THE DYNAMICS OF THE NURSING PROCESS

This approach made it necessary to define the role of each member of the team. Nurses became concerned about defining and retaining that which is essentially nursing and establishing nursing as a profession. Definitions, concepts and theories of nursing began to appear with in­ creasing frequency by writers such as Olivia Gowan, Dorothy Johnson, Virginia Henderson and others. The term nursing process was first mentioned in the 1950’s. Early in the 1960’s it was defined but not immedi­ ately accepted. The concept nursing process only gained acceptability recently after different nurses and nursing committees had presented their versions.


INTRODUCTION
T HE nursing process is a scientific method of approaching and plan ning the nursing care of the patient.It is an ongoing process and has a dif ferent meaning for each patient at different stages of his illness.It also varies from one nurse to another and at different levels of a nurse's profes sional maturity and in different nursing situations.
Among nursing writers who define the nursing process, Yura and Walsh see it as . . .an orderly, system atic m anner o f determ ining the clien t's p roblem s, m a kin g pla n s to solve them , initidting the plan or assign ing others to im p lem en t it, a n d evaluating the e x te n t to w hich the plan was effective in resolving the p ro b lem s id en tified.1 In practising the nursing process one focuses attention more on the in dividual patient and his problems than on the features of his disease.Therefore, this approach is a patientcentred, comprehensive activity which entails definite logical steps.

THE HISTORICAL BACK GROUND
In the very early days nursing, as a vocation, was practised by men and women who came forward volun tarily to minister to the sick and suf fering.Through their concern for other people they did their best to meet the basic human needs ot the sick.The quality of this type of nursing depended on the judgement of experienced helpers.
In the days of Florence Nightingale (1820-1910) nursing took on a definite structure.Nightingale in troduced reforms and set admirable goals.She strove to provide the best care for her patients and succeeded in giving nursing the respectability it deserved.She established a foun dation from which nursing continued to evolve up to the present date.After Nightingale's era there was a period of lag in nursing until the World War II period which was characterised by the accumulation of knowledge.The knowledge included advances in medicine which prompted changes that spilled over to nursing.Among the innovations was the multi-disciplinary team approach to patient care.This approach made it necessary to define the role of each member of the team.Nurses became concerned about defining and retaining that which is essentially nursing and establishing nursing as a profession.Definitions, concepts and theories of nursing began to appear with in creasing frequency by writers such as Olivia Gowan, Dorothy Johnson, Virginia Henderson and others.
The term nursing process was first mentioned in the 1950's.Early in the 1960's it was defined but not immedi ately accepted.The concept nursing process only gained acceptability recently after different nurses and nursing committees had presented their versions.
As a method of nursing the nursing process can only be described ade quately against the concept or within the context of nursing.

DYNAMISM IN NURSING
The propelling force of the nursing process lies in the changes in the many related facets of nursing situ ations and the interwoven needs of individual patients.This on-going feature of the nursing process is aptly described by Burger and  The nursing process operates whenever there is a patient and a nurse, be it in a home situation, an institutional setting or an extrainstitutional locality.It attains the preventive dimension if necessary, the promotive dimension if the health of the individual needs to be improved; a curative dimension in a therapeutic context, and a rehabili tative dimension if maximum func tioning is to be restored.
According to Henderson's defi nition of nursing the goals of nursing are health, recovery or a peaceful death.Therefore, the nursing process applied to an acutely or a critically ill patient will have a different content to that applied to a well client whose health must be promoted.It will again take a different shape to make it possible to meet the needs of a dying patient if he is to die peacefully.
In implementing the nursing pro cess the nurse should capture and preserve the essence of nursing by showing genuine interest, empathy and understanding of the patient's predicament.She should show con cern for her patient's needs, exercise care in such a way that the patient feels wanted; do all in her power to help cure the patient's illness or disease; and co-ordinate her activi ties with those of her colleagues.The nursing process should be so compre hensive that, as Sister Gowan puts it, it means . . .involving the to ta l patient; p ro m o tin g spiritual, m en ta l a n

d physical health; stressing health education a n d health preser vation, m inistering to the sick, caring f o r the p a tie n t's en viron m ent; giving health service to the fa m ily , the c o m m u n ity a n d the individual,4
This means that the nursing pro cess takes care of the total man in his environment.
The holistic approach balances on supportive functional areas.The area of nursing education provides the pre-required knowledge to enable the nurse practitioner to understand his patient/client: how and why he behaves in a particular manner, what to do for him and when to do it.The area of nursing administration pro vides the manpower and material re quirements conducive to applying the nursing process.Nursing research is a propelling force towards im proved and effective nursing.

STEPS IN THE NURSING PROCESS
There are definite logical stages or elements contained in any nursing situation.South African writers identify five elements whereas American writers such as Marriner, Yura and Walsh, Watson and others describe only four elements.

Step 1: The patient's needsassessment
This step is regarded by American writers as the assessment.It consists of identifying and defining the patient's problem.At this stage the nurse collects all the relevant data concerning the patient's condition.This information is obtained from the patient, his relatives and his com munity.Secondary sources such as medical and social records, nurse's rounds, reports during the change of shift are helpful.It is ideal to devise a format, such as a questionnaire or checklist, that is flexible and can be adapted to the variety of the patient's problems.Using this, the nurse inter views the patient and his relatives through various communication techniques, such as open-ended questions, and examinations.There after she makes accurate observations, using all her senses plus the variety of tools available.
To enable the nurse to assess the patient effectively a good knowledge of biological, natural and social sciences is necessary.She should be clear as to what is pathological and what is normal or what the m o d el o f wellness is.5She bases her assessment on basic human neéds.For that she could use as a guide one of the theo retical models such as Maslow's hierachy of needs.According to Maslow man's needs are physiologi cal needs including the need for food, oxygen, elimination, rest, water and physical activity which must be satis fied; the need for safety and security; the need for love and belonging; and finally the need for self-esteem.These needs should be satisfied in the order given, for they stand in the order of priority.
The nurse collects and analyses all the available information about the patient while focussing on the preventive, curative, promotive and rehabilitative aspects of patient care.The information is sorted, analysed and recorded.Some hospitals have designed the nursing history form for this purpose.
The stage of assessment begins with taking the nursing history and ends with making the nursing diag nosis -the nurse spells out the prob lem of the patient and is ready to em bark on a plan of action.

Step 2: Reaction by the nurseplanning
Formulating a plan to solve the patient's problems needs thought and improves with experience.A plan should not be a rigid framework for people to fit into.It should be a set of guidelines which are flexible and adaptable.
Ideally, all those who will be participating in the nursing care, in cluding the patient and his relatives, should be involved when designing the care plan.Having identified the problem, and drawn inferences, the nurse takes decisions as to what to do, where, when, how and why it is to be done, and by whom it is going to be done.In consultation with the patient and significant others, the priorities are set.The extent to which the patient is involved depends on his mental state, his level of intelligence and his physical condition.Lifethreatening issues such as an obstruc ted airway and impaired circulation should receive highest priority.Priorities can then be assigned ac cording to Maslow's hierachy of physiological needs.
Immediate, proximate and ulti mate goals should be set.The im mediate goal may be solving the major problems such as eliminating pain, relaxing a spasm or putting a limb in the best possible position for healing to take place.The inter mediate goals may be prevention of complications such as contractures, sepsis and the spread of infection.The long-term goal may be a maxi mal degree of independent function ing, regaining and maintaining good health, preventing a relapse or recurrence of the disease.
The planning proceeds to deciding what actions should be taken to sa tisfy the patient's needs and to attain the goals and which and how many people are needed to execute the plan.A well-developed referral sys tem is needed to assign different tasks to appropriate personnel such as social problems to the social worker, physical exercises to the physiotherapist, speech problems to the speech therapist; legal matters to the lawyer; and spiritual problems to the minister of religion.
The means and methods of doing things to meet the needs and reach the goals are specified.The planner takes into account the time factor, supplies and human and material resources.The planners of the nurs ing process should avoid making a plan that will fall into step with the established traditions.The plan should be realistic, practical and ap propriate to the particular individual, depending on the patient's age, sex, life-style, level of education, socio economic status and cultural back ground.
The plan is then written reflecting, in addition to the above, the patient's abilities, preferences and limitations.
Copies of the plan should be distrib uted among all who will take part in implementing it.
The planning step thus begins with the nursing diagnosis and ends with the team getting ready for nursing action.

Step 3: Intervention by the nurse implementation
The plan which is a blueprint for action is then executed.Whether the plan will succeed or not depends largely on the nurse's intellectual and technical abilities as well as good interpersonal relations and the extent of therapeutic use of self.Implemen tation starts when the patient is ad mitted to his bed and ends when the patient is restored to his pre-illness condition within his family, and his community.It can also end when the patient's body is removed after death.
The unfolding of the nursing plan consists of the nurse carrying out the doctor's orders, undertaking nursing actions and referring patients to other agencies or other departments, as necessary.The nurse maintains the personal and the environmental hygiene of the patient.She gives treat ments, drugs and medications.She does tests and nursing procedures, observes, records and reports on the patient; communicates and interacts with the patient, his relatives and other members of the health team; provides health education to the patient and his relatives and re-trains the patient by helping him to help himself.
A well designed plan will have a system of referral.Referrals afford continuity of patient care.They may be written or verbal, and they help the patient to regain the highest degree of wellness.Referrals can be made to a social agency, a clinic, a nursing home, a special home, a specialist, a public health agency, a rehabilitative centre or to another de partment in the same hospital.
Implementation of a plan means initiating care and facilitating con tinuity of care from one department or agency to another.It is the process whereby immediate, proximate and ultimate goals are reached.It may give rise to another plan.In all nurs ing situations the reaction and the response of the patient are vital factors in assessing whether goals are being attained.

Step 4: Assessment by the nurse evaluation
This step involves pausing and looking back at what has been done and at responses that have occurred since the initial step.The purpose is to establish whether the objectives are being achieved, whether the plan needs to be amended or to be aban doned and started all over again.It is a mental step in which the nurse stands apart from the team to see if it is functioning as expected and if, and to what extent the patient is benefit ing.Yura and Walsh maintain that: evaluation m eans to appraise the client's behavioural changes due to the actions o f the nurse."6 The nurse evaluates in terms of the patient's progress towards health, to see whether the patient is recovering as was anticipated.The patient's be haviour and condition at the time of evaluation should compare favour ably with that which was described in the nursing care plan.The evaluation can be daily, weekly or it can be done before the patient is discharged.The nursing audit, a formal systematic written appraisal of progress, is a useful tool.It can be used for evalu ating the patient's progress and the quality of care.It helps to improve patient care by unveiling serious problems and significant weaknesses.Through the nursing audit it is poss ible to detect if nurses know what they are doing, when, where, why and how they are doing it.
The activity of evaluation should also include self-evaluation.Here, the nurse does some introspection and self-quizzing to take stock of her own performance, find her strong points and detect her weaknesses and decide on how she can improve.
Evaluation of the personnel par ticipating in the nursing process is vital.A comparison is made between the performance that is observable at the time and the desired performance.The reason for the discrepancy is sought and if possible eliminated.

All aspects of evaluation should have the patient as the central figure.
The patient should therefore be in volved, depending on his mental and physical condition.Useful infor mation can be gained from his family and relatives if they are available.
A number of evaluative devices can be used, such as the nursing con ference, nursing audit, anecdotal record, checklist, critical incident and rating.The choice of evaluation tool should be made at the planning stage of the nursing process.Decid ing on which instrument to use de pends on whether the particular tool measures what it is supposed to measure, in other words whether it is valid.The evaluator should ask such questions as: Are the patient's needs being met?Are the goals realistic?Are they being attained?Are the best methods being employed?Is man power and material appropriate and enough?What is lacking?What new goals should be set?What better ap proaches can be used?How does the patient feel about all this?Similar and many other questions will ensure collection of relevant and meaningful information.
Having been collected the infor mation is analysed and synthesised and a picture emerges.It becomes apparent whether the plan should be amended, adapted or started afresh, or whether the implementation should continue.Evaluation not only improves patient care, but is also an educational exercise for the nurse.

Step 5: Recording of the four steps
In South Africa recording is re garded as the last step in the nursing process.American writers see this as an activity that is part of each and every step and therefore not a separ ate entity.The recording step entails writing and preserving everything, from the patient's personal particu lars to his property, treatment, tests, movements, responses, progress, complications, condition, admission, discharges, death, operations up to his food and an account of how and when the nurse featured in all these.
The nurse is obliged to keep accurate records of all she does as these records are legal documents.Safety of the patient's person and property is preserved through accu rately kept records.The nurse must account for her actions by presenting written proof of what care she pro vided for a patient, accountability is an important element in nursing.By virtue of her professional status and proximity to the patient the nurse is entrusted with the patient's life, person and property.Accurately kept records will help her out in case she is accused of malpractice.Through recording, the continuity of patient care is ensured for instance in cases when the staff changes shifts or departments or when the patient changes departments through transfer.

D -Do. The nurse activates the p la n that has been d eveloped by p erfo rm in g the fu n c tio n s a n d duties. This m eans taking definite action to get the plan im p lem ented. "
The five D's can be used by the nurse to effect the nursing process systematically and to plan realisti cally.These actions cut across all the steps of the nursing process.The planning can also be approached by utilising Kipling's six honest serving men: who, why, what, where, how and when.

OTHER ASPECTS OF THE NURSE'S ROLE
In an attempt to be thorough in rendering this individualised care the nurse usually finds herself unable to meet the many demands and needs of all het patients.Because of modern machinery, tools, equipment and pre-packed supplies the nurse is able to give good care to many patients within a reasonable period of time.Technological advances have added a new dimension to nursing practice and removed certain limitations to patient care.
The nurse practitioner should al ways aim at accuracy and punctuality.This must be reflected in her historytaking, observations, tests, examin ations, recordings, reports, planning, interventions and evaluations.
In executing the nursing process the nurse functions dependently, interdependently and independently.Independently she makes findings, draws conclusions and takes de cisions as guided by her training and professional experience.Her func tioning depends on the co-operation and condition of the patient and on the fact that she is the extended arm of the medical practitioner.Although she spearheads the working of the health team, like a cog in the wheel, she functions interdependently in co operation and in consultation with the other members of the total health team.
The nursing process accommodates the cultural component.The nurse must be familiar with practices that are taboo in the culture of her patient and those that are norms of his so ciety.Her health guidance and health education will be effective and mean ingful only if it is in keeping with what is acceptable in her patient's culture.Catering for the human ele ment gives colour and life to the nursing process, and, therefore, cannot be over emphasised.
If the nursing process is to be meaningful to its recipient the nurse must reach out across the ethnic, re ligious, political and cultural barriers to demonstrate genuine concern for and involvement with her patient.
For the best results the nurse should deliberately seek to win the patient's confidence.It is the small, apparently insignificant gestures that foster a healthy relationship between the distressed, apprehensive patient and the unknown stranger -the nurse.On the part of the nurse, willingness to help; thoughtfulness; anticipation of the patient's needs; the readiness to listen and to answer questions in a patient, kindly, nonjudgemental manner; and the light touch of the nurse's hand will go a long way towards making the patient's life easier.If the nurse can be more personal and address the patient by his name, show respect for his personal preferences, orientate the patient to his environment, ex plain what will happen and what is expected of him -not only will the patient's tension be relieved, but his anxiety dispelled and the way will be paved to either a speedy recovery or to a peaceful death.

CONCLUSION
In the light of the foregoing it is apparent that the nursing process is one of the most valuable scientific methods of effecting nursing practice.It is dynamic in nature -it's five steps follow each other logically and interlock like the rings of a chain.The process takes it's form from the particular patient, the nature of the environment and the particular nurse.It can take on colour and gain depth depending on the multitude of factors and forces that have a bearing on the nursing situation.To make a success of the nursing process takes a seasoned nurse who is willing to do some homework and hard work.