Abstract

Objective

This study aimed to determine the nursing diagnoses that nursing students identified in the care plan they prepared for the patients they cared for. This took place during the clinical practice of consultation-liaison psychiatric nursing within the context of the mental health and diseases nursing course.

Method

In this retrospective study, nursing care plans prepared by nursing students (n=66) in the clinical practice of consultation-liaison psychiatric nursing who took the mental health and diseases nursing course in the spring semester of 2022-2023  were examined.

Results

Of the patients for whom a nursing care plan was prepared, 27.3% were treated in the neurology clinic, 24.2% in the physical therapy and rehabilitation clinic, 25.8% in the infection clinic, and 22.7% in the oncology clinic. Students identified 497 nursing diagnoses in 66 cases. The most commonly identified diagnoses were risk for falls (66.2%), anxiety (45.5%), pain (45.5%), disturbed sleep pattern (45.5%), risk of infection (45.5%), self-care deficit (42.4%), and impaired physical mobility (33.3%).

Conclusion

When the nursing diagnoses identified by the students were evaluated, it was found that they identified more diagnoses related to  physiological domains than to  psychosocial domains and had problems addressing the patient holistically. However, it was observed that student nurses identified very few or no nursing diagnoses related to sexuality and principles of life patterns.

Introduction

Providing high-quality health care to society constitutes the main purpose of nursing (1). The nursing process, which is an essential part of nursing education, standards, and implementation legislation across the nation, provides high-quality nursing care. According to the American Nurses Association, the nursing process provides the basis of nursing practices that offer patient-centered, holistic care, and bring together nurses working in different places (2). The nursing process is an approach that consists of data collection, diagnosis, planning, implementation, and evaluation steps, and ensures the systematic delivery of nursing care (3). This approach is also defined as  involving problem-solving and decision-making processes to provide qualified and individualized nursing care (4). Nursing diagnoses encompass the individual’s current health problems, potential risks, and health promotion needs and these diagnoses are classified according to the NANDA-I taxonomy. The data collection and diagnosis stages of the nursing process enhance students’ critical thinking and clinical decision-making skills, contributing to the delivery of individualized and quality nursing care (3, 5).

Professional nursing education is the process of acquiring theoretical  practical education (6). The nursing process is a major part of practical nursing education, and during this education, students are expected to utilize the nursing process to make interventions for the needs of each patient (7). The goal of written nursing care plans is to guide students to focus on providing individualized nursing care (8); therefore, they are an indispensable part of nursing education (9). The goal of care plans as an educational tool is to develop critical thinking skills in students through data analysis and evaluation, verification of problems caused by nursing diagnoses or complications, goal setting, development of realistic interventions, and assessment of the effectiveness of the care plan (2). In the study by Taşkın Yılmaz et al. (10) examining student-prepared nursing care plans, 65.9% of the students stated that the use of the nursing process in patient care was necessary, while 34.1% stated that it was not necessary. In a study, nursing students had difficulty  determining the correct nursing diagnosis, while applying the nursing process (11).

In non-psychiatric clinics, consultation-liaison psychiatry (CLP) nursing provides  an understanding of the patient’s physical illnesses and enables the inclusion of psychological and social factors (12). At the same time, it ensures that psychiatric nursing services become widespread in general health services. In other words, it deals with the patient, through a biopsychosocial model. The holistic evaluation of the patient allows the patient’s psychosocial problems to be recognized, the treatment process to be individualized and  better managed (13). As a result, the patient’s stress and anxiety decrease, and their participation in treatment increases, positively affecting the healing process (14). In a study involving nurses working in non-psychiatric clinics, it was determined that nurses had difficulty providing nursing care to patients with mental problems (13). The main purpose of the CLP nurse is to prevent and reduce psychiatric disorders in patients hospitalized in medical services, to treat them, to guide the individual to cope with the disease and the life problems that arise as a result of the disease, and to provide a holistic approach to the patient (12).

Therefore, it has an important place as the clinical practice area of the Mental Health and Diseases Nursing course. The aim of mental health nursing undergraduate education and clinical practice is to help students acquire professional behaviors such as teamwork, communication skills, and interaction with patients and their families. In mental health nursing clinical practice, it is important to encourage the development of cognitive, affective, and behavioral skills and to fulfill the tasks in line with the learned skills (15). Controlling the tasks expected to be fulfilled by student nurses is done by implementing the nursing process, by implementing nursing care plans. In a study, it was determined that the diagnoses  by the students were mostly related to physical health problems and that they did not address the patient holistically (14). When we examined other studies in the literature, it was revealed that nursing students  had deficiencies in applying the nursing process and did not address the patient holistically (16, 17).

CLP nursing clinical practice offers an area where students can evaluate the patient’s biopsychosocial state. Therefore, the purpose of this study was to identify the nursing diagnoses indicated by nursing students for the patients  they cared for during CLP nursing clinical practice within the scope of the mental health and diseases nursing course.

Material and Method

Design of Study

This was a retrospective and descriptive study in which nursing diagnoses made by undergraduate students during the nursing course on mental health and diseases were determined. The population of this study consisted of the nursing care plans prepared by undergraduate students studying in the Nursing undergraduate program of the Faculty of Health Sciences of a university. These plans were prepared in the CLP nursing clinical practice within the scope of Mental Health and Diseases Nursing Practice education in the spring semester of the 2022-2023 academic year. Rather than employing purposive sampling, the entire population was targeted (n=66). Ethical approval was obtained for the study from the Trakya University Faculty of Medicine Non-interventional Scientific Research Ethics Committee (approval no: 12/21, date: 28.08.2023). In addition, informed consent was obtained from the students who agreed to use their nursing care plans for the study.

Data Collection

The data were obtained from the nursing care plans, prepared according to the NANDA diagnosis list and based on the Activities of Daily Living,  used by the students in the Mental Health and Diseases Nursing training. The clinical implementation of the training was carried out in four clinics (Neurology, Medical Oncology, Infectious Diseases, Physical Therapy, and Rehabilitation) in a medical faculty hospital between February and May 2023.

Each student group conducted clinical practice two days a week for four weeks. In order for the students’ care plans to be evaluated, they were required to follow up for at least two weeks with the patients for whom they prepared nursing care plans  and implement the nursing process. In this way, the minimum care time that each student provided to their patient was maintained equal. The data were obtained from the nursing care plans that the students prepared at the end of their clinical practice period according to their clinical rotation schedules. According to the clinical rotation plans, students submitted their nursing care plans to the responsible faculty member on the first Monday following the week they left the CLP clinics. The students’ identification of patient problems in their nursing care plans was evaluated by the researcher and categorized according to NANDA criteria based on Activities of Daily Living. The care plans were reviewed, and the nursing diagnoses were evaluated. The students prepared the nursing care plan for one patient; in addition, they contributed to other nursing practices in the clinic.

Statistical Analysis

In the evaluation of the data, the NANDA-I Taxonomy-II and the “Nursing Diagnoses Handbook” written by Carpenito-Moyet and translated into Turkish by Erdemir and Türk (5) were used as a guide.  If the diagnoses written in the care plans were not included in Taxonomy II or expressed differently, the diagnoses were accepted as incorrect. The major and minor diagnoses required to make the diagnosis in the “Handbook of Nursing Diagnoses” were evaluated to determine whether the data related to each diagnosis were sufficient or not. minor descriptive characteristics were evaluated. The number of nursing diagnoses identified by the students, and the frequency with which the diagnoses were made, expressed as numbers and percentages in, the SPSS 25.0 program, was used for the evaluation.

Results

The clinics where the students practiced as part of their mental health and disease nursing training are given in Table 1. When the clinics where the students submitted care plans were analyzed, 27.3% were neurology clinics, 24.2% in the physical therapy and rehabilitation clinic, 25.8% in the infection clinic, and 22.7% in the oncology clinic (Table 1).

The 49 nursing diagnoses identified by the students in general clinics within the scope of mental health and disease nursing practice are given in Table 2. When the NANDA nursing diagnoses were analyzed according to Gordon’s FSS model, a total of 497 nursing diagnoses in 11 patterns were identified by the students. According to the functional health patterns, 18.3% of the students identified nursing diagnoses in the areas of nutrition, 19.7% in the activity/rest pattern, 13.3% in the perception/cognition pattern, 10.5% in the health promotion pattern, and 8.9% in the role relationship pattern. When we look at the most common diagnoses, we see that the risk for falls (66.2%), anxiety (45.5%), pain (45.5%), disturbed sleep pattern (45.5%), risk of infection (45.5%), self-care deficit (42.4%), and deterioration in physical mobility (33.3%) are prevalent (Table 2).

When we examined the mental status assessment section of the data collection form, it was found that students mostly evaluated posture (42.4%) and emotional facial expression (40.9%) in appearance/general behaviour, attention/concentration (37.9%) in cognition, process (43.9%) in thought, mood (66.7%) in affect, and capacity of calculate (66.7%) in special skills and competence (Table 3).

Discussion

This study was conducted to determine the nursing diagnoses that nursing students identified in their nursing care plans, in CLP nursing clinical practice within the context of the mental health and diseases nursing course.

When we consider the diagnoses determined by the students, first of all, among the diagnoses determined according to functional health patterns, 19.7% fell into the activity/rest pattern, 18.3% into the nutrition pattern, 13.3% into the perception/cognition pattern, 10.5% into the health promotion pattern, and 8.9% into the role relationship pattern. It was found that 0.6% of the students identified a diagnosis in the sexuality pattern and none in the life principles pattern. Similarly, in Kaçmaz and Tektaş’s (14) study, which examined the care plans of nursing students, it was stated that students did not make any diagnosis in the pattern of life principles and made very few diagnoses in the field of sexuality. Similar results were found in many studies (18-20). It is a striking result that the students identified only three nursing diagnoses in the sexuality pattern and none in the life principles area. In the theoretical course and practice of mental health and disease nursing, it is emphasized that both the sexual dimension and the value and belief dimension of the individual  should be addressed. It should also be taken into consideration that the individual’s value and belief system affect health behaviors. In particular, the fact that sexual topics are seen as taboo by our society and that talking about them is believed to be shameful may have made it difficult for students to both ask questions and get answers in this area. Taşkın Yılmaz et al. (10) found in their study to determine nursing students’ views on the data collection phase and the difficulties they experienced that sexuality and life principles patterns were two of the three patterns where students felt inadequate and had difficulty with data collection.

It was determined that the most frequently used nursing diagnoses among 49 different nursing diagnoses in students’ nursing care plans were fall risk, anxiety, pain, disturbed sleep pattern, infection risk, self-care deficit, and impaired physical mobility. In a study conducted by Kaçmaz and Tektaş (14) in which they examined the diagnoses that students identified for CLP nursing in general clinics, it was found that the risk of infection, acute pain, disturbed sleep pattern, anxiety, and risk of falls were prevalent. In another study, the use of nursing diagnoses by intern students was examined and it was found that students mostly used acute pain, disturbed sleep pattern, and infection risk diagnoses (19). In a study conducted by Karaçay Yıkar and Nazik (21), it was found that students mostly used the diagnoses of infection risk, knowledge deficit, imbalanced nutrition, constipation, fatigue, and fear. In a similar study examining the care plans prepared by the students, it was found that the students mostly identified the diagnoses of activity intolerance, acute pain, and disturbed sleep patterns (20). In a study conducted by Taşdemir and Kızılkaya (22) on the nursing diagnoses determined by students in the clinical practice of mental health and diseases nursing course, it was found that the most common diagnoses in CLP clinics were infection risk, change in sleep pattern, anxiety, activity intolerance, ineffective coping, and trauma risk. In this study, similar to the literature, it was determined that the nursing diagnoses made by the students belonged to the physiological dimension of the individual, and the diagnoses related to the psychosocial dimension were less frequent. This situation also reveals the difficulties experienced by students in the nursing process. In many studies, students stated that they had difficulty with the data collection and diagnosis steps of the nursing process (10, 23, 24). A study addressing the problems experienced by students in using the nursing process and determining diagnoses identified the lack of theoretical knowledge, lack of communication skills, ineffective use of time in clinical practice, and insufficient data obtained from the patient as the reasons for the difficulties they experienced (25). The care plans in this study, made within the scope of CLP nursing clinical practice, suggest that the students experienced inadequacy in evaluating the patient holistically.

Study Limitations

The limitations of this study include that it was conducted in a single center, included student nurses’ care plans in the content of the study for one semester, and had an insufficient number of instructors for a more comprehensive evaluation of care plans in the clinics due to the high number of students.

Conclusion

As a result of this study, it is recommended that students should develop skills in determining the nursing diagnoses by using different teaching methods  to gain a holistic perspective in evaluating the patient, to conduct case studies frequently, and to convey that nursing care is an important tool in basing the nursing profession on scientific foundations.