The nursing process has served a useful purpose. However, if it is synonymous with problem solving in the service of the client, it is no more peculiar to nursing than to medicine, dentistry, social work or physiotherapy…. It fails to stress the value of collaboration of health professionals and particularly the importance of developing the self-reliance of clients.—Virginia Henderson
(Halloran, 1995, pp. 210–211)
It is time for professional nurses practicing in long-term care (LTC) settings to consider Virginia Henderson's prescient statement. These settings include institutional and community care, post-acute care facilities, skilled nursing facilities (SNFs), assisted living (AL), and home care. Direct care workers, whether certified or licensed, comprise most of the workforce in these settings. These workers are increasingly recognized as essential members of the health care team. Yet, the notion that only RNs are capable of problem solving (i.e., using the nursing process) significantly limits our capacity to benefit from the contributions of staff members who are not RNs.
Why is it that staff who are not RNs are believed to not have the capacity to contribute to clinical problem solving but are capable of problem solving in their personal lives? This lack of regard for their problem-solving skills comes at a cost to society at large. For example, researchers reported that dismissiveness of certified nursing assistants' (CNAs') clinical observations has, in part, contributed to their experiences of not being respected, resulting in chronic turnover of CNAs working in SNFs (Bowers et al., 2003). How will empowerment of CNAs, as advocated by the cultural transformation movement in SNFs, be increased by their participation in clinical decision making if only RNs are able to problem solve?
The intervention of nursing surveillance provides a means of transcending the limitations and parochialism of the nursing process while providing the mechanism by which RNs add unique value in health care delivery. RN surveillance has been defined as RNs' “purposeful and ongoing acquisition, interpretation, and synthesis of data for clinical decision-making” (Bulechek & McCloskey, 1999, p. 524). RN surveillance supports recognition of the essential value of direct care workers' clinical observations and capacity to problem solve while not erasing the unique contributions of RNs. Others have recognized the limitations of exclusive focus on the nursing process. For example, Kelly and Joel (1985) noted that consideration must be given to alternative constructs, such as critical thinking, diagnostic reasoning, and skill acquisition. In the landmark 2004 Institute of Medicine report Keeping Patients Safe: Transforming the Work Environment of Nurses, Bowers et al. (2004) argued that surveillance is the unique domain of RNs. Schmidt (2010) conceptualized surveillance as nurses “knowing what is going on, being close to the action, and taking action to protect patients from harm” (p. 400). Pfrimmer et al. (2017) built on this concept by describing nursing surveillance as a means of finding meaning in nursing work through “knowing the patient; [having] a shared understanding, and decision making, and thinking ahead” (p. 48). Understanding surveillance as a foundational nursing intervention is consistent with a patient safety framework. Surveillance reflects the dynamic nature of caregiving and adverse events that may occur over time rather than at one point in time.
Nurse researchers in non-LTC settings have studied nursing surveillance as the construct used to understand the relationship between nursing practices and harm, including near misses, adverse events, failures to rescue, and failures in detecting clinical deterioration Nurse researchers have reported that greater nursing surveillance capacity is associated with better quality of care and fewer adverse events (Dellefield et al., 2021).
It is possible that nursing surveillance provides the mechanism for further study of the relationship between higher RN staffing levels in SNFs and indicators. These quality indicators have included fewer pressure injuries, better quality measures, lower restraint use, decreased risk of rehospitalization, fewer deficiency citations, decreased mortality, and decreased incidence of urinary tract infections (Dellefield et al., 2015). These are all outcomes that typically occur over time. The value added by RN surveillance might be used to counter the common industry practice of using licensed vocational/practical nurses as substitutes for RNs.
One may think of the nursing care delivery system as a surveillance system, one that increases the likelihood that we “do no harm.” Surveillance increases RNs' awareness of the importance of time as a variable associated with client safety. Many adverse events in LTC evolve over time, transcending a shift, a day, or a week. It is recognition of patterns, trends, and changes in condition that result in clinical decision making that characterizes competent and safe RN practice. In LTC settings, the idea of surveillance has the capacity to elevate the value and meaning of repetitive tasks performed at work that may lose their value if seen as ends in themselves, rather than means to quality experiences and outcomes. Used as a RN intervention, surveillance provides a means of understanding how paraprofessionals legitimately contribute to the purposeful and ongoing acquisition of data and use problem solving and decision making while performing their work. RNs have the education and experience to effectively interpret and oversee these discrete concepts over time; however, this can only be done if clinical information is freely exchanged among members of the team who are not RNs.
Two evidence-based examples of non-RN participation in assessment and data collection involving certified nursing assistants' in LTC settings include their contributions to pain management (Liu, 2014) and participation in a two-step delirium detection protocol (Fick et al., 2018). The INTERACT quality improvement program provides another example of how clinical information exchanged between non-RN nursing staff and RNs has the potential to reduce avoidable hospitalizations (Ouslander et al., 2014). These examples demonstrate how RNs and non-RNs successfully participated in the surveillance process, in essence.
The nursing process is no longer an adequate descriptor of the unique intervention that RNs provide to clients. Among other limitations, the nursing process is inextricably linked with care plans. Efficacy and practical use of care plans have not been demonstrated empirically (Dellefield, 2006; Dellefield & Corazzini, 2015). Professional nurses and the society that we serve may derive greater benefit if we focused more on the relationship between the nursing care delivery system and surveillance than the production of lengthy and generic care plans.
It is time to recognize that, after more than 50 years since the nursing process was identified by Dr. Ida Orlando (Halloran, 1995), it has served its purpose. It is time to move on to surveillance as the construct that characterizes the unique contribution of RNs who coordinate client surveil-lance over time. Further research on nursing surveillance may help RNs practicing in LTC settings create care plans that are evidence-based and demonstrate a relationship between quality-of-care plan documents and actual care delivery.
Mary Ellen Dellefield, PhD, RN, FAAN
Research Nurse Scientist
VA San Diego Healthcare System
San Diego, California
（哈罗兰，1995 年，第 210-211 页）
现在是在长期护理 (LTC) 环境中执业的专业护士考虑 Virginia Henderson 的先见之明的时候了。这些环境包括机构和社区护理、急性后护理设施、专业护理设施 (SNF)、辅助生活 (AL) 和家庭护理。直接护理人员，无论是经过认证的还是有执照的，都占这些环境中的大部分劳动力。这些工人越来越被认为是医疗保健团队的重要成员。然而，只有注册护士才能解决问题（即使用护理过程）的观念极大地限制了我们从非注册护士的工作人员的贡献中受益的能力。
为什么非注册护士的员工被认为没有能力为临床问题解决做出贡献，但有能力解决他们个人生活中的问题？对他们解决问题的能力缺乏重视，整个社会都付出了代价。例如，研究人员报告说，对认证护理助理 (CNA) 的临床观察不屑一顾，部分原因是他们的经历不受尊重，导致在 SNF 中工作的 CNA 长期更替（Bowers 等人，2003 年）。如果只有 RN 能够解决问题，那么 SNF 中的文化转型运动所倡导的 CNA 如何通过他们参与临床决策来增加授权？
护理监督的干预提供了一种超越护理过程的局限性和狭隘性的手段，同时提供了注册护士在医疗保健服务中增加独特价值的机制。RN 监测被定义为 RN 的“有目的和持续的数据采集、解释和合成，以用于临床决策”（Bulechek & McCloskey，1999 年，第 524 页）。RN 监测支持承认直接护理人员的临床观察和解决问题的能力的基本价值，同时不会抹去 RN 的独特贡献。其他人已经认识到完全专注于护理过程的局限性。例如，凯利和乔尔 ( 1985) 指出必须考虑替代结构，例如批判性思维、诊断推理和技能习得。在具有里程碑意义的 2004 年医学研究所报告《保证患者安全：改变护士的工作环境》中，Bowers 等人。( 2004 ) 认为监视是 RN 的独特领域。Schmidt ( 2010 ) 将监视概念化为护士“了解正在发生的事情，接近行动，并采取行动保护患者免受伤害”（第 400 页）。普弗里默等人。( 2017) 建立在这一概念的基础上，将护理监督描述为通过“了解患者；[具有] 共同的理解、决策和超前思考”（第 48 页）。将监测理解为一种基本的护理干预与患者安全框架是一致的。监测反映了护理和不良事件的动态性质，这些事件可能随着时间的推移而不是在某个时间点发生。
非 LTC 环境中的护士研究人员已经研究了护理监督作为用于了解护理实践与伤害之间关系的结构，包括未遂事件、不良事件、抢救失败和未能发现临床恶化 护士研究人员报告说，加强护理监督能力与更好的护理质量和更少的不良事件相关（Dellefield 等人，2021 年）。
护理监督有可能为进一步研究 SNF 中较高的 RN 人员配备水平与指标之间的关系提供机制。这些质量指标包括更少的压力损伤、更好的质量措施、更少的约束使用、降低再住院风险、更少的缺陷引用、降低死亡率和降低尿路感染的发生率（Dellefield 等，2015）。这些都是随着时间的推移通常会发生的结果。RN 监测的附加值可用于对抗使用持照职业/实践护士代替 RN 的常见行业做法。
人们可能会将护理提供系统视为一种监视系统，它增加了我们“不造成伤害”的可能性。监视提高了注册护士对时间作为与客户安全相关的变量的重要性的认识。LTC 中的许多不良事件随着时间的推移而演变，超越了一个班次、一天或一周。正是对模式、趋势和状况变化的识别，导致临床决策制定，这是合格和安全的 RN 实践的特征。在 LTC 环境中，监视的概念有能力提升工作中执行的重复性任务的价值和意义，如果将其视为目的本身，而不是提高体验和结果的手段，这些任务可能会失去价值。用作RN干预，监视提供了一种理解辅助专业人员如何合法地为有目的和持续的数据采集做出贡献的方法，并在执行工作时使用解决问题和决策。随着时间的推移，RN 具有有效解释和监督这些离散概念的教育和经验；然而，这只有在非注册护士的团队成员之间自由交换临床信息时才能实现。
非 RN 在 LTC 环境中参与认证护理助理的评估和数据收集的两个循证示例包括他们对疼痛管理的贡献 ( Liu, 2014 ) 和参与两步谵妄检测协议 ( Fick et al., 2018 年）。INTERACT 质量改进计划提供了另一个例子，说明非 RN 护理人员和 RN 之间交换的临床信息如何有可能减少可避免的住院治疗（Ouslander 等，2014）。这些例子从本质上展示了注册护士和非注册护士如何成功地参与监视过程。
护理过程不再是 RN 为客户提供的独特干预的充分描述。除其他限制外，护理过程与护理计划密不可分。护理计划的有效性和实际使用尚未得到实证证明（Dellefield，2006 年；Dellefield & Corazzini，2015 年）。如果我们更多地关注护理提供系统与监控之间的关系，而不是制定冗长的通用护理计划，那么专业护士和我们所服务的社会可能会从中受益。
现在是时候认识到，自从艾达·奥兰多博士 ( Halloran, 1995 )确定护理过程 50 多年后，它已经达到了它的目的。现在是时候将监视作为表征随着时间的推移协调客户监视的 RN 的独特贡献的构造。对护理监督的进一步研究可能有助于在 LTC 环境中执业的 RN 制定以证据为基础的护理计划，并证明护理质量计划文件与实际护理提供之间的关系。
Mary Ellen Dellefield，博士，注册护士，FAAN