A Quality Improvement Project: What First-year Nursing Students Include in Their Nursing Care Plans for Patients With Acute or Chronic Wounds

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Ostomy Wound Management 2017;63(10):42–47 doi:10.25270/owm.2017.4247
Barbara Pieper, PhD, RN, CWOCN, ACNS-BC, FAAN; Janean Monahan, PhD, RN; Mary Kathryn Keves-Foster, MSN, RN; Julia Farner, DNP, BSN, RN, HHP; Dalia Alhasanat, PhD, BSN, RN; and Maha Albdour, PhD, RN, APHN-BC

Abstract

Nursing education research is lacking with regard to nursing care plans for patients who have a wound and use of the nursing diagnosis impaired skin integrity. The purpose of this quality improvement project was to inform teaching about nursing care planning for patients with wounds by examining what first-year nursing students attending a fundamentals of nursing course in a Bachelor of Science in Nursing program included in a nursing process assignment when caring for an assigned patient who had an acute or chronic wound.

Because they were in their clinical rotation, students had access to the patients’ medical records to facilitate composing the care plan; they also could ask the patient for information. Assessment data were entered on a predetermined form based on Gordon’s Functional Patterns. Using this information, students had to provide 3 possible diagnoses and select 1 upon which they developed the care plan intended to include patient description, wound description, dressing, and nursing diagnoses and impressions. The forms then were analyzed for assessment completeness. Thirty-eighty (38) care plans completed by students were collected on patients that included 23 men and 28 African-Americans; mean age of the patients was 60.11 ± 14.17  (range 20–87)  years. Wounds included 25 surgical incisions, 4 pressure ulcers/injuries, 7 “other” wounds, and 2 not identified. None of the students’ assessments provided a detailed wound description. The most common wound descriptors were location (n =19) and drainage (n = 15). For 8 patients, students stated the wound was covered by a dressing. Thirty (30) nursing diagnoses were listed. The most common nursing diagnoses were impaired physical mobility or activity intolerance, impaired comfort, impaired skin integrity, imbalanced nutrition, and risk for infection. These nursing students had beginning skills in patient and wound assessment and writing nursing care plans about patients with impaired skin integrity. Students need to increase their depth of wound assessment and need more experience planning care for patients with wounds.

 

A wound is an injury to tissue caused by severing or impact; typically, the skin is cut or broken. A wound may be the result of surgery or an acute or complex health care problem. Approximately 51.4 million inpatient surgical procedures and 17 million outpatient surgeries, many of which include an incision, are performed in the United States each year; plus, 6.5 million patients have chronic wounds (eg, pressure injury, venous ulcer, diabetic neuropathic foot ulcer).1-3 Thus, a wound is a common occurrence in health care. 

Because nurses have a critical role in assessing, planning, and implementing care for patients with wounds, nursing students need to learn nursing care planning as it applies to patients with wounds. A plan for nursing care provides direction for the nursing team to individualize care and help patients meet their health goals. Publications4-6 that address the nursing process note a nursing care plan: 1) helps with continuity of patient care and is compatible with the interdisciplinary team’s plan of care; 2) helps direct documentation; 3) is a guide for assigning staff to care for patients; 4) is responsive to the individual needs of patients and is culturally appropriate; 5) is based on scientific principles and incorporates research; 6) addresses patient discharge; and 7) has a developmental, psychosocial, spiritual, and physiologic focus. 

Nursing care plan writing generally starts in beginning nursing courses and is a critical and indispensable part of nursing education. Instructors have observed learning to write a nursing care plan can be demanding and stressful for their students.7 The purpose of this quality improvement project was to examine what details first-year nursing students included in a nursing care plan assignment when a patient had an acute or chronic wound. The results of this project will be used to inform teaching about nursing care planning for patients with wounds and reinforce the importance of wound assessment.

Literature

There is not a great deal of research about nursing education with regard to nursing care plans for patients with wounds or the use of the nursing diagnosis impaired skin integrity. When impaired skin integrity is mentioned, it is often 1 of several variables of a nursing care plan project. For example, in their intervention study in Sweden, Falk and Bjorvell8 included impaired/risk skin integrity and risk for pressure injury. The study was not about wounds per se, but whether the use of the North American Nursing Diagnosis Association (NANDA) classification9 affected nursing students’ choice of nursing interventions. Thirty-three (33) nursing students assigned to an orthopedic unit participated; the intervention group (n = 19) had access to the NANDA classification textbook and attended a presentation on the subject while the comparison group (n = 14) did not. Nursing diagnoses/interventions about skin — namely, impaired/risk skin integrity and risk for pressure injury — were listed for 22 of 97 interventions (22.7%) in the intervention group and for 33 of 121 interventions (27.2%) in the comparison group. Both groups were similar in the frequencies of nursing diagnoses and interventions. The authors concluded nursing students were able to analyze patient data and formulate nursing care plans.

In a descriptive study, Can and Erol7 assessed the self-perceived levels of nursing students (N = 55) regarding their sufficiency at preparing patient care plans and determined the effects of nursing care plans on students’ occupational development. Self-perceived sufficiency was described as the student’s self-rating of ability to perform patient assessment, identify nursing diagnoses, and prepare nursing care plans. The study took place during oncology training in Turkey. Students completed a demographic form and a 40-question, self-perceived sufficiency form about all aspects of nursing care plans; 67.3% of students said they were capable of determining nursing diagnosis criteria for the skin and 63.6% were comfortable determining nursing diagnosis regarding direction of patient assessment when skin was a factor. The correlations between the patient’s assessment for skin and components of nursing care plans were significant for the aim, nursing interventions, evaluation, and nursing record (r = .33 to .50). Among the participating students, 60% reported that preparing and implementing nursing care plans had positive effects on their occupational development. They encouraged educators to think about the best curricular timing for teaching nursing care plans. Nursing care plan knowledge needs to be reviewed and used in a practical way to enhance occupational development. 

Turk et al10 performed a descriptive study to determine nursing diagnoses that freshman nursing students used in their first clinical practice course in Turkey. Data were collected from 208 care plans developed by 61 nursing students. They used domains of Taxonomy II North American Nursing Diagnosis Association – International9 (NANDA-I). The study found students identified 31 different diagnoses in 9 domains of NANDA-I. The most common domains were safety/protection, activity/rest, comfort, elimination and exchange, and nutrition. The most-used nursing diagnoses were risk of infection, acute pain, constipation, disturbed sleep pattern, anxiety, activity intolerance, impaired physical mobility, and risk of trauma. Risk for impaired skin integrity (2.7%) and impaired skin integrity (1.4%) were infrequently listed. The study authors concluded beginning students had insufficient knowledge about diseases and thus were not able to make holistic assessments of their patients. The students’ nursing diagnoses also were affected by their beginning assessment and novice critical thinking skills.

In a descriptive study in Turkey to determine use of and opinions regarding nursing diagnoses, Yönt et al11 used a vignette developed by faculty to reflect content taught to 32 first-year students in the first semester. Students identified 15 out of the 18 predetermined nursing diagnoses for the vignette. The most frequently identified diagnoses were disturbed sleep pattern, nutritional imbalance, constipation, chronic pain, and anxiety. Impaired skin integrity was identified by 16 students (50%). A description of the vignette was not presented for comparison/accuracy; without this information, it was difficult to determine whether the nursing diagnosis about impaired skin integrity was critical to the patient’s plan of care. The authors concluded students were knowledgeable regarding commonly used nursing diagnoses even though they had limited clinical experience and recommended use of case study vignettes in nursing education.

Karadaq et al12 compared the effects of using case studies and simulated patients in teaching 70 second-year nursing students in Turkey to plan their nursing care; these instructional approaches were believed to help students develop their critical thinking and problem-solving skills and transfer theory into practice. The case used in the study described a patient with spinal cord trauma. The students were placed into 2 equal groups using either the case study or simulation teaching method. Impaired skin integrity was one of the most commonly identified nursing diagnoses, and the majority of nursing diagnoses involved physiological versus psychosocial problems. The students in the simulation group identified more nursing diagnoses and interventions than those in the case study group (33 versus 20). The 2 methods did not differ significantly on contributing to planning care or interventions. Students’ perceptions were that the simulated patient experience contributed significantly more to learning than the case study.  

To summarize, a limited amount of research has addressed students’ development of nursing care plans for patients who have wounds. However, patients with acute or chronic wounds are present in all health care settings and students need to plan care for them. Studies reported inconsistent findings regarding beginning students’ ability to perform holistic assessments and identify nursing diagnoses. For example, students were reported to be comfortable assessing the skin7,12 but a nursing diagnosis about impaired skin integrity was infrequently included in their plans of care.8,10 Because they had only beginning assessment and critical thinking skills, students experienced stress when learning care planning and may need the content repeated in subsequent nursing courses.7 Simulated patient experiences were effective in teaching care planning.12 

Nursing education continues to evolve in terms of teaching strategies such as classroom hours, exposure to patients with varied health care needs, and use of case studies and simulations. Strengthening components of the nursing curriculum in terms of the nursing process may help nursing students increase their confidence and ability to work with patients with wounds.

This quality improvement project was conducted to inform teaching about nursing care planning for patients with wounds and to reinforce with students the importance of wound assessment by examining what first-year nursing students in a Bachelor of Science in Nursing program included in a nursing care plan assignment when caring for an assigned patient with a wound in an acute care setting. 

Nursing Process Educational Experience During First-year Nursing Courses

Students in their first-year of nursing courses at an urban, research-intensive university received content related to the nursing process/nursing care plans in 2 courses: a professional development course and a fundamentals of nursing course. Both courses used the same textbook for content regarding the components of the nursing process. Faculty from both courses shared information regarding what the students were taught. The professional development course has 5, 1-hour lectures about the nursing process as well as practice with case studies. The fundamentals course includes 1) a theoretical/lecture component, 2) skills laboratory practice, and 3) clinical practice (1 day per week). 

During the theoretical/lecture component of the course, students received 3 lecture hours about wounds and their care that included surgical incisions and pressure ulcers/injuries as the wound prototypes. The lecture content included photographs and discussed aspects of wound assessment such as wound type, location, size, depth, drainage, odor, induration, erythema, and infection.

The Skills Laboratory included a 1-hour DVD about wound care and practice with changing a dressing on an incision as well as information regarding the care of wound drains, irrigation, and wound packing. The Skills Laboratory was used for skill practice and was faculty-taught. By the end of the semester, students had to perform certain skills at a passing level. 

The nursing process assignment with a patient was part of clinical practice. Students had clinical experiences in 1 of 3 acute care hospitals on medical/surgical units. During clinical practice, 6 hours were reserved for content, discussion, and practice with the nursing process. The nursing process content was presented to all students by the same clinical teacher for consistency. For practice, faculty gave students a case study of a patient and questions to answer about that case study. Based on that assessment and analysis of problem areas of the case study, students wrote their first care plan. After practice with the case study, students completed a detailed assessment and nursing care plan for 1 of their assigned patients in the hospital setting. The care plan exercise involving an assigned patient in the hospital was done 1 time at the end of the course.                   

Study Methods

Because this was a quality improvement project (not a human subjects research study), it was not necessary to request Institutional Review Board approval. The authors assessed a component of an internal educational program in terms of beginning nursing students’ use of the nursing process. Faculty examined students’ use of the nursing process for patients with wounds and improved the course in terms of wound assessment information and use of the nursing process. 

This project was developed and conducted by the faculty of Wayne State University who taught fundamentals of nursing during the Fall 2015 and Winter 2016 semesters. Data were extracted from the students’ nursing care plans and analyzed in terms of components of wound assessment and care and nursing diagnoses. Student names were covered with a permanent marker or cut off to ensure confidentiality. 

Across 2 semesters, 7 instructors taught 126 students in a clinical setting. A copy of each care plan submitted was duplicated before being returned to students. Of the 126 care plans submitted, 80 (63.5%) were available for analysis; of these, 46 were discarded because pages were missing, incorrect components of the nursing care plan were duplicated, and/or care plans were returned to the student before duplication. 

Care plan components. The care plan was part of the syllabus and included several sections/components. The introduction included general information about the patient in terms of medical diagnoses, surgical history, and demographics. The assessment section was based on Gordon’s Functional Patterns.13 Students were required to describe the patient in terms of 10 functional patterns. Information about wounds was located in the nutrition/metabolism skin/wound pattern. The functional pattern was accompanied by information the student should consider in the patient’s assessment for that pattern and was included as a sidebar on the form. The information on the form was not all-inclusive but rather used to prompt the student to consider what to include. The students were asked to provide information about the patient’s diagnostic tests and medications and summarize content about the patient as nursing impressions. Finally, students were to provide what they thought were the top 3 nursing diagnoses and select 1 upon which to develop their care plans. Typically, the students took this information home and had 1 week to complete the assignment.

Care plan analysis. Components of the nursing care plan were analyzed by 2 of the study authors and assessed for inclusion of patient demographic information (ie, age, race, and gender); wound type and  description (ie, location, size, drainage, granulation, epithelialization, necrotic tissue, induration, and erythema); signs/symptoms of infection; and wound treatment/dressing. The 3 nursing diagnoses listed for patients with wounds were written/recorded on a paper and counted. Data were tabulated/recorded in Excel and imported into IBM SPSS (Armonk, NY). Descriptive statistics were used to determine the presence/response to each item on the assessment form and mean ± SD for age. 

Results

Patient description. Of the 80 patients with nursing care plans (23 men [60.5%], 28 African American [73.68%], mean age 60.11 ± 14.17  (range 20–87) years, 38 (47.5%) had a wound. Twenty-five (25) patients (65.8%) had surgical incisions, 4 (10.5%) had pressure ulcers/injuries, and 7 (18.4%) were other wounds (eg, stab, laceration, or burn) (see Table 1). owm_1017_pieper_table1

Wound description. None of the students’ assessments provided a detailed wound description. The most common wound descriptors were location (19) and drainage (15), followed by signs/symptoms of infection (6) and wound size (6). The presence or absence of granulation tissue (2) or necrotic tissue (2) was infrequently mentioned; none of the assessments reported epithelialization.

Dressing. For 8 patients (21.1%), students stated the wound was covered by a dressing: 3 wounds were covered with gauze, 1 with xeroform and petrolatum dressing, and in 2 triple antibiotic ointment was used. The most common treatment was negative pressure wound therapy (4).

Nursing diagnoses and impressions. Thirty (30) nursing diagnoses for the patients with wounds were listed. The most common nursing diagnoses were impaired physical mobility or activity intolerance (17), impaired comfort (14), impaired skin integrity (13), nutrition imbalance (7), and risk for infection (6) (see Table 2). owm_1017_pieper_table2

Twenty (20) students (52.6%) mentioned the wound when recording their nursing impressions. The most common nursing impression was the need to teach about the wound (3). Only 3 students opted to write their nursing care plan about the nursing diagnosis of impaired skin integrity; their patients had pressure ulcers/injuries.

Discussion

Clinical practice is one of the most anxiety-producing components of nursing education7 — in part because learning to develop nursing care plans takes time. Comprehensive patient assessment is important for care planning; nursing students need multiple opportunities to develop nursing care plans for patients with wounds because the care plan may guide the patient care team. The purpose of this quality improvement project was to examine what first-year nursing students included in a nursing process assignment when a patient had an acute or chronic wound. The authors examined how students identified and described the wound and related nursing diagnoses. This was the students’ first nursing care plan assignment for an acutely ill, hospitalized patient. Even though students had received lecture content about wounds, their descriptions of the wound and wound care were poor. Multiple nursing diagnoses were identified; only 3 students developed the nursing care plan around the wound-related nursing diagnosis. 

In this study, surgical incisions were the most common wound. To improve documentation, nursing students need an understanding of the assessment of the surgical patient.8 Clinical instructors assert postoperative assessment of the patient needs to include the incision as part of diagnostic reasoning; the incision’s description is crucial. Educators plan to reinforce the importance of surgical incision assessment in future semesters.

Wound descriptions are needed to document a patient’s level of care and identify patient self-care needs. Insufficient assessment of the wound can lead to failure of the problem-solving process for the patient.7 Wound descriptions by students in this study lacked depth of discernment. Content about wound description was part of the lecture component of the course; students need to integrate lecture and textbook content into clinical practice. During the lecture component of the course, a greater focus was placed on wound assessment than previously. Opportunities for practice describing wounds also can be provided in post-clinical conferences, learning laboratories, and other simulated experiences. Where necessary, faculty can provide pictures of wounds for students to practice writing wound descriptions, share these descriptions in class, and learn how to improve their notations. In this study, care plan forms were improved by adding more wound descriptors to the nutrition/metabolism skin/wound pattern portion of the form. 

Students rarely mentioned wound dressings or treatments in their nursing care plans. The type of dressing and wound care will affect instruction of the patient and family regarding at-home care. Including wound care and dressings in care planning is important for documentation and for facilitating the support of continuity, quality, and safe care.13 As a result of this study, faculty enhanced their teaching about wound dressings and treatments. Students are encouraged to interact and question nurses and wound care specialists about dressings and treatments.

Generally, students participating in this project did not include a skin integrity nursing diagnosis in their nursing care plan. Learning to write and use nursing diagnoses can be difficult. The study by Yönt et al14 found determining an appropriate nursing diagnosis and developing a nursing process from data collected were the most difficult areas for nursing students. Approximately 32% of students were able to identify a patient problem and state a nursing diagnosis; 32% had difficulty stating patient care needs when using a nursing diagnosis. The most commonly used nursing diagnoses included pain, knowledge deficit, constipation, anxiety, and insufficient nutrition for body requirements. Impaired skin integrity was not mentioned.11,14 In contrast, Karadag et al12 reported impaired tissue integrity as one of the most common nursing diagnoses noted by nursing students.

Nursing faculty must prepare students to care for patients with acute clinical problems in a constantly changing health care environment.12 Nursing faculty must balance assignments in terms of course content/objectives, experiences that students need, experiences available, and experiences students have had. Nursing instructors try to provide students exposure to and experience with providing care to patients with varying illnesses and levels of care needs. In this project, students may have provided care to patients with wounds during the course but not when the care plan assignment was due. The current authors did not ascertain how many other patients with wounds received care from the students, what nursing diagnoses were identified for those patients, how different patients were discussed with the instructor, or what students recorded about the wound on the medical record. Because of previous clinical experiences involving patients with wounds and the desire to broaden learning experiences, the student may have selected a nursing diagnosis other than skin integrity for the nursing care plan assignment. Faculty need to examine the findings and decide how to best incorporate more depth in wound care assessment. These data showed students need practice assessing wounds and documenting their findings. Possibly a skill laboratory practicum could require students to document their wound assessment after they completed wound care on a mannequin. Results of this project need to be shared with faculty teaching students in their junior and senior years. Learning is a growth process, and students should be held accountable for greater depth in use of the nursing process and documentation of patient care as they progress through the program.

As a result of this study, faculty have helped students understand what is included in a comprehensive wound description and wound treatment/dressing. Faculty carefully read and grade care plans and hold students accountable for accuracy and depth of content. Students’ learning expectations should be continued into subsequent courses so learning goals can incrementally increase. Faculty have used findings from this project to improve both the lecture component of the course and the cues for wound description on the nursing process form.

Limitations

This quality improvement study had limitations. Nursing care planning for patients with wounds was examined in only 1 course; how students enhanced their knowledge about wound assessment, nursing diagnoses, and care plans in subsequent courses is not known. The number of patients with wounds was small, thus making generalizations about depth of content difficult. In addition, the number of nursing process papers discarded because of missing data was high. 

Conclusion         

Professional nursing education is based on knowledge for critical thinking and decision- making.7,15 Nursing students in this quality improvement study had beginning skills in writing nursing care plans about impaired skin integrity: wounds were poorly described and reports rarely stated if a dressing was present. Other researchers have noted insufficient and scattered documentation about wound care.16-18 Because this was the students’ first clinical course and exposure to nursing process and nursing diagnosis, they hopefully will progress in depth of assessment and its application to care planning. Learning the steps of the nursing process takes time. Addressing the development and implementation of nursing care plans during clinical experiences allows students to integrate theoretical knowledge into practice and develop their skills to provide quality nursing care. n

References

1. Centers for Disease Control and Prevention. Inpatient Surgery. Available at: www.cdc.gov/nchs/fastats/inpatient-surgery.htm. Accessed May 12, 2015.

2. Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763–771.

3. Wier LM, Steiner CA, Owens PL. Surgeries in Hospital Owned Outpatient Facilities. HCUP Statistical Brief #188. Agency for Health Care Research and Quality, 2015. Available at:  http://h.cup-us.ahrq.gov/reports/statbriefs/sb188-Surgeries-Hospital-Out.... Accessed October 3, 2016.

4. Taylor CR, Lillis C, Lynn P, LeMone P. Outcome identification and planning. In: Taylor CR, Lillis C, Lynn P, LeMone P. Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care. Philadelphia, PA: Wolters Kluwer/Lippincott Williams Wilkins;2015;275–301.

5. RN Central. What is a Nursing Care Plan and Why is it Needed? Available at:  http://www.rncentral.com/nursing-library/careplans/. Accessed July 26, 2016.

6. American Nurses Association. The Nursing Care Plan. Available at: www.nursingworld.org/EspeciallyforYou/StudentNurses/Thenursingprocess.aspx. Accessed July 26, 2016.

7. Can G, Erol O. Nursing students’ perceptions about nursing care plans: a Turkish perspective. Int J Nurs Pract. 2012;18(1):12–19.

8. Falk J, Björvell C. Does the use of a classification for nursing diagnoses affect nursing students’ choice of nursing interventions?  Nurs Inform. 2012.  2012;2012:108.

9. Herdman TH, Kamitsuru S. NANDA International Nursing Diagnoses: Definitions and Classification 2018-2020, 11th ed. Stuttgard, Germany: Thieme Medical Publishing;2016.

10. Türk G, Tugrul E, Sahbaz M. Determination of nursing diagnoses used by students in the first clinical practice. Int J Nurs Knowl. 2013;24(3):129–133.

11. Yönt GH, Korhan EA, Erdemir F, Müller-Staub M. Nursing diagnoses determined by first year students: a vignette study. Int J Nurs Knowl. 2014;25(1):39–42.

12. Karadag M, Caliskan N, Iseri O. Effects of case studies and simulated patients on students’ nursing care plan. Int J Nurs Knowl. 2016;27(2):87–94.

13. Taylor C, Lillis C, Lynn P, LeMone P. Assessing. In: Taylor C, Lillis C, Lynn P, LeMone P (eds). Fundamentals of Nursing. The Art  and Science of Person-Centered Nursing Care. Philadelphia, PA: Wolters Kluwer;2014:240.

14. Keenan GM, Yakel E, Tschannen D, Mandeville M. Documentation and the nurse care planning process. In: Hughes RG (ed). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Available at: www.ncbi.nlm.nih.gov/books/NBK2674/. Accessed July 26, 2016. 

15. Yönt GH, Khorshid L, Eser I. Examination of nursing diagnoses used by nursing students and their opinions about nursing diagnoses. Int J Nurs Terminol Classif. 2009;20(4):162–168.

16. Ballantyne H. Developing nursing care plans. Nurs Stand. 2016;30(26):51–60.

17. Ehrenberg A, Birgersson C. Nursing documentation of leg ulcers: adherence to clinical guidelines in a Swedish primary health care district. Scand J Caring Sci. 2003;17(3):278–284.

18. Gunningberg L, Lindholm C, Carlsson M, Sjödén PO. The development of pressure ulcers in patients with hip fractures: inadequate nursing documentation is still a problem. J Adv Nurs. 2000;31(5):1155–1164.

 

Potential Conflicts of Interest: none disclosed

 

Dr. Pieper is a Professor/Nurse Practitioner; Dr. Monahan is an Assistant Professor, Clinical; Ms. Keves-Foster and Dr. Farner are clinical instructors; and Dr. Alhasanat and Dr. Albdour are Assistant Professors, College of Nursing, Wayne State University, Detroit, MI. Please address correspondence to: Barbara Pieper, PhD, RN, CWOCN, ACNS-BC, FAAN, College of Nursing, Wayne State University, 5557 Cass Avenue, Detroit, MI 48202; email:  bapieper@comcast.net.

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