this chapter, the nurse analyzes the vital signs data and determines the blood pressure, heart rate, and respiratory rate are elevated, and the oxygen saturation is decreased for this patient. These findings are considered “relevant cues.”

Clustering Information/Seeing Patterns/Making Hypotheses

After analyzing the data and determining relevant cues, the nurse  clusters  data into patterns. Assessment frameworks such as Gordon’s  Functional Health Patterns  assist nurses in clustering information according to evidence-based patterns of human responses. See the box below for an outline of Gordon’s Functional Health Patterns. [ 4 ]  Concepts related to many of these patterns will be discussed in chapters later in this book.

Example.  Refer to Scenario C of the “Assessment” section of this chapter. The nurse clusters the following relevant cues: elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, shortness of breath, a medical history of heart failure, and currently prescribed a diuretic medication. These cues are clustered into a generalization/pattern of fluid balance, which can be classified under Gordon’s Nutritional-Metabolic Functional Health Pattern. The nurse makes a hypothesis that the patient has excess fluid volume present.

Gordon’s Functional Health Patterns [ 5 ]

Health Perception-Health Management:  A patient’s perception of their health and well-being and how it is managed

Nutritional-Metabolic:  Food and fluid consumption relative to metabolic need

Elimination:  Excretory function, including bowel, bladder, and skin

Activity-Exercise:  Exercise and daily activities

Sleep-Rest:  Sleep, rest, and daily activities

Cognitive-Perceptual:  Perception and cognition

Self-perception and Self-concept:  Self-concept and perception of self-worth, self-competency, body image, and mood state

Role-Relationship:  Role engagements and relationships

Sexuality-Reproductive:  Reproduction and satisfaction or dissatisfaction with sexuality

Coping-Stress Tolerance:  Coping and effectiveness in terms of stress tolerance

Value-Belief:  Values, beliefs (including spiritual beliefs), and goals that guide choices and decisions

Identifying Nursing Diagnoses

After the nurse has analyzed and clustered the data from the patient assessment, the next step is to begin to answer the question, “What are my patient’s human responses (i.e., nursing diagnoses)?” A  nursing diagnosis  is defined as, “A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.” [ 6 ]  Nursing diagnoses are customized to each patient and drive the development of the nursing care plan. The nurse should refer to a care planning resource and review the definitions and defining characteristics of the hypothesized nursing diagnoses to determine if additional in-depth assessment is needed before selecting the most accurate nursing diagnosis.

Nursing diagnoses are developed by nurses, for use by nurses. For example, NANDA International (NANDA-I) is a global professional nursing organization that develops nursing terminology that names actual or potential human responses to health problems and life processes based on research findings. [ 7 ]  Currently, there are over 220 NANDA-I nursing diagnoses developed by nurses around the world. This list is continuously updated, with new nursing diagnoses added and old nursing diagnoses retired that no longer have supporting evidence. A list of commonly used NANDA-I diagnoses are listed in  Appendix A . For a full list of NANDA-I nursing diagnoses, refer to a current nursing care plan reference.

NANDA-I nursing diagnoses are grouped into 13 domains that assist the nurse in selecting diagnoses based on the patterns of clustered data. These domains are similar to Gordon’s Functional Health Patterns and include health promotion, nutrition, elimination and exchange, activity/rest, perception/cognition, self-perception, role relationship, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development.

Knowledge regarding specific NANDA-I nursing diagnoses is not assessed on the NCLEX. However, analyzing cues and creating hypotheses are part of the measurement model used to assess a candidate’s clinical judgment. Read more about the NCLEX and Next Generation NCLEX in the “ Scope of Practice ” chapter.

Nursing diagnoses vs. medical diagnoses.

You may be asking yourself, “How are nursing diagnoses different from medical diagnoses?” Medical diagnoses focus on diseases or other medical problems that have been identified by the physician, physician’s assistant, or advanced nurse practitioner. Nursing diagnoses focus on the  human response  to health conditions and life processes and are made independently by RNs. Patients with the same medical diagnosis will often  respond  differently to that diagnosis and thus have different nursing diagnoses. For example, two patients have the same medical diagnosis of heart failure. However, one patient may be interested in learning more information about the condition and the medications used to treat it, whereas another patient may be experiencing anxiety when thinking about the effects this medical diagnosis will have on their family. The nurse must consider these different responses when creating the nursing care plan. Nursing diagnoses consider the patient’s and family’s needs, attitudes, strengths, challenges, and resources as a customized nursing care plan is created to provide holistic and individualized care for each patient.

Example.  A medical diagnosis identified for Ms. J. in Scenario C in the “Assessment” section is heart failure. This cannot be used as a nursing diagnosis, but it can be considered as an “associated condition” when creating hypotheses for nursing diagnoses. Associated conditions are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents that are not independently modifiable by the nurse, but support accuracy in nursing diagnosis. The nursing diagnosis in Scenario C will be related to the patient’s response to heart failure.

Additional Definitions Used in NANDA-I Nursing Diagnoses

The following definitions of patient, age, and time are used in association with NANDA-I nursing diagnoses:

The NANDA-I definition of a “patient” includes:

• Individual:  a single human being distinct from others (i.e., a person).
• Caregiver:  a family member or helper who regularly looks after a child or a sick, elderly, or disabled person.
• Family:  two or more people having continuous or sustained relationships, perceiving reciprocal obligations, sensing common meaning, and sharing certain obligations toward others; related by blood and/or choice.
• Group:  a number of people with shared characteristics generally referred to as an ethnic group.
• Community:  a group of people living in the same locale under the same governance. Examples include neighborhoods and cities. [ 8 ]

The age of the person who is the subject of the diagnosis is defined by the following terms: [ 9 ]

• Fetus:  an unborn human more than eight weeks after conception, until birth.
• Neonate:  a person less than 28 days of age.
• Infant:  a person greater than 28 days and less than 1 year of age.
• Child:  a person aged 1 to 9 years
• Adolescent:  a person aged 10 to 19 years
• Adult:  a person older than 19 years of age unless national law defines a person as being an adult at an earlier age.
• Older adult:  a person greater than 65 years of age.

The duration of the diagnosis is defined by the following terms: [ 10 ]

• Acute:  lasting less than 3 months.
• Chronic:  lasting greater than 3 months.
• Intermittent:  stopping or starting again at intervals
• Continuous:  uninterrupted, going on without stop.

New Terms Used in 2018-2020 NANDA-I Diagnoses

The 2018-2020 edition of  Nursing Diagnoses  includes two new terms to assist in creating nursing diagnoses: at-risk populations and associated conditions. [ 11 ]

At-Risk Populations  are groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences.

Associated Conditions  are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis [ 12 ]

Types of Nursing Diagnoses

There are four types of NANDA-I nursing diagnoses: [ 13 ]

• Problem-Focused
• Health Promotion – Wellness

A  problem-focused nursing diagnosis  is a “clinical judgment concerning an undesirable human response to health condition/life processes that exist in an individual, family, group, or community.” [ 14 ]  To make an accurate problem-focused diagnosis, related factors and defining characteristics must be present.  Related factors  (also called etiology) are causes that contribute to the diagnosis.  Defining characteristics  are cues, signs, and symptoms that cluster into patterns. [ 15 ]

A  health promotion-wellness nursing diagnosis  is “a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential.” These responses are expressed by the patient’s readiness to enhance specific health behaviors. [ 16 ] A health promotion-wellness diagnosis is used when the patient is willing to improve a lack of knowledge, coping, or other identified need.

A  risk nursing diagnosis  is “a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes.” [ 17 ]  A risk nursing diagnosis must be supported by risk factors that contribute to the increased vulnerability. A risk nursing diagnosis is different from the problem-focused diagnosis in that the problem has not yet actually occurred. Problem diagnoses should not be automatically viewed as more important than risk diagnoses because sometimes a risk diagnosis can have the highest priority for a patient. [ 18 ]

A  syndrome diagnosis  is a “clinical judgment concerning a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.” [ 19 ]

Establishing Nursing Diagnosis Statements

When using NANDA-I nursing diagnoses, NANDA-I recommends the structure of a nursing diagnosis should be a statement that includes the  nursing diagnosis  and  related factors  as exhibited by  defining characteristics . The accuracy of the nursing diagnosis is validated when a nurse is able to clearly link the defining characteristics, related factors, and/or risk factors found during the patient’s assessment. [ 20 ]

To create a nursing diagnosis statement, the registered nurse completes the following steps. After analyzing the patient’s subjective and objective data and clustering the data into patterns, the nurse generates hypotheses for nursing diagnoses based on how the patterns meet defining characteristics of a nursing diagnosis.  Defining characteristics  is the terminology used for observable signs and symptoms related to a nursing diagnosis. [ 21 ]  Defining characteristics are included in care planning resources for each nursing diagnosis, along with a definition of that diagnosis, so the nurse can select the most accurate diagnosis. For example, objective and subjective data such as weight, height, and dietary intake can be clustered together as defining characteristics for the nursing diagnosis of nutritional status.

When creating a nursing diagnosis statement, the nurse also identifies the cause of the problem for that specific patient.  Related factors  is the terminology used for the underlying causes (etiology) of a patient’s problem or situation. Related factors should not be a medical diagnosis, but instead should be attributed to the underlying pathophysiology that the nurse can treat. When possible, the nursing interventions planned for each nursing diagnosis should attempt to modify or remove these related factors that are the underlying cause of the nursing diagnosis. [ 22 ]

Creating nursing diagnosis statements has traditionally been referred to as “using PES format.” The  PES  mnemonic no longer applies to the current terminology used by NANDA-I, but the components of a nursing diagnosis statement remain the same. A nursing diagnosis statement should contain the problem, related factors, and defining characteristics. These terms fit under the former PES format in this manner:

Problem (P)  – the patient  p roblem (i.e., the nursing diagnosis)

Etiology (E)  – related factors (i.e., the  e tiology/cause) of the nursing diagnosis; phrased as “related to” or “R/T”

Signs and Symptoms (S)  – defining characteristics manifested by the patient (i.e., the  s igns and  s ymptoms/subjective and objective data) that led to the identification of that nursing diagnosis for the patient; phrased with “as manifested by” or “as evidenced by.”

Examples of different types of nursing diagnoses are further explained below.

Problem-Focused Nursing Diagnosis

A problem-focused nursing diagnosis contains all three components of the  PES format :

Problem (P)  – statement of the patient response (nursing diagnosis)

Etiology (E)  – related factors contributing to the nursing diagnosis

Signs and Symptoms (S)  – defining characteristics manifested by that patient

SAMPLE PROBLEM-FOCUSED NURSING DIAGNOSIS STATEMENT

Refer to Scenario C of the “Assessment” section of this chapter. The cluster of data for Ms. J. (elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, and shortness of breath) are defining characteristics for the NANDA-I Nursing Diagnosis  Excess Fluid Volume . The NANDA-I definition of  Excess Fluid Volume  is “surplus intake and/or retention of fluid.” The related factor (etiology) of the problem is that the patient has excessive fluid intake. [ 23 ]

The components of a  problem-focused nursing diagnosis  statement for Ms. J. would be:

Fluid Volume Excess

Related to excessive fluid intake

As manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, increased weight of 10 pounds, and the patient reports, “ My ankles are so swollen .”

A correctly written problem-focused nursing diagnosis statement for Ms. J. would look like this:

Fluid Volume Excess related to excessive fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”

Health-Promotion Nursing Diagnosis

A health-promotion nursing diagnosis statement contains the problem (P) and the defining characteristics (S). The defining characteristics component of a health-promotion nursing diagnosis statement should begin with the phrase “expresses desire to enhance”: [ 24 ]

Signs and Symptoms (S)  – the patient’s expressed desire to enhance

SAMPLE HEALTH-PROMOTION NURSING DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. demonstrates a readiness to improve her health status when she told the nurse that she would like to “learn more about my health so I can take better care of myself.” This statement is a defining characteristic of the NANDA-I nursing diagnosis  Readiness for Enhanced Health Management , which is defined as “a pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae, which can be strengthened.” [ 25 ]

The components of a  health-promotion nursing diagnosis  for Ms. J. would be:

Problem (P):  Readiness for Enhanced Health Management

Symptoms (S):  Expressed desire to “learn more about my health so I can take better care of myself.”

A correctly written health-promotion nursing diagnosis statement for Ms. J. would look like this:

Enhanced Readiness for Health Promotion as manifested by expressed desire to “learn more about my health so I can take better care of myself.”

Risk Nursing Diagnosis

A risk nursing diagnosis should be supported by evidence of the patient’s risk factors for developing that problem. Different experts recommend different phrasing. NANDA-I 2018-2020 recommends using the phrase “as evidenced by” to refer to the risk factors for developing that problem. [ 26 ]

A risk diagnosis consists of the following:

As Evidenced By  – Risk factors for developing the problem

SAMPLE RISK DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. has an increased risk of falling due to vulnerability from the dizziness and weakness she is experiencing. The NANDA-I definition of  Risk for Falls  is “increased susceptibility to falling, which may cause physical harm and compromise health.” [ 27 ]

The components of a  risk diagnosis  statement for Ms. J. would be:

Problem (P)  – Risk for Falls

As Evidenced By  – Dizziness and decreased lower extremity strength

A correctly written risk nursing diagnosis statement for Ms. J. would look like this:

Risk for Falls as evidenced by dizziness and decreased lower extremity strength.

Syndrome Diagnosis

A syndrome is a cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions. To create a syndrome diagnosis, two or more nursing diagnoses must be used as defining characteristics (S) that create a syndrome. Related factors may be used if they add clarity to the definition, but are not required. [ 28 ]

A syndrome statement consists of these items:

Problem (P)  – the syndrome

Signs and Symptoms (S)  – the defining characteristics are two or more similar nursing diagnoses

SAMPLE SYNDROME DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Clustering the data for Ms. J. identifies several similar NANDA-I nursing diagnoses that can be categorized as a  syndrome . For example,  Activity Intolerance  is defined as “insufficient physiological or psychological energy to endure or complete required or desired daily activities.”  Social Isolation  is defined as “aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.” These diagnoses can be included under the the NANDA-I syndrome named  Risk for Frail Elderly Syndrome.  This syndrome is defined as a “dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domains of health (physical, functional, psychological, or social) and leads to increased susceptibility to adverse health effects, in particular disability.” [ 29 ]

The components of a  syndrome nursing diagnosis  for Ms. J. would be:

– Risk for Frail Elderly Syndrome

– The nursing diagnoses of  Activity Intolerance  and  Social Isolation

Additional related factor: Fear of falling

A correctly written syndrome diagnosis statement for Ms. J. would look like this:

Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling

Prioritization

After identifying nursing diagnoses, the next step is prioritization according to the specific needs of the patient. Nurses prioritize their actions while providing patient care multiple times every day.  Prioritization  is the process that identifies the most significant nursing problems, as well as the most important interventions, in the nursing care plan.

It is essential that life-threatening concerns and crises are identified immediately and addressed quickly. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds for life-threatening concerns. In critical situations, the steps of the nursing process are performed through rapid clinical judgment. Nurses must recognize cues signaling a change in patient condition, apply evidence-based practices in a crisis, and communicate effectively with interprofessional team members. Most patient situations fall somewhere between a crisis and routine care.

There are several concepts used to prioritize, including Maslow’s Hierarchy of Needs, the “ABCs” (Airway, Breathing and Circulation), and acute, uncompensated conditions. See the infographic in Figure 4.7 [30]  on  The How To of Prioritization .

The How To of Prioritization

Maslow’s Hierarchy of Needs  is used to categorize the most urgent patient needs. The bottom levels of the pyramid represent the top priority needs of physiological needs intertwined with safety. See Figure 4.8 [31]  for an image of Maslow’s Hierarchy of Needs. You may be asking yourself, “What about the ABCs – isn’t airway the most important?” The answer to that question is “it depends on the situation and the associated safety considerations.” Consider this scenario – you are driving home after a lovely picnic in the country and come across a fiery car crash. As you approach the car, you see that the passenger is not breathing. Using Maslow’s Hierarchy of Needs to prioritize your actions, you remove the passenger from the car first due to safety even though he is not breathing. After ensuring safety and calling for help, you follow the steps to perform cardiopulmonary resuscitation (CPR) to establish circulation, airway, and breathing until help arrives.

Maslow’s Hierarchy of Needs

In addition to using Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation, the nurse also considers if the patient’s condition is an acute or chronic problem. Acute, uncompensated conditions generally require priority interventions over chronic conditions. Additionally, actual problems generally receive priority over potential problems, but risk problems sometimes receive priority depending on the patient vulnerability and risk factors.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Four types of nursing diagnoses were identified for Ms. J.:  Fluid Volume Excess, Enhanced Readiness for Health Promotion, Risk for Falls , and  Risk for Frail Elderly Syndrome . The top priority diagnosis is  Fluid Volume Excess  because it affects the physiological needs of breathing, homeostasis, and excretion. However, the  Risk for Falls  diagnosis comes in a close second because of safety implications and potential injury that could occur if the patient fell.

American Nurses Association. (2021).  Nursing: Scope and standards of practice  (4th ed.). American Nurses Association.  ↵

Herdman, T. H., & Kamitsuru, S. (Eds.). (2018).  Nursing diagnoses: Definitions and classification, 2018-2020 . Thieme Publishers New York.  ↵

Herdman, T. H., & Kamitsuru, S. (Eds.). (2018).  Nursing diagnoses: Definitions and classification, 2018-2020.  Thieme Publishers New York.  ↵

Gordon, M. (2008).  Assess notes: Nursing assessment and diagnostic reasoning.  F.A. Davis Company.  ↵

NANDA International. (n.d.).  Glossary of terms .  https://nanda ​.org/nanda-i-resources ​/glossary-of-terms /  ↵

NANDA International. (n.d.).  Glossary of terms .  https://nanda ​.org/nanda-i-resources ​/glossary-of-terms/   ↵

NANDA International. (n.d.).  Glossary of terms.   https://nanda ​.org/nanda-i-resources ​/glossary-of-terms/   ↵

“The How To of Prioritization” by Valerie Palarski for  Chippewa Valley Technical College  is licensed under  CC BY 4.0   ↵

“ Maslow's hierarchy of needs.svg ” by  J. Finkelstein  is licensed under  CC BY-SA 3.0   ↵

4.5. OUTCOME IDENTIFICATION

Outcome Identification  is the third step of the nursing process (and the third Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” The RN collaborates with the health care consumer, interprofessional team, and others to identify expected outcomes integrating the health care consumer’s culture, values, and ethical considerations. Expected outcomes are documented as measurable goals with a time frame for attainment. [ 1 ]

An  outcome  is a “measurable behavior demonstrated by the patient responsive to nursing interventions.” [ 2 ]  Outcomes should be identified before nursing interventions are planned. After nursing interventions are implemented, the nurse will evaluate if the outcomes were met in the time frame indicated for that patient.

Outcome identification includes setting short- and long-term goals and then creating specific expected outcome statements for each nursing diagnosis.

Short-Term and Long-Term Goals

Nursing care should always be individualized and patient-centered. No two people are the same, and neither should nursing care plans be the same for two people. Goals and outcomes should be tailored specifically to each patient’s needs, values, and cultural beliefs. Patients and family members should be included in the goal-setting process when feasible. Involving patients and family members promotes awareness of identified needs, ensures realistic goals, and motivates their participation in the treatment plan to achieve the mutually agreed upon goals and live life to the fullest with their current condition.

The nursing care plan is a road map used to guide patient care so that all health care providers are moving toward the same patient goals.  Goals  are broad statements of purpose that describe the overall aim of care. Goals can be short- or long-term. The time frame for short- and long-term goals is dependent on the setting in which the care is provided. For example, in a critical care area, a short-term goal might be set to be achieved within an 8-hour nursing shift, and a long-term goal might be in 24 hours. In contrast, in an outpatient setting, a short-term goal might be set to be achieved within one month and a long-term goal might be within six months.

A nursing goal is the overall direction in which the patient must progress to improve the problem/nursing diagnosis and is often the opposite of the problem.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. had a priority nursing diagnosis of  Fluid Volume Excess.  A broad goal would be, “ Ms. J. will achieve a state of fluid balance. ”

Expected Outcomes

Goals are broad, general statements, but outcomes are specific and measurable.  Expected outcomes  are statements of measurable action for the patient within a specific time frame that are responsive to nursing interventions. Nurses may create expected outcomes independently or refer to classification systems for assistance. Just as NANDA-I creates and revises standardized nursing diagnoses, a similar classification and standardization process exists for expected nursing outcomes. The Nursing Outcomes Classification (NOC) is a list of over 330 nursing outcomes designed to coordinate with established NANDA-I diagnoses. [ 3 ]

Patient-Centered

Outcome statements are always patient-centered. They should be developed in collaboration with the patient and individualized to meet a patient’s unique needs, values, and cultural beliefs. They should start with the phrase “The patient will…” Outcome statements should be directed at resolving the defining characteristics for that nursing diagnosis. Additionally, the outcome must be something the patient is willing to cooperate in achieving.

Outcome statements should contain five components easily remembered using the “SMART” mnemonic: [ 4 ]

• M easurable
• A ttainable/Action oriented
• R elevant/Realistic

See Figure 4.9 [ 5 ]  for an image of the SMART components of outcome statements. Each of these components is further described in the following subsections.

SMART Components of Outcome Statements

Outcome statements should state precisely what is to be accomplished. See the following examples:

• Not specific:  “The patient will increase the amount of exercise.”
• Specific:  “The patient will participate in a bicycling exercise session daily for 30 minutes.”

Additionally, only one action should be included in each expected outcome. See the following examples:

• “The patient will walk 50 feet three times a day with standby assistance of one and will shower in the morning until discharge”  is actually two goals written as one. The outcome of ambulation should be separate from showering for precise evaluation. For instance, the patient could shower but not ambulate, which would make this outcome statement very difficult to effectively evaluate.
• Suggested revision is to create two outcomes statements so each can be measured: The patient will walk 50 feet three times a day with standby assistance of one until discharge. The patient will shower every morning until discharge.

Measurable outcomes have numeric parameters or other concrete methods of judging whether the outcome was met. It is important to use objective data to measure outcomes. If terms like “acceptable” or “normal” are used in an outcome statement, it is difficult to determine whether the outcome is attained. Refer to Figure 4.10 [ 6 ]  for examples of verbs that are measurable and not measurable in outcome statements.

Figure 4.10

Measurable Outcomes

See the following examples:

• Not measurable:  “The patient will drink adequate fluid amounts every shift.”
• Measurable:  “The patient will drink 24 ounces of fluids during every day shift (0600-1400).”

Action-Oriented and Attainable

Outcome statements should be written so that there is a clear action to be taken by the patient or significant others. This means that the outcome statement should include a verb. Refer to Figure 4.11 [ 7 ]  for examples of action verbs.

Figure 4.11

Action Verbs

• Not action-oriented:  “The patient will get increased physical activity.”
• Action-oriented:  “The patient will list three types of aerobic activity that he would enjoy completing every week.”

Realistic and Relevant

Realistic outcomes consider the patient’s physical and mental condition; their cultural and spiritual values, beliefs, and preferences; and their socioeconomic status in terms of their ability to attain these outcomes. Consideration should be also given to disease processes and the effects of conditions such as pain and decreased mobility on the patient’s ability to reach expected outcomes. Other barriers to outcome attainment may be related to health literacy or lack of available resources. Outcomes should always be reevaluated and revised for attainability as needed. If an outcome is not attained, it is commonly because the original time frame was too ambitious or the outcome was not realistic for the patient.

• Not realistic:  “The patient will jog one mile every day when starting the exercise program.”
• Realistic:  “The patient will walk ½ mile three times a week for two weeks.”

Time Limited

Outcome statements should include a time frame for evaluation. The time frame depends on the intervention and the patient’s current condition. Some outcomes may need to be evaluated every shift, whereas other outcomes may be evaluated daily, weekly, or monthly. During the evaluation phase of the nursing process, the outcomes will be assessed according to the time frame specified for evaluation. If it has not been met, the nursing care plan should be revised.

• Not time limited: “The patient will stop smoking cigarettes.”
• Time limited:  “The patient will complete the smoking cessation plan by December 12, 2021.”

In Scenario C in Box 4.3, Ms. J.’s priority nursing diagnosis statement was  Fluid Volume Excess related to excess fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”  An example of an expected outcome meeting SMART criteria for Ms. J. is,  “The patient will have clear bilateral lung sounds within the next 24 hours.”

4.6. PLANNING

Planning  is the fourth step of the nursing process (and the fourth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” The RN develops an individualized, holistic, evidence-based plan in partnership with the health care consumer, family, significant others, and interprofessional team. Elements of the plan are prioritized. The plan is modified according to the ongoing assessment of the health care consumer’s response and other indicators. The plan is documented using standardized language or terminology. [ 1 ]

After expected outcomes are identified, the nurse begins planning nursing interventions to implement.  Nursing interventions  are evidence-based actions that the nurse performs to achieve patient outcomes. Just as a provider makes medical diagnoses and writes prescriptions to improve the patient’s medical condition, a nurse formulates nursing diagnoses and plans nursing interventions to resolve patient problems. Nursing interventions should focus on eliminating or reducing the related factors (etiology) of the nursing diagnoses when possible. [ 2 ]  Nursing interventions, goals, and expected outcomes are written in the nursing care plan for continuity of care across shifts, nurses, and health professionals.

Planning Nursing Interventions

You might be asking yourself, “How do I know what evidence-based nursing interventions to include in the nursing care plan?” There are several sources that nurses and nursing students can use to select nursing interventions. Many agencies have care planning tools and references included in the electronic health record that are easily documented in the patient chart. Nurses can also refer to other care planning books our sources such as the Nursing Interventions Classification (NIC) system. Based on research and input from the nursing profession, NIC categorizes and describes nursing interventions that are constantly evaluated and updated. Interventions included in NIC are considered evidence-based nursing practices. The nurse is responsible for using clinical judgment to make decisions about which interventions are best suited to meet an individualized patient’s needs. [ 3 ]

Direct and Indirect Care

Nursing interventions are considered direct care or indirect care.  Direct care  refers to interventions that are carried out by having personal contact with patients. Examples of direct care interventions are wound care, repositioning, and ambulation.  Indirect care  interventions are performed when the nurse provides assistance in a setting other than with the patient. Examples of indirect care interventions are attending care conferences, documenting, and communicating about patient care with other providers.

Classification of Nursing Interventions

There are three types of nursing interventions: independent, dependent, and collaborative. (See Figure 4.12 [ 4 ]  for an image of a nurse collaborating with the health care team when planning interventions.)

Figure 4.12

Collaborative nursing interventions, independent nursing interventions.

Any intervention that the nurse can independently provide without obtaining a prescription is considered an  independent nursing intervention . An example of an independent nursing intervention is when the nurses monitor the patient’s 24-hour intake/output record for trends because of a risk for imbalanced fluid volume. Another example of independent nursing interventions is the therapeutic communication that a nurse uses to assist patients to cope with a new medical diagnosis.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of an evidence-based independent nursing intervention is,  “The nurse will reposition the patient with dependent edema frequently, as appropriate.” [ 5 ]  The nurse would individualize this evidence-based intervention to the patient and agency policy by stating,  “The nurse will reposition the patient every 2 hours.”

Dependent Nursing Interventions

Dependent nursing interventions  require a prescription before they can be performed. Prescriptions are orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider. [ 6 ]  A  primary health care provider  is a member of the health care team (usually a physician, advanced practice nurse, or physician’s assistant) who is licensed and authorized to formulate prescriptions on behalf of the client. For example, administering medication is a dependent nursing intervention. The nurse incorporates dependent interventions into the patient’s overall care plan by associating each intervention with the appropriate nursing diagnosis.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of a dependent nursing intervention is,  “The nurse will administer scheduled diuretics as prescribed.”

Collaborative nursing interventions  are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, respiratory therapists, physical therapists, and occupational therapists. These actions are developed in consultation with other health care professionals and incorporate their professional viewpoint. [ 7 ]

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of a collaborative nursing intervention is consulting with a respiratory therapist when the patient has deteriorating oxygen saturation levels. The respiratory therapist plans oxygen therapy and obtains a prescription from the provider. The nurse would document “ The nurse will manage oxygen therapy in collaboration with the respiratory therapist ” in the care plan.

Individualization of Interventions

It is vital for the planned interventions to be individualized to the patient to be successful. For example, adding prune juice to the breakfast meal of a patient with constipation will only work if the patient likes to drink the prune juice. If the patient does not like prune juice, then this intervention should not be included in the care plan. Collaboration with the patient, family members, significant others, and the interprofessional team is essential for selecting effective interventions. The number of interventions included in a nursing care plan is not a hard and fast rule, but enough quality, individualized interventions should be planned to meet the identified outcomes for that patient.

Creating Nursing Care Plans

Nursing care plans are created by registered nurses (RNs). Documentation of individualized nursing care plans are legally required in long-term care facilities by the Centers for Medicare and Medicaid Services (CMS) and in hospitals by The Joint Commission. CMS guidelines state, “Residents and their representative(s) must be afforded the opportunity to participate in their care planning process and to be included in decisions and changes in care, treatment, and/or interventions. This applies both to initial decisions about care and treatment, as well as the refusal of care or treatment. Facility staff must support and encourage participation in the care planning process. This may include ensuring that residents, families, or representatives understand the comprehensive care planning process, holding care planning meetings at the time of day when a resident is functioning best and patient representatives can be present, providing sufficient notice in advance of the meeting, scheduling these meetings to accommodate a resident’s representative (such as conducting the meeting in-person, via a conference call, or video conferencing), and planning enough time for information exchange and decision-making. A resident has the right to select or refuse specific treatment options before the care plan is instituted.” [ 8 ]  The Joint Commission conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care. [ 9 ]

Many facilities have established standardized nursing care plans with lists of possible interventions that can be customized for each specific patient. Other facilities require the nurse to develop each care plan independently. Whatever the format, nursing care plans should be individualized to meet the specific and unique needs of each patient. See Figure 4.13 [ 10 ]  for an image of a standardized care plan.

Figure 4.13

Standardized Care Plan

Nursing care plans created in nursing school can also be in various formats such as concept maps or tables. Some are fun and creative, while others are more formal.  Appendix B  contains a template that can be used for creating nursing care plans.

4.7. IMPLEMENTATION OF INTERVENTIONS

Implementation  is the fifth step of the nursing process (and the fifth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse implements the identified plan.” The RN may delegate planned interventions after considering the circumstance, person, task, communication, supervision, and evaluation, as well as the state Nurse Practice Act, federal regulation, and agency policy. [ 1 ]

Implementation of interventions requires the RN to use critical thinking and clinical judgment. After the initial plan of care is developed, continual reassessment of the patient is necessary to detect any changes in the patient’s condition requiring modification of the plan. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing safe care.

During the implementation phase of the nursing process, the nurse prioritizes planned interventions, assesses patient safety while implementing interventions, delegates interventions as appropriate, and documents interventions performed.

Prioritizing Implementation of Interventions

Prioritizing implementation of interventions follows a similar method as to prioritizing nursing diagnoses. Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation are used to establish top priority interventions. When possible, least invasive actions are usually preferred due to the risk of injury from invasive options. Read more about methods for prioritization under the “ Diagnosis ” subsection of this chapter.

The potential impact on future events, especially if a task is not completed at a certain time, is also included when prioritizing nursing interventions. For example, if a patient is scheduled to undergo a surgical procedure later in the day, the nurse prioritizes initiating a NPO (nothing by mouth) prescription prior to completing pre-op patient education about the procedure. The rationale for this decision is that if the patient ate food or drank water, the surgery time would be delayed. Knowing and understanding the patient’s purpose for care, current situation, and expected outcomes are necessary to accurately prioritize interventions.

Patient Safety

It is essential to consider patient safety when implementing interventions. At times, patients may experience a change in condition that makes a planned nursing intervention or provider prescription no longer safe to implement. For example, an established nursing care plan for a patient states,  “The nurse will ambulate the patient 100 feet three times daily.”  However, during assessment this morning, the patient reports feeling dizzy today, and their blood pressure is 90/60. Using critical thinking and clinical judgment, the nurse decides to not implement the planned intervention of ambulating the patient. This decision and supporting assessment findings should be documented in the patient’s chart and also communicated during the shift handoff report, along with appropriate notification of the provider of the patient’s change in condition.

Implementing interventions goes far beyond implementing provider prescriptions and completing tasks identified on the nursing care plan and must focus on patient safety. As front-line providers, nurses are in the position to stop errors before they reach the patient. [ 2 ]

In 2000 the Institute of Medicine (IOM) issued a groundbreaking report titled  To Err Is Human: Building a Safer Health System . The report stated that as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors.  To Err Is Human  broke the silence that previously surrounded the consequences of medical errors and set a national agenda for reducing medical errors and improving patient safety through the design of a safer health system. [ 3 ]  In 2007 the IOM published a follow-up report titled  Preventing Medication Errors  and reported that more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. This report emphasized actions that health care systems could take to improve medication safety. [ 4 ]

Read additional information about specific actions that nurses can take to prevent medication errors; go to the “Preventing Medication Errors” section of the “ Legal/Ethical”  chapter of the Open RN  Nursing Pharmacology  textbook.

In an article released by the Robert Wood Johnson Foundation, errors involving nurses that endanger patient safety cover broad territory. This territory spans “wrong site, wrong patient, wrong procedure” errors, medication mistakes, failures to follow procedures that prevent central line bloodstream and other infections, errors that allow unsupervised patients to fall, and more. Some errors can be traced to shifts that are too long that leave nurses fatigued, some result from flawed systems that do not allow for adequate safety checks, and others are caused by interruptions to nurses while they are trying to administer medications or provide other care. [ 5 ]

The Quality and Safety Education for Nurses (QSEN) project began in 2005 to assist in preparing future nurses to continuously improve the quality and safety of the health care systems in which they work. The vision of the QSEN project is to “inspire health care professionals to put quality and safety as core values to guide their work.” [ 6 ]  Nurses and nursing students are expected to participate in quality improvement (QI) initiatives by identifying gaps where change is needed and assisting in implementing initiatives to resolve these gaps.  Quality improvement  is defined as, “The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).” [ 7 ]

Delegation of Interventions

While implementing interventions, RNs may elect to delegate nursing tasks.  Delegation  is defined by the American Nurses Association as, “The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel or licensed practical nurses (LPNs) while retaining accountability for the outcome.” [ 8 ]  RNs are accountable for determining the appropriateness of the delegated task according to condition of the patient and the circumstance; the communication provided to an appropriately trained LPN or UAP; the level of supervision provided; and the evaluation and documentation of the task completed. The RN must also be aware of the state Nurse Practice Act, federal regulations, and agency policy before delegating. The RN cannot delegate responsibilities requiring clinical judgment. [ 9 ]  See the following box for information regarding legal requirements associated with delegation according to the Wisconsin Nurse Practice Act.

Delegation According to the Wisconsin Nurse Practice Act

During the supervision and direction of delegated acts a Registered Nurse shall do all of the following:

Delegate tasks commensurate with educational preparation and demonstrated abilities of the person supervised.

Provide direction and assistance to those supervised.

Observe and monitor the activities of those supervised.

Evaluate the effectiveness of acts performed under supervision. [ 10 ]

The standard of practice for Licensed Practical Nurses in Wisconsin states, “In the performance of acts in basic patient situations, the LPN. shall, under the general supervision of an RN or the direction of a provider:

Accept only patient care assignments which the LPN is competent to perform.

Provide basic nursing care. Basic nursing care is defined as care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.

Record nursing care given and report to the appropriate person changes in the condition of a patient.

Consult with a provider in cases where an LPN knows or should know a delegated act may harm a patient.

Perform the following other acts when applicable:

Assist with the collection of data.

Assist with the development and revision of a nursing care plan.

Reinforce the teaching provided by an RN provider and provide basic health care instruction.

Participate with other health team members in meeting basic patient needs.” [ 11 ]

Read additional details about the scope of practice of registered nurses (RNs) and licensed practical nurses (LPNs) in Wisconsin’s Nurse Practice Act in  Chapter N 6 Standards of Practice .

Read more about the American Nurses Association’s  Principles of Delegation.

Table 4.7 outlines general guidelines for delegating nursing tasks in the state of Wisconsin according to the role of the health care team member.

General Guidelines for Delegating Nursing Tasks

Documentation of Interventions

As interventions are performed, they must be documented in the patient’s record in a timely manner. As previously discussed in the “Ethical and Legal Issues” subsection of the “ Basic Concepts ” section, lack of documentation is considered a failure to communicate and a basis for legal action. A basic rule of thumb is if an intervention is not documented, it is considered not done in a court of law. It is also important to document administration of medication and other interventions in a timely manner to prevent errors that can occur due to delayed documentation time.

Coordination of Care and Health Teaching/Health Promotion

ANA’s Standard of Professional Practice for Implementation also includes the standards  5A   Coordination of Care  and  5B   Health Teaching and Health Promotion . [ 12 ]   Coordination of Care  includes competencies such as organizing the components of the plan, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and holistic care by the interprofessional team.  Health Teaching and Health Promotion  is defined as, “Employing strategies to teach and promote health and wellness.” [ 13 ]  Patient education is an important component of nursing care and should be included during every patient encounter. For example, patient education may include teaching about side effects while administering medications or teaching patients how to self-manage their conditions at home.

Refer to Scenario C in the “Assessment” section of this chapter. The nurse implemented the nursing care plan documented in Appendix C. Interventions related to breathing were prioritized. Administration of the diuretic medication was completed first, and lung sounds were monitored frequently for the remainder of the shift. Weighing the patient before breakfast was delegated to the CNA. The patient was educated about her medications and methods to use to reduce peripheral edema at home. All interventions were documented in the electronic medical record (EMR).

4.8. EVALUATION

Evaluation  is the sixth step of the nursing process (and the sixth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [ 1 ]  Both the patient status and the effectiveness of the nursing care must be continuously evaluated and the care plan modified as needed. [ 2 ]

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a patient’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a patient, discusses the care plan with others on the interprofessional team, or reviews updated laboratory or diagnostic test results. Nursing care plans should be updated as higher priority goals emerge. The results of the evaluation must be documented in the patient’s medical record.

Ideally, when the planned interventions are implemented, the patient will respond positively and the expected outcomes are achieved. However, when interventions do not assist in progressing the patient toward the expected outcomes, the nursing care plan must be revised to more effectively address the needs of the patient. These questions can be used as a guide when revising the nursing care plan:

• Did anything unanticipated occur?
• Has the patient’s condition changed?
• Were the expected outcomes and their time frames realistic?
• Are the nursing diagnoses accurate for this patient at this time?
• Are the planned interventions appropriately focused on supporting outcome attainment?
• What barriers were experienced as interventions were implemented?
• Does ongoing assessment data indicate the need to revise diagnoses, outcome criteria, planned interventions, or implementation strategies?
• Are different interventions required?

Refer to Scenario C in the “Assessment” section of this chapter and Appendix C . The nurse evaluates the patient’s progress toward achieving the expected outcomes.

For the nursing diagnosis  Fluid Volume Excess , the nurse evaluated the four expected outcomes to determine if they were met during the time frames indicated:

The patient will report decreased dyspnea within the next 8 hours.

The patient will have clear lung sounds within the next 24 hours.

The patient will have decreased edema within the next 24 hours.

The patient’s weight will return to baseline by discharge.

Evaluation of the patient condition on Day 1 included the following data: “ The patient reported decreased shortness of breath, and there were no longer crackles in the lower bases of the lungs. Weight decreased by 1 kg, but 2+ edema continued in ankles and calves .” Based on this data, the nurse evaluated the expected outcomes as “ Partially Met ” and revised the care plan with two new interventions:

Request prescription for TED hose from provider.

Elevate patient’s legs when sitting in chair.

For the second nursing diagnosis,  Risk for Falls , the nurse evaluated the outcome criteria as “ Met ” based on the evaluation, “ The patient verbalizes understanding and is appropriately calling for assistance when getting out of bed. No falls have occurred. ”

The nurse will continue to reassess the patient’s progress according to the care plan during hospitalization and make revisions to the care plan as needed. Evaluation of the care plan is documented in the patient’s medical record.

4.9. SUMMARY OF THE NURSING PROCESS

You have now learned how to perform each step of the nursing process according to the ANA Standards of Professional Nursing Practice. Critical thinking, clinical reasoning, and clinical judgment are used when assessing the patient, creating a nursing care plan, and implementing interventions. Frequent reassessment, with revisions to the care plan as needed, is important to help the patient achieve expected outcomes. Throughout the entire nursing process, the patient always remains the cornerstone of nursing care. Providing individualized, patient-centered care and evaluating whether that care has been successful in achieving patient outcomes are essential for providing safe, professional nursing practice.

Video Review of Creating a Sample Care Plan [ 1 ]

4.10. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

Instructions: Apply what you’ve learned in this chapter by creating a nursing care plan using the following scenario. Use the template in   Appendix B   as a guide.

The client, Mark S., is a 57-year-old male who was admitted to the hospital with “severe” abdominal pain that was unable to be managed in the Emergency Department. The physician has informed Mark that he will need to undergo some diagnostic tests. The tests are scheduled for the morning.

After receiving the news about his condition and the need for diagnostic tests, Mark begins to pace the floor. He continues to pace constantly. He keeps asking the nurse the same question (“How long will the tests take?”) about his tests over and over again. The patient also remarked, “I’m so uptight I will never be able to sleep tonight.” The nurse observes that the client avoids eye contact during their interactions and that he continually fidgets with the call light. His eyes keep darting around the room. He appears tense and has a strained expression on his face. He states, “My mouth is so dry.” The nurse observes his vital signs to be: T 98, P 104, R 30, BP 180/96. The nurse notes that his skin feels sweaty (diaphoretic) and cool to the touch.

Critical Thinking Activity:

Group (cluster) the subjective and objective data.

Create a problem-focused nursing diagnosis (hypothesis).

Develop a broad goal and then identify an expected outcome in “SMART” format.

Outline three interventions for the nursing diagnosis to meet the goal. Cite an evidence-based source.

Imagine that you implemented the interventions that you identified. Evaluate the degree to which the expected outcome was achieved: Met – Partially Met – Not Met.

• IV GLOSSARY

The act or process of pleading for, supporting, or recommending a cause or course of action. [ 1 ]

Unconditionally acceptance of the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care. [ 2 ]

Groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences. [ 3 ]

Medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis. [ 4 ]

Care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable. [ 5 ]

A relationship described as one in which the whole person is assessed while balancing the vulnerability and dignity of the patient and family. [ 6 ]

Individual, family, or group, which includes significant others and populations. [ 7 ]

The observed outcome of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care. [ 8 ]

A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.  [ 9 ]

Grouping data into similar domains or patterns.

Nursing interventions that require cooperation among health care professionals and unlicensed assistive personnel (UAP).

While implementing interventions during the nursing process, includes components such as organizing the components of the plan with input from the health care consumer, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and person-centered care by the interprofessional team. [ 10 ]

Reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow. [ 11 ]

Subjective or objective data that gives the nurse a hint or indication of a potential problem, process, or disorder.

“Top-down thinking” or moving from the general to the specific. Deductive reasoning relies on a general statement or hypothesis—sometimes called a premise or standard—that is held to be true. The premise is used to reach a specific, logical conclusion.

Observable cues/inferences that cluster as manifestations of a problem-focused, health-promotion diagnosis, or syndrome. This does not only imply those things that the nurse can see, but also things that are seen, heard (e.g., the patient/family tells us), touched, or smelled. [ 12 ]

The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel while retaining accountability for the outcome. [ 13 ]

Interventions that require a prescription from a physician, advanced practice nurse, or physician’s assistant.

Interventions that are carried out by having personal contact with a patient.

An electronic version of the patient’s medical record.

A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values. [ 14 ]

Statements of measurable action for the patient within a specific time frame and in response to nursing interventions. “SMART” outcome statements are specific, measurable, action-oriented, realistic, and include a time frame.

An evidence-based assessment framework for identifying patient problems and risks during the assessment phase of the nursing process.

A judgment formed from a set of facts, cues, and observations.

Broad statements of purpose that describe the aim of nursing care.

Employing strategies to teach and promote health and wellness. [ 15 ]

Any intervention that the nurse can provide without obtaining a prescription or consulting anyone else.

Interventions performed by the nurse in a setting other than directly with the patient. An example of indirect care is creating a nursing care plan.

A type of reasoning that involves forming generalizations based on specific incidents.

Interpretations or conclusions based on cues, personal experiences, preferences, or generalizations.

Nurses who have had specific training and passed a licensing exam. The training is generally less than that of a Registered Nurse. The scope of practice of an LPN/LVN is determined by the facility and the state’s Nurse Practice Act.

A disease or illness diagnosed by a physician or advanced health care provider such as a nurse practitioner or physician’s assistant. Medical diagnoses are a result of clustering signs and symptoms to determine what is medically affecting an individual.

Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity. [ 16 ]

Specific documentation of the planning and delivery of nursing care that is required by The Joint Commission.

A systematic approach to patient-centered care with steps including assessment, diagnosis, outcome identification, planning, implementation, and evaluation; otherwise known by the mnemonic “ADOPIE.”

Data that the nurse can see, touch, smell, or hear or is reproducible such as vital signs. Laboratory and diagnostic results are also considered objective data.

A measurable behavior demonstrated by the patient that is responsive to nursing interventions. [ 17 ]

The format of a nursing diagnosis statement that includes:

Problem (P) – statement of the patient problem (i.e., the nursing diagnosis)

Etiology (E) – related factors (etiology) contributing to the cause of the nursing diagnosis

Signs and Symptoms (S) – defining characteristics manifested by the patient of that nursing diagnosis

Orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider. [ 18 ]

Information collected from the patient.

Member of the health care team (usually a medical physician, nurse practitioner, etc.) licensed and authorized to formulate prescriptions on behalf of the client. [ 19 ]

The skillful process of deciding which actions to complete first, second, or third for optimal patient outcomes and to improve patient safety.

The “combined and unceasing efforts of everyone — health care professionals, patients and their families, researchers, payers, planners, and educators — to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).” [ 20 ]

Developing a relationship of mutual trust and understanding.

A nurse who has had a designated amount of education and training in nursing and is licensed by a state Board of Nursing.

The underlying cause (etiology) of a nursing diagnosis when creating a PES statement.

Patients have the right to determine what will be done with and to their own person.

Principles and procedures in the discovery of knowledge involving the recognition and formulation of a problem, the collection of data, and the formulation and testing of a hypothesis.

Information collected from sources other than the patient.

Data that the patient or family reports or data that the nurse makes as an inference, conclusion, or assumption, such as  “The patient appears anxious.”

Any unlicensed personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. [ 21 ]

Obtaining Subjective Data in a Care Relationship

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021. Chapter 4 Nursing Process.
• PDF version of this title (216M)

In this Page

• NURSING PROCESS INTRODUCTION
• BASIC CONCEPTS
• OUTCOME IDENTIFICATION
• IMPLEMENTATION OF INTERVENTIONS
• SUMMARY OF THE NURSING PROCESS
• LEARNING ACTIVITIES

Other titles in this collection

• Open RN OER Textbooks

Related Items in Bookshelf

• All Textbooks

Bulk Download

• Bulk download content from FTP

Related information

• PMC PubMed Central citations
• PubMed Links to PubMed

Recent Activity

• Chapter 4 Nursing Process - Nursing Fundamentals Chapter 4 Nursing Process - Nursing Fundamentals

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

Nursing theories

Open access articles on nursing theories and models.

Faye Glenn Abdellah's Theory

Twenty-One Nursing Problems

INTRODUCTION.

"Nursing is based on an art and science that mold the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people , sick or well, cope with their health needs." - Abdellah

Abdellah explained nursing as a comprehensive service, which includes:

Recognizing the nursing problems of the patient

Deciding the appropriate course of action to take in terms of relevant nursing principles

Providing continuous care of the individuals total needs

Providing continuous care to relieve pain and discomfort and provide immediate security for the individual

Adjusting the total nursing care plan to meet the patient’s individual needs

Helping the individual to become more self directing in attaining or maintaining a healthy state of mind & body

Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations

Helping the individual to adjust to his limitations and emotional problems

Working with allied health professions in planning for optimum health on local, state, national and international levels

• Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet the health needs of people.

ABOUT THE THEORIST AND THEORETICAL SOURCES

Abdellah’s patient - centred approach to nursing was developed inductively from her practice and is considered a human needs theory.

The theory was created to assist with nursing education and is most applicable to the education of nurses.

Although it was intended to guide care of those in the hospital, it also has relevance for nursing care in community settings.

MAJOR ASSUMPTIONS, CONCEPTS & RELATIONSHIPS

She uses the term ‘she’ for nurses, ‘he’ for doctors and patients, and refers to the object of nursing as ‘patient’ rather than client or consumer.

She referred to Nursing diagnosis during a time when nurses were taught that diagnosis was not a nurses’ prerogative.

Assumptions

Assumptions were related to

change and anticipated changes that affect nursing;

the need to appreciate the interconnectedness of social enterprises and social problems;

the impact of problems such as poverty, racism, pollution, education, and so forth on health care delivery;

changing nursing education

continuing education for professional nurses

development of nursing leaders from under reserved groups

Abdellah and colleagues developed a list of 21 nursing problems.They also identified 10 steps to identify the client’s problems. 11 nursing skills to be used in developing a treatment typology

10 STEPS TO IDENTIFY CLIENTS' PROBLEMS

Learn to know the patient

Sort out relevant and significant data

Make generalizations about available data in relation to similar nursing problems presented by other patients

Identify the therapeutic plan

Test generalizations with the patient and make additional generalizations

Validate the patient’s conclusions about his nursing problems

Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his behavior

Explore the patient’s and family’s reaction to the therapeutic plan and involve them in the plan

Identify how the nurses feels about the patient’s nursing problems

Discuss and develop a comprehensive nursing care plan

11 NURSING SKILLS

Observation of health status 

Skills of communication

Application of knowledge

Teaching of patients and families

Planning and organization of work

Use of resource materials

Use of personnel resources

Problem-solving

Direction of work of others

Therapeutic use of the self

Nursing procedure

21 NURSING PROBLEMS

Three major categories

Physical, sociological, and emotional needs of clients

Types of interpersonal relationships between the nurse and patient

Common elements of client care

BASIC TO ALL PATIENTS

To maintain good hygiene and physical comfort

To promote optimal activity: exercise, rest and sleep

To promote safety through the prevention of accidents, injury, or other trauma and through the prevention of the spread of infection

To maintain good body mechanics and prevent and correct deformity

SUSTENAL CARE NEEDS

To facilitate the maintenance of a supply of oxygen to all body cells

To facilitate the maintenance of nutrition of all body cells

To facilitate the maintenance of elimination

To facilitate the maintenance of fluid and electrolyte balance

To recognize the physiological responses of the body to disease conditions

To facilitate the maintenance of regulatory mechanisms and functions

To facilitate the maintenance of sensory function.

REMEDIAL CARE NEEDS

To identify and accept positive and negative expressions, feelings, and reactions

To identify and accept the interrelatedness of emotions and organic illness

To facilitate the maintenance of effective verbal and non verbal communication

To promote the development of productive interpersonal relationships

To facilitate progress toward achievement of personal spiritual goals

To create and / or maintain a therapeutic environment

To facilitate awareness of self as an individual with varying physical , emotional, and developmental needs

RESTORATIVE CARE NEEDS

To accept the optimum possible goals in the light of limitations, physical and emotional

To use community resources as an aid in resolving problems arising from illness

To understand the role of social problems as influencing factors in the case of illness

ABDELLAH’S THEORY AND THE FOUR MAJOR CONCEPTS

Nursing is a helping profession.

• Nursing care is doing something to or for the person or providing information to the person with the goals of meeting needs, increasing or restoring self-help ability, or alleviating impairment.

Nursing is broadly grouped into the 21 problem areas to guide care and promote use of nursing judgment.

Nursing to be comprehensive service. 

Abdellah describes people as having physical, emotional, and sociological needs.

Patient is described as the only justification for the existence of nursing.

Individuals (and families) are the recipients of nursing

Health, or achieving of it, is the purpose of nursing services.

In Patient–Centered Approaches to Nursing, Abdellah describes health as a state mutually exclusive of illness.

Although Abdellah does not give a definition of health, she speaks to “total health needs” and “a healthy state of mind and body” in her description of nursing as a comprehensive service.

SOCIETY AND ENVIRONMENT

Society is included in “planning for optimum health on local, state, national, and international levels”. However, as she further delineated her ideas, the focus of nursing service is clearly the individual.

The environment is the home or community from which patient comes.

CHARACTERISTICS OF THE THEORY

Abdellah’s theory has interrelated the concepts of health, nursing problems, and problem solving.

Problem solving is an activity that is inherently logical in nature.

Framework focus on nursing practice and individuals.

The results of testing such hypothesis would contribute to the general body of nursing knowledge

Easy to apply in practice.

USE OF 21 PROBLEMS IN THE NURSING PROCESS

ASSESSMENT PHASE

Nursing problems provide guidelines for the collection of data.

A principle underlying the problem solving approach is that for each identified problem, pertinent data are collected.

The overt or covert nature of the problems necessitates a direct or indirect approach, respectively.

NURSING DIAGNOSIS

The results of data collection would determine the client’s specific overt or covert problems.

These specific problems would be grouped under one or more of the broader nursing problems.

This step is consistent with that involved in nursing diagnosis

PLANNING PHASE

The statements of nursing problems most closely resemble goal statements. Once the problem has been diagnosed, the nursing goals have been established.

IMPLEMENTATION

Using the goals as the framework, a plan is developed and appropriate nursing interventions are determined.

• The most appropriate evaluation would be the nurse progress or lack of progress toward the achievement of the stated goals..

Progressive Patient Care :: Models of Nursing Care Delivery

Using Abdellah’s concepts of health, nursing problems, and problem solving, the theoretical statement of nursing that can be derived is the use of the problem solving approach with key nursing problems related to health needs of people. From this framework, 21 nursing problems were developed.

Abdellah’s theory provides a basis for determining and organizing nursing care. The problems also provide a basis for organizing appropriate nursing strategies.

George Julia B. Nursing theories: The base of professional nursing practice 3rd edition. Norwalk, CN: Appleton and Lange; 1990.

Abdellah, F.G. The federal role in nursing education. Nursing outlook. 1987, 35(5),224-225.

Abdellah, F.G. Public policy impacting on nursing care of older adults .In E.M. Baines (Ed.), perspectives on gerontological nursing. Newbury, CA: Sage publications. 1991.

Abdellah, F.G., & Levine, E. Preparing nursing research for the 21st century. New York: Springer. 1994.

Abdellah, F.G., Beland, I.L., Martin, A., & Matheney, R.V. Patient-centered approaches to nursing (2nd ed.). New York: Mac Millan. 1968.

Abdellah, F.G. Evolution of nursing as a profession: perspective on manpower development. International Nursing Review, 1972); 19, 3..

Abdellah, F.G.). The nature of nursing science. In L.H. Nicholl (Ed.), perspectives on nursing theory. Boston: Little, Brown, 1986.

This page was last updated on: 20/08/2020

• Adult Nursing
• Critical Care Nursing
• Family Nursing
• Holistic Nursing
• Home Health Nursing – visiting nurse
• Neonatal Intensive Care Nursing
• Pediatric Nursing
• Perinatal Nursing
• Psychiatric and Mental Health Nursing
• Public Health or Community Nursing
• Rehabilitation Nursing
• Faye Abdellah
• Phil Barker
• Dr. Patricia Benner
• Helen C. Erickson
• Katie Eriksson
• Lydia E. Hall
• Virginia Henderson
• Dorothy E. Johnson
• Imogene King
• Katharine Kolcaba
• Madeleine Leininger
• Myra Estrine Levine
• Ramona Mercer
• Betty Neuman
• Margaret A. Newman
• Florence Nightingale
• Ida Jean Orlando
• Dorothea E. Orem
• Rosemarie Rizzo Parse
• Nola Pender
• Hildegard Peplau
• Isabel Hampton Robb
• Martha E. Rogers
• Nancy Roper
• Sister Callista Roy
• Henry Stack-Sullivan
• Joyce Travelbee
• Jean Watson
• Ernestine Wiedenbach
• Alfred Adler
• Lawrence Kohlberg
• Robert R. Carkhuff
• Albert Bandura
• Carl O. Helvie
• Dr. Joyce Fitzgerald
• Clarissa Harlowe Barton
• Mary Ann Bickerdyke
• Mary Carson Breckinridge
• Dorothea Lynde Dix
• Sarah Emma Edmonds
• Helen Fairchild
• Eddie Bernice Johnson
• Mary Todd Lincoln
• Mary Eliza Mahoney
• Malinda Ann Judson Richards
• Dr. Lauranne Sams
• Margaret Higgins Sanger
• Dame Cicely Mary Saunders
• Mary Jane Seacole
• Susie King Taylor
• Lillian D. Wald
• Alyce Faye Wattleton
• Walt Whitman
• National Nurses Week
• First Annual Travel Nurse Day
• AACN Synergy Model
• Trans-Cultural Nursing
• Evidence-Based Nursing
• Modern Nursing
• Nursing Techniques
• Methods of Nursing
• Nursing Theories and a Philosophy of Nursing
• Nursing Mentors
• Nursing Leaders
• How to Study and Pass the NCLEX
• How to Study in Nursing School
• Pain Scale 1-10
• Nursing Clinicals and Nursing Theories
• Nursing Program
• Nursing Theory Definition
• Nursing Ethics and the Nursing Process
• History of Nursing
• Definition of Nursing
• The Nursing Process
• Nursing Care Plans in Action
• Nursing Technology
• Nursing Home Jobs and Getting Qualified
• Standards and Criteria Used by the NLNAC
• How Much Does Nursing School Cost
• Unsubsidized Nursing Student Loans
• A Statistical Look at Patient-Centered Care
• Being A Nurse At Christmas
• Nemours Brings Nursing Opportunities to Central Florida
• How Have the Sequester Cuts Affected Nursing and Health Care

21 Nursing Problems by Faye Abdellah

The Twenty-One Nursing Problems Theory was developed by Faye Glenn Abdellah . Her model of nursing was progressive for the time in that it refers to a nursing diagnosis during a time in which nurses were taught that diagnoses were not part of their role in health care.

There are specific characteristics identifiable in the Twenty-One Nursing Problems. The theory has interrelated the concepts of health, nursing problems, and problem-solving. Problem-solving is an activity that is inherently logical in nature. The framework focuses on nursing practice and individual patients.

The twenty-one nursing problems identified in the nursing theory are comprised of ten steps used to identify the patient’s problems and eleven skills used in developing a treatment typology or nursing care plan .

The ten steps to identify the patient’s problems are:

• Learn to know the patient
• Sort out relevant and significant data
• Make generalizations about available data in relation to similar nursing problems presented by other patients
• Identify the therapeutic plan
• Test generalizations with the patient and make additional generalizations
• Validate the patient’s conclusions about his nursing problems
• Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his behavior
• Explore the patient’s and family’s reaction to the therapeutic plan and involve them in the plan
• Identify how the nurses feel about the patient’s nursing problems
• Discuss and develop a comprehensive nursing care plan

The eleven nursing skills in the theory are:

• observation of health status
• skills of communication
• application of knowledge
• teaching of patients and families
• planning and organization of work
• use of resource materials
• use of personnel materials
• problem-solving
• direction of work of others
• therapeutic use of the self
• nursing procedure

The twenty-one nursing problems fall into three categories: physical, sociological, and emotional needs of patients; types of interpersonal relationships between the patient and nurse; and common elements of patient care.

The needs of patients are divided into four categories: basic to all patients, sustenal care needs, remedial care needs, and restorative care needs.

Needs that are basic to all patients are to maintain good hygiene and physical comfort; promote optimal activity, including exercise, rest and sleep; promote safety through the prevention of accidents, injury or other trauma and through the prevention of the spread of infection; and maintain good body mechanics and prevent or correct deformity.

Sustenal care needs facilitate the maintenance of a supply of oxygen to all body cells; facilitate the maintenance of nutrition of all body cells; facilitate the maintenance of elimination; facilitate the maintenance of fluid and electrolyte balance; recognize the physiological responses of the body to disease conditions; facilitate the maintenance of regulatory mechanisms and functions; and facilitate the maintenance of sensory function.

Remedial care needs identify and accept positive and negative expressions, feelings, and reactions; identify and accept the interrelatedness of emotions and organic illness; facilitate the maintenance of effective verbal and non-verbal communication; promote the development of productive interpersonal relationships; facilitate progress toward achievement of personal spiritual goals; create and maintain a therapeutic environment; and facilitate awareness of the self as an individual with varying physical, emotional, and developmental needs.

Restorative care needs include the acceptance of the optimum possible goals in light of limitations, both physical and emotional; the use of community resources as an aid to resolve problems that arise from illness; and the understanding of the role of social problems as influential factors in the case of illness.

According to the Twenty-One Nursing Problems model, patients are described as having physical, emotional, and sociological needs. People are also the only justification for the existence of nursing. That is, without people, nursing would not be a profession since they are the recipients of nursing.

Patient-centered approaches to nursing health are described as a state mutually exclusive of illness. Abdellah does not provide a definition of health, but speaks to “total health needs” and “a healthy state of mind and body” in her description of nursing.

In this nursing model , society is included in “planning for optimum health on local, state, national, and international levels.” However, the focus of nursing is the individual. The environment is the home or community from which the patient comes.

Nursing is a helping profession. Nursing care is doing something for or to the patient or giving the patient information with the goals of meeting needs, increasing or restoring self-help ability, or alleviating impairments. The role of the nurse is to help the patient achieve goals to reach optimum health.

Abdellah explained nursing as a comprehensive service, which includes:

• Recognizing the nursing problems of the patient
• Deciding the appropriate course of action to take in terms of relevant nursing principles
• Providing continuous care of the individual’s total needs
• Providing continuous care to relieve pain and discomfort and provide immediate security for the individual
• Adjusting the total nursing care plan to meet the patient’s individual needs
• Helping the individual to become more self-directing in attaining or maintaining a healthy state of body and mind
• Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations
• Helping the individual to adjust to his limitations and emotional problems
• Working with allied health professions in planning for optimum health on local, state, national, and international levels
• Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet people’s health needs

The twenty-one problems can be applied to the nursing process . In the assessment phase, the nursing problems provide guidelines for data collection. The results of data collection determines the patient’s specific problems, which leads to the nursing diagnosis. The statements of nursing problems resemble goal statements, so once the patient has been diagnosed, nursing goals have already been established. The goals can be used as a framework to develop a plan and nursing interventions. In terms of evaluation, the nurse’s progress or lack of progress toward the achievement of stated goals is the appropriate evaluation. The theory provides a basis for determining and organizing nursing care, as well as a basis for organizing nursing strategies.