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ViewsUsing an A+D = A Approach to Nursing Assessment & Performance
By Ava Sammarco
A (Assessment) + D (Documentation) = Action
Assessment
The basis of nursing care rests on the ability of the nurse to utilize assessment of the patient as the first step of the nursing process (Toney-Butler & Thayer, 2020). The power behind the assessment serves as the foundation for the basis and delivery of care and as such it is important that nurses sharpen and hone their assessment skills daily. We have all been impacted by the current health pandemic and yet, it has never been more important to refocus and dedicate our efforts to this crucial step of the nursing process.
Assessment data (subjective and objective) is collected and reviewed and within this first step of the nursing process, establishes the framework for delivery of care. Without a proper assessment done in a timely manner, patient care outcomes can be severely affected. Thus, assessment remains the critical foundation of nursing care.
Documentation
With the completion of assessment, the nurse must use documentation to note findings and convey information leading to a plan of action. The old adage, “if it is not documented, then it is not done”, remains as the cornerstone of ethical/legal principles and nurses should be empowered by their sense of duty, responsibility, and accountability to make sure that their documentation is accurate and within the defined parameters of timeliness (McBride et. al., 2018). Electronic health records (EHRs) have led to the creation of a checklist/templated framework that contains both advantages and disadvantages.
Advantages relate to the consistency and format of the note whereas the disadvantages relate to the concept that if there isn’t a box or checklist component, nurses may have little experience and/or impetus to create a narrative note. Too often in this electronic age, where technology has taken over the documentation of healthcare practice, the narrative note has gone by the wayside. Nurses should utilize documentation effectively, accurately, and most of all, comprehensively to ensure that nothing is missed on the patients’ health record.
Action
Implied in the action statement is the nurses’ inherent duty to function as an advocate for his/her patients who are sick and under their care. Nurses are not merely performers of health-related tasks but rather have demonstrated themselves as part of the frontline heroes of the healthcare profession. Dimino et.al. (2020) suggests that nurses should focus on their ability to utilize their psychological capital (PsyCap) which manifests as HERO levels (hope, efficacy, resilience, and optimism) to be better prepared to face the health pandemic challenges.
Nursing care is comprehensive containing both qualitative and quantitative measurements and literally, the nurse (at the bedside or functioning at the clinic or in the community) serves as the intermediary for the patient as it relates to healthcare delivery. Following through on assessments and documentation, the nurse plays a critical role in the planning, implementation, and evaluation of care. The coordinated action of the nurse to function as a member of the interdisciplinary care team is fundamental to improving better health outcomes for patients.
Let’s do the Math – A + D = A Which Leads to Better Health Outcomes
So, let’s do the math, so to speak, and make sure that nurses perform their due diligence, by starting out with assessment, followed by documentation, and leading to action. Each step of the process can become somewhat cyclical in nature. Healthcare is not a static interface but rather nurses and all healthcare providers must continuously assess, document, and act and repeat the process until the healthcare issue is resolved and/or healthcare outcome is improved. No longer does the healthcare of the patient exist in isolation and all members of the healthcare interdisciplinary team must be part of the process.
References:
Dimino, K., Horan, K. M., & Stephenson, C. (2020). Leading our frontline HEROES through times of crisis with a sense of hope, efficacy, resilience, and optimism. Nurse Leader, 18(6), 592–596. https://doi.org/10.1016/j.mnl.2020.05.011
McBride, S., Tietze, M., Robichaux, C., Stokes, L., & Weber, E. (2018). Identifying and addressing ethical issue with use of electronic health records. OJIN, 23(1). https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-23-2018/No1-Jan-2018/Identifying-and-Addressing-Ethical-Issues-EHR.html
Toney-Butler, T.J. & Thayer, J.M. [Updated 2020 Jul 10]. Nursing process. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499937/
Bio‐ Daryle Wane, Ph.D., APRN, FNP-BC
Daryle Wane, PhD, APRN, FNP-BC has 41 years’ experience in the professional discipline of nursing and 29 years’ experience in higher education and is currently the BSN Program Director of the Bachelor of Science in Nursing Program at Pasco-Hernando State College in New Port Richey, Florida. Dr. Wane has taught nursing classes across the curriculum and designed nursing programs functioning as a subject matter expert and participant member of the Instructional Technology Design team.
Dr. Wane has also authored several publications in nursing and nutrition and serves as a Peer Reviewer for several journals/organizations as well as being an Academic Editor/Editorial Review Board Member for several medical and nursing journals. Dr. Wane has given several keynote addresses at state, national, and international levels and served as an organizing committee member (2nd Florida Nursing Association (FNA) Nursing Research & Evidenced-Based Practice Nursing Conference in 2016, 2nd National Nursing World (NCW) Conference in Las Vegas in 2017, and the 2nd Global Conference on Nursing & Healthcare in London in 2018.
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Using an A+D = A Approach to Nursing Assessment & Performance
By Nurse Advisor Magazine (Official)
The basis of nursing care rests on the ability of the nurse to utilize assessment of the patient as the first step of the nursing process.
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