International Journal of Orthopaedic and Trauma Nursing
Volume 16, Issue 1 , Pages 3-12, February 2012

Assessments of patients’ pain, nutrition and skin in clinical practice: Registered and enrolled nurses’ perceptions

  • Bååth Carina, PhD, RN

      Affiliations

    • Department of Nursing, Karlstad University, SE-651 88 Karlstad, Sweden
    • Corresponding Author InformationCorresponding author. Tel.: +46 547002089; fax: +46 54836996.
    • ,
  • Wilde-Larsson Bodil, PhD, RNT (Professor)

      Affiliations

    • Department of Nursing, Karlstad University, SE-651 88 Karlstad, Sweden
    • Department of Nursing, Hedmark University College, Norway
    • ,
  • Idvall Ewa, PhD, RNT (Professor)

      Affiliations

    • Faculty of Health and Society, Malmö University, Sweden
    • ,
  • Hall-Lord Marie-Louise, PhD, RNT (Professor)

      Affiliations

    • Department of Nursing, Karlstad University, SE-651 88 Karlstad, Sweden
    • Department of Nursing, Gjovik University College, Norway

published online 16 August 2011.

Article Outline

Abstract 

Aim

The aim of the study was to describe registered and enrolled nurses’ perceptions of how they assess patients’ pain, nutrition and skin.

Introduction

Planning for pain, nutrition and skin care management is an essential part of nursing. In Sweden, it is common that registered and enrolled nurses work together in the care of patients.

Method

Interviews with nine registered and nine enrolled nurses were analyzed using qualitative content analysis.

Results

One theme; blurring boundaries between registered and enrolled nurses regarding pain, nutrition and skin suit assessments was identified. The manifest content of interviews is described in four categories: nurse–patient interaction, using oneself as a tool, collaborating with colleagues and listening to patients’ next of kin.

Conclusion

The analysis showed a blurring of boundaries between RNs and ENs regarding pain, nutrition and skin suit assessments. How they perform their assessments conforms to a large extent. However, even if the activities are the same, the education levels of RNs and ENs are different and therefore the assessment of the patients might be different in clinical practice. Taking the results into account it is important that RNs and ENs collaborate regarding assessment of the patients’ pain, nutrition and skin suit.

Keywords: Registered nurses, Enrolled nurses, Perception, Assessment, Pain, Nutrition, Skin, Pressure, Ulcer

 

Editor’s Comments

Pain, nutrition and skin care together make, arguably, the trio of the most important and ‘essential’ aspects of orthopaedic nursing care – having an impact on all clinical outcomes. It is, however, unusual for a study to bring these three aspects together ‘in one place’ such as is the case in this study. These three are also interrelated in terms of the way they impact on each other. The use of a qualitative approach here has enabled a comparison to be made between different ‘levels’ of nurses in relation to their education and role. This helps to highlight the need for continuing professional education as well as leadership of the ‘essentials’ of practice such as these. Not matter what ‘grade’ of practitioner cares for the patient.

JS-T

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Introduction 

Planning for effective pain, nutrition and skin care management is an essential part of nursing care. Therefore it is necessary to assess patients’ pain, risk for malnutrition and pressure ulcers (PU) in order to carry out adequate nursing interventions (Yura and Walsh, 1988, Weber and Kelly, 2009). Clinical guidelines are developed to assist health care professionals in the care of patients. There are international guidelines for pain management, (SP, 1992, McCaffery and Pasero, 1999) nutrition, (EPUAP, 2003, Kondrup et al., 2003) and PU (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel, 2009).

Moreover, there are also national guidelines in Sweden for pain (Vårdhandboken, 2008), nutrition (Larsson et al., 2004, Socialstyrelsen, 2001) and for PU prevention and care (Vårdhandboken, 2009). Pain, nutrition and PU are three nursing care domains for which quality indicators have been developed in Sweden (Christensson et al., 2007, Ek et al., 2007, Idvall et al., 2001). Despite clinical guidelines and quality indicators, pain, malnutrition and PU are common problems among patients with hip fracture (Bååth et al., 2010, Hallström et al., 2000, Hommel et al., 2007, Olofsson et al., 2007) and stroke (Langhorne et al., 2000, Westergren et al., 2001, Widar and Ahlström, 2002).

Studies have shown that registered nurses’ (RNs) assessments of the patients are not always adequate regarding pain (Sloman et al., 2001, Wilson, 2007), nutritional status (Mowe et al., 2006, Mowe et al., 2008) and skin condition (Sharp and McLaws, 2006). RNs’ attitudes and experiences may influence the assessment of patients’ pain (Sjöström et al., 1997). Kowanko et al. (1999) showed that most RNs and ENs were aware that they lacked the knowledge and skills needed to assess nutritionally vulnerable patients. Furthermore, RNs considered nutritional care to be important, but many had difficulties in raising its priority above other nursing activities. Buss et al. (2004) found that the knowledge about the patients’ PUs among ENs is based on experience and information from colleagues, including RNs. Moore and Price (2004) showed that positive attitudes towards PU prevention are not enough to ensure that this practice is adequately carried out. For example, the higher PU prevention is valued, the greater the likelihood of preventive practices being carried out (Maylor and Torrance, 1999).

In Sweden, it is common that RNs and ENs work as a team in the care of the patients. RNs and ENs have different educational levels and different responsibilities. RNs have a university degree (Degree of Bachelor of Science in Nursing) and are registered by the National Board of Health and Welfare. ENs have completed an upper secondary school education with emphasis on nursing. RNs have the main responsibility for assessment, planning, intervention, documentation and evaluation of nursing care (Socialstyrelsen, 2005). However, ENs also assesses patients’ needs and are responsible for their own nursing actions (SFS, 1998:531, SFS, 2010:659). To our knowledge, there are no studies that illuminate both RNs’ and ENs’ perceptions of their assessments of patients’ pain, nutrition and skin. A study of this kind can provide an insight into how RNs and ENs assess the patients in clinical practice. The aim of the study was to describe RNs’ and ENs’ perceptions of how they assess patients’ pain, nutrition and skin, using a qualitative design.

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Method 

Participants 

A strategic sample was recruited from a previous study including 50 RNs (49 women and one man) and 61 ENs (58 women and three men) working at the orthopedic and stroke wards in three hospitals in two county councils in Sweden (Bååth et al., 2008). Altogether, 19 nurses (10 RNs and 9 ENs) were invited (11 nurses from the first county council and 8 nurses from the second county council). Eighteen (9 RNs and 9 ENs), 17 women and one man, with a variation in age and number of years of work experience, agreed to participate. The RNs’ average age was 42.3 (SD 11.98) and the average years of work experience from nursing was 14.4 (SD 13.71). Mean age for the ENs was 49.0 (SD 7.76) with 12.1 (SD 8.44) years of work experience.

Data collection 

The interviews were arranged to take place at the hospital, at a time and venue that suited each RN and EN. All interviews were carried out in a place without any disturbances. The interviews were performed by two of the authors (CB, n=11 (6 RNs and 5 ENs), EI, n=7 (3 RNs and 4 ENs)), lasted between 54 and 72min and were tape-recorded and transcribed verbatim by the first author (CB). The interviews began with one the following three open questions: “How do you assess the patients’ pain?, how do you assess the patients’ nutrition?, and how do you assess the patients’ skin condition?” Individual follow-up questions were asked to elicit more detailed responses. In order to focus during the interview and keep the participants on track, the three open questions were written on a paper and shown to the participants during the interview and this helped them to reflect upon their experiences in assessing the patients’ pain, nutrition and skin condition. This openness made it possible to have a dialog with the participants (Kvale, 1997).

Data analysis 

A qualitative content analysis was used to analyze the interview text. Qualitative content analysis is a method that deals with manifest as well as latent content in the text (Graneheim and Lundman, 2004). A category refers mainly to a descriptive level of content, where the researcher takes the content of the text into consideration, dealing with differences and similarities, i.e. the manifest content. Analyzing what the text is about involves an interpretation of the underlying meaning of the text, and this is referred to as the latent content. There is a constant forwards and backwards movement between the whole and parts of the texts (Graneheim and Lundman, 2004), guided by the aim of the study.

The manifest content analysis started with the first author (CB) listening to the tapes and reading through the transcribed interview texts several times to gain a sense of the whole. The text was divided into meaning units that were condensed. The condensed meaning units were then abstracted and given a code. The various codes were compared based on variations and sorted into eleven subcategories, and then into four categories, which constitute the manifest content. All authors (CB, BWL, EI, and MLHL) discussed the codes, subcategories and categories that emerged and revised these until agreement was reached. In the latent analysis the researchers reflected upon the findings and the underlying meaning was formulated into one theme (Graneheim and Lundman, 2004). Quotations from the interviews were translated and checked carefully to ensure that nuances of the original Swedish text were correctly and consistently rendered into English.

Ethical considerations 

The medical directors at the hospitals consented to the study being carried out. The Ethical and Research Committees of Karlstad University and Linköping University approved the study. The participants received written and oral information about the study. The participants were informed that participation in the study was voluntary and that they could interrupt the interview whenever they wished and withdraw from the study at any time. Informed consent was obtained before the interview. All data were treated strictly confidentially.

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Results 

One theme; blurring of boundaries between RNs and ENs regarding pain, nutrition and skin assessment, was identified. During the interviews it became clear that both RNs and ENs assessed the patients’ pain, nutrition and skin. However, there seemed to be no established boundaries as to who performs the assessment or in what way it is performed.

In the following section, the manifest content of the interviews is presented in relation to the four categories: nurse–patient interaction, using oneself as a tool, collaborating with colleagues and listening to patients’ next of kin (Table 1). Each category is first presented based on what RNs and ENs have in common, and thereafter based on what is specific for each group.

Table 1. Overview of theme (n=1), categories (n=4) and subcategories (n=11) constructed from the analysis of the interviews with RNs and ENs.
ThemeCategoriesSub-categories
Blurring of boundaries between RNs and ENs regarding pain, nutrition and skin assessments.Nurse–patient interactionTo ask questions and to listenA1,2,3B1,2,3
To have a nurse–patient dialogA1,2,3B1,2,3
To use assessment toolsA1,2,3B1,2,3
To trust the patientsA1
Using oneself as a toolTo observeA1,2,3B1,2,3
To touchA1,2,3B1,3
To trust the clinical eyeA1,2,3
Collaborating with colleaguesTo listen and to collaborateA1,2,3B1,2,3
To read and writeA1,2,3B2,3
To trust assessment performed by colleaguesA1,2,3
Listening to patients’ next of kinTo listenA1,2,3
A=RN, B=EN
1=pain, 2=nutrition, 3=skin condition,

Nurse–patient interaction 

To ask questions and to listen to the patients is valuable for gathering information throughout the assessment process. The nurses thought that the use of simple open questions was a way to assess the patients in relation to pain, nutrition and skin. One open question is often used initially, such as “How are you feeling?”, followed by questions to clarify specific needs or problems, such as “Are you in pain?” or “Are you thirsty?” or “Are you comfortable?”

The RNs often start questioning the patients immediately upon their arrival at the hospital, in order to elicit information from the patients regarding their history. However, ENs usually asks questions during basic nursing care. The patients often reply directly to the questions asked by the nurses. Sometimes, the nurses ask questions to obtain additional information. Subsequently, it is important to listen thoroughly without rushing the patient and to be receptive and pay attention to what the patients say. Some RNs said that ENs often are in a better position to ask and listen to the patient. ENs are more often at the patient’s bedside, while RNs have to do other assignments.

“I felt that EN could most easily listen to the patient, as she is often in the patient’s room, while I have to run around with other things”… (RN5)

To have a dialog means to make assessments together with the patient, often over a period of time. The nurses assess and evaluate pain together with the patients, either while the patient is resting in bed or during rehabilitation. Hence, it is important to discuss comfort, for example type of mattresses and skin pain with the patients, and intervene immediately with appropriate equipment. Moreover, it is also essential to assess what patients are eating, to evaluate the fluid and food intake list regularly together with the patients, and to talk about eating and swallowing difficulties during or after mealtimes.

“It is important to evaluate food and beverage along with the patient… they don’t eat enough, I might ask why… maybe have to change… if it is difficult to swallow, it’s easier to make the assessment if I know the patient and can evaluate the answers from the patient over a period of time…” (RN1)

To use assessment tools, for example Mini Nutritional Assessment (MNA) in order to identify risk for malnutrition and Modified Norton Scale (MNS) to evaluate risk for PU is another way to assess the patients. One RN mentioned that although assessment tools might not be used per se, the tool is used through memory in everyday practice. The assessment tool could help and underline important aspects to intervene.

“You often get answers to the different parts of MNS through the conversation with the patient, in particular regarding mental status, which becomes obvious during a conversation.” (EN6)

Furthermore, the use of Visual Analogue Scale (VAS) together with the patient can make it easier for the RNs to assess pain and evaluate pain intensity. One EN stated that she measures the patient’s pain using VAS. She asks the patient to mark pain intensity on the VAS scale and then hands over the information to the RN in charge. One EN thought it is preferable to use the assessment tools herself rather than get a report from the RN, because it gives an increased awareness of patients’ pain or whether the patients are at risk for PU or malnutrition.

The RNs mentioned how important it is to accept a patient’s answer, to trust the patient, for example during pain assessment. It is important to be attentive to patients’ signs and answers and to make the patients feel safe and secure. The RNs said it is easier to trust the patient if they have cared for the patient before. The RNs also talked about situations when they do not trust the patient. In this situation, RNs can make decisions without considering the patients’ own opinions.

“If the patient estimates the worst possible pain, but I am of the opinion that they will be fine, I won’t give them a full dose, but wait and trust my own assessment more.” (RN2)

Using oneself as a tool 

To observe is another way to assess the patient. The nurses said that assessment of signals from the patients is valid, especially when the patients are not able to speak. The observations can for example include the patient’s body movements, paleness, grimaces and color of the face, as well as more physical clinical signs such as temperature and heart rate. Furthermore, the nurses mentioned that they know that patients with hip fracture and/or patients with stroke could be at risk for pressure ulcers, malnutrition and pain. Therefore they observe the patient’s skin as well as other signals during nursing care. If nurses for instance are to wash a bedridden patient, they can easily observe both the patient’s pain and the patient’s skin.

“Well, sometimes the patient can’t talk… Then you have to observe while you are with the patient… see how they react … take part in relocation, grimacing… pale, in a cold sweat… Often they are flushed or pale... look about to faint, they’re all white in their faces and I can see this on them…” (RN1)

Another way to assess is to touch the patient. Nurses used their hands to touch the patient’s skin. Using their hands gives them valuable information about the patient. One RN said that to pinch the skin helps her to identify turgor, as well as patients who are at risk for PU. One EN said that she put her hands on the patient’s hip to assess if the patient was in pain.

“As an EN I see how the patient reacts during nursing care...putting a hand on the hip is enough… their facial expressions… when you touch the skin, how they react… reveals pain… not forget your hands during assessment” (EN4).

The RNs talked about to trust “the clinical eye”. The RNs sometimes make a direct connection between the patients’ immobility, moisture of the skin and the risk for PU. Moreover, it is possible to observe for example if a patient has gained or lost weight and to recognize if the patient is at risk for developing PU. They claimed to know, as soon as they entered a room, whether the patient was in pain, based on how he or she looked.

“As soon as you step into the room, your assessment starts… Sometimes I can just see that this patient is at risk of malnutrition or having a PU… my clinical eye as an RN and my experience of nursing care… makes it easier to see the unique patient in the bed” (RN5).

Collaborating with colleagues 

To listen and collaborate is an ongoing process carried out among colleagues during the working shift. There are regular rounds/meetings and handovers at the ward, where all or some of the colleagues in a team participate. A team includes RNs, ENs, physicians, physiotherapists and occupational therapists. During rounds and team meetings the patient care is planned, based on the assessments and verbal reports among and between the colleagues in the team. RNs mentioned that they often ask ENs to participate at rounds and communicate their assessment of the patients.

“We have good communication between us” (RN9) “we report our assessments… by the end of a working shift… even during the day in case something happens.” (EN3)

To read and write in the patients’ records, including nursing documentation and bedside notes, is another way of collaborating between and among colleagues in the team. One RN said that the first thing she does is to read the relevant documentation in a patient’s chart, in order to be prepared for the meeting with the patient. Several RNs said that they were obliged to document both their own and the ENs’ assessments. This takes time away from the patient in direct nursing care.

“It is important to inform oneself about what is written in the records… inform oneself about the assessments previously made by colleagues… helps in your work. We have an obligation to document, and this takes time in order to have time to write, you have to get an EN to help with the assessment” (RN4)

One EN said that ENs do not document their own assessment in the patient record. They report their assessments to RNs, who do the documentation. Nevertheless, ENs mentioned that they mostly make the bedside notes, such as turning schedule and food and dietary intake lists.

“I often write things in the patient’s room, different lists accompanying position changes, beverage is important to be able to read, and… important to follow up on the beverage and food intake… to report to the RN continuously, often when a patient eats or drinks poorly…” (EN1)

To trust assessments performed by colleagues in the team is essential. The RNs trust the ENs’ assessments, because the ENs often have experience of and knowledge about nursing patients with hip fracture or stroke. Therefore, RNs ask ENs to assess the patient’s condition and report the assessment to the RNs. This makes it possible for RNs to prioritize other nursing activities. However, ENs mentioned an increase of unspoken demands from the RNs to make assessments in relation to pain, nutrition and skin condition.

“I’m not always the first one to meet the patient… a lot of times it’s the ENs who come into the patient first. Often the patient needs help with something and they are then able to observe for example the patient’s pain or skin. Many ENs have huge experience and I have confidence in their knowledge. As an RN you are forced to prioritize other nursing activities… the ENs are in the caring perspective.” (RN6).

Listening to patients’ next of kin 

To listen to the patients’ next of kin and to be sensitive to what the next of kin might say about the patient is perceived as important. They can give valuable information about the patient’s health status and everyday life situation, which is important in the patient’s care. For example, one RN was concerned about a patient’s nutritional status, and therefore asked the patient’s next of kin to describe the patient’s eating habits at home. Furthermore, the next of kin were contributing with information about the patients’ history of pain and mobility.

“Next of kin convey very valuable information…, might say a bit more about things that aren’t possible to observe… why the patient doesn’t want to eat… then perhaps the patient’s next of kin can say why or if there are other underlying concerns.” (RN9)

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Discussion 

The aim of the present study was to describe RNs’ and ENs’ perceptions of how they assess patients’ pain, nutrition and skin. One theme; blurring of boundaries between RNs and ENs regarding pain, nutrition and skin assessment, was identified. During the interviews it became clear that both RNs and ENs assessed the patients’ pain, nutrition and skin. However, there seemed to be no established boundaries as to who performs the assessment or in what way it is performed. This finding is congruent with studies of Chaboyer et al. (2008) and Gibson and Heartfield (2005). However, a lack of differentiation between RNs’ and ENs’ work roles and activities was also found (Gibson and Heartfield, 2005). The importance of the right education and right workforce has previously been discussed in a study by (Chaboyer et al., 2008). In the present study, RNs asked ENs to assess the patients and thereafter report it to them. To make these assessments one EN perceived this as an unspoken demand from the RNs. In a recent Australian study, the ENs’ practice was extended to tasks and skills and doing work on behalf of RNs. Furthermore, the ENs undertook nursing activities beyond their level of preparation (Milson-Hawke and Higgins, 2004). In the present study, RNs talked about being forced to prioritize other nursing activities instead of assessing patients’ pain, nutrition and skin. Some previous studies highlight the RNs’ difficulties in raising priorities in patient care (Bachrach-Lindström et al., 2007, Kowanko et al., 1999, Moore and Price, 2004). If RNs do not prioritize direct patient care, it might mean that they are dependent of colleagues’ assessments. This could be a reason for why the RNs describe how important it is to trust their colleagues. Funkesson et al. (2007) found that RNs who participated in direct patient care worked in a more holistic and less routine-based manner.

Both RNs and ENs considered the nurse–patient interaction as important. The initial assessment was characterized by asking questions and listening to the patients’ answers, also found in previous studies (Kim et al., 2005, Manias et al., 2004, Rickards and Hubbert, 2007, Sjöström et al., 2000). Jones (2004) demonstrated that the basic structure of the initial assessment in hospital settings consists of a very simple chain of questions, where the nurse acts exclusively as questioner and patients as responders. Sjöström et al. (1997) found listening to what the patient said a more successful strategy for RNs in assessing pain than relaying how a patient looked. Pain is a subjective phenomenon, which makes the patients’ own descriptions of their experienced pain crucial. Sjöström et al. (2000) showed that listening to the patients yields the smallest deviation from patients’ own ratings. In clinical practice, much of the pain communication takes place within the context of an everyday dialog between patients and RNs (Blomqvist and Hallberg, 2001). RNs and ENs in the present study talked about the importance of listening to the patients and thereafter intervening immediately with PU prevention. Spilsbury et al. (2007) concluded that it is important to listen to and learn from the patients in order to understand the importance of comfort and positioning in bed for patients (Spilsbury et al., 2007). The RNs and ENs talked about using assessment tools in patient care, referring to MNA-SF and MNS. Both these tools are designed as a questionnaire-based format. Each item or subscale examines a known risk factor for malnutrition and PU. Another study found that nurses’ attitudes ranged from somewhat very positive to negative about using risk assessment tools clinically (Layman Young et al., 2006). It is also important to be aware that assessment tools do not always yield absolute truth and therefore they have to be complemented with a RNs or ENs assessment.

The RNs in the present study said it is important to trust the patient’s answers. This is easier if they have previous work experience in orthopedic and stroke units, as well as if they have cared for the patient before. To know the person over a period of time leads to less routine thinking concerning pressure ulcer prevention (Funkesson et al., 2007). The RNs need to be more active at the bedside in all aspects of nursing care. Swedish nursing care is often organized according to group allocation, so perhaps the concept of patient focused care, (Myers, 1998) could be one possibility when working closer with the patients. Still, to trust the patients is important according to Sellman, 2006, Sellman, 2007. Patients’ experiences should be valued as evidence contributing to the decision-making process, along with the assessments of health care professionals (Rycroft-Malone et al., 2004).

RNs and ENs in the present study talked about using their senses in the assessment (using oneself as a tool). To observe the patients’ body language and to touch their skin can advise and help the nurses in the care of patients. To observe patients’ facial expressions during mobility was considered one way to alleviate or prevent pain (Blomqvist, 2003). To trust the clinical eye is another way for RNs to assess the patient. The RNs’ knowledge helps them to recognize and compare cues with what they have previously seen in a similar patient they have cared for. According to Benner et al. (1996), the skill of an expert nursing practitioner is characterized by intuition and holistic grasp, yet the progression to clinical expertise takes time (Benner et al., 1996). Beeckman (2011) concluded that the attitudes towards PU prevention are significantly correlated with the application of adequate prevention, but no correlation was found between knowledge level and the application of adequate prevention.

It is necessary to collaborate with colleagues both regarding the assessment and patient care (Bachrach-Lindström et al., 2007, Hedberg and Sätterlund Larsson, 2004). In the present study, the ENs were asked to participate during patient rounds and communicate their assessments of the patients. However, RNs have a key role in the nutritional care of patients and in achieving collaboration among the health care team members (Aydin and Karaöz, 2008).

To read and to write in the documentation was another way to assess the patients’ needs. RNs are responsible for documenting in the patient records, their own and ENs’ assessments (including bedside documentation) during their working shift. According to Swedish law (SFS, 1995:562, SOSFS, 2008:14) the documentation should include information which is necessary for the patient care, for example assessment of pain, nutrition and skin.

Some methodological aspects of the study will be addressed. The qualitative content analysis method by Graneheim and Lundman (2004) was found to be relevant and useful for the aim of the study. In qualitative research the concepts of credibility, dependability, transferability and confirmability have been used to describe various aspects of trustworthiness (Lincoln and Guba, 1985), out of which the first three have been operationalized by Graneheim and Lundman (2004). Before the interviews were accomplished, all authors took an active part in its planning, including the interview questions, which increased the credibility (Polit and Beck, 2006). Choosing participants (both RNs and ENs) with varied age and work experience contributes to varied data. During the interviews an ongoing informal check-in with the participants was done to clarify the data. The informants were recruited from a previous study (Bååth et al., 2008). This could have played a role in which assessment tools they discussed during the interviews. Furthermore, the length of the interviews and a place suitable for the nurses also established credibility (Lincoln and Guba, 1985). Credibility also concerns the question of judging similarities within and differences between categories (Graneheim and Lundman, 2004), which in this study was increased, as all researchers were involved in the analysis. The fact that more than one researcher was involved in the process also strengthens the dependability (Lincoln and Guba, 1985, Polit and Beck, 2006).

Dependability refers to the stability of data over time. In order to obtain dependability, the interviews started with the same open questions. However, the follow-up questions may differ among the two interviewers. Moreover, the interviews were tape-recorded and transcribed verbatim. A systematic analysis was performed by continuously returning to the whole and parts in the texts during the analysis (Graneheim and Lundman, 2004, Lincoln and Guba, 1985, Polit and Beck, 2006).

The findings are based on the verbal contribution of nine RNs and nine ENs working in orthopedic and stroke setting, as well as their ability to discuss and describe how they assess the patients in relation to pain, nutrition and skin condition. The results may provide knowledge about how nurses in clinical practice assess the patients.

To strengthen confirmability, i.e. the objectivity of the data, the process has been described and enhanced by a comprehensive presentation of findings and by including quotations from the participants in the study results (Lincoln and Guba, 1985).

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Conclusions 

The analysis from the interviews showed a blurring of boundaries between RNs and ENs regarding pain, nutrition and skin assessments. RNs and ENs usually work jointly through the assessment phase regarding the nursing care, however, ENs could also assess and meet the patient solely. How they perform their assessments conforms to a large extent. However, even if the activities are the same, the education levels of RNs and ENs are different and therefore the assessment of the patients might be different in clinical practice. Taking the results into account, it is important that RNs and ENs collaborate regarding assessment of the patients’ pain, nutrition and skin. Thus further education and training in assessment of patients’ pain, nutrition, and skin should be available for all health professionals. Perhaps the use of interactive education could be one solution to improve both RNs and ENs knowledge and attitudes towards assessments. It is of utmost important that RNs and ENs develop their competence through using their competence. Ongoing education is of vital importance in all areas of nursing.

Therefore more studies on how, when and why RNs and ENs assess patients in daily practice is needed. Further research is also needed in order to compare and analyze the results of RNs and ENs concerning the assessments and their responsibilities related to these assessments.

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Conflict of interest statement 

Authors declare that they had no conflict of interest in conducting the research study.

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Contributions 

Study design: CB, ML-HL, EI, BWL: collected data CB, EI: data analysis CB, ML-HL, EI BWL, drafted the manuscript CB, supervised by ML-HL, EI and BWL.

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Ethical statement 

Full ethical approval was conducted prior to conducting the study. The study was approved both by Ethical Committees at Karlstad University and Linköping University.

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Funding source 

No funding was obtained for this study.

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Acknowledgements 

Special thanks to all RNs and ENs for their participation in the study, and to Ms Ellinor Larsen for linguistic editing of the manuscript. The authors would like to acknowledge the financial support received from the Department of Research and Public Health at the County Council of Värmland.

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PII: S1878-1241(11)00030-X

doi:10.1016/j.ijotn.2011.04.001

International Journal of Orthopaedic and Trauma Nursing
Volume 16, Issue 1 , Pages 3-12, February 2012

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