The fourth stage of nursing process: Implementation. Nursing practical skills. Types of nursing interventions..
IMPLEMENTING NURSING CARE
Implementation, the fourth step in the nursing process, involves the execution of the nursing plan of care derived during the planning phase of the nursing process. It involves completion of nursing activities to accomplish predetermined goals and to make progress toward achievement of specific outcomes. The execution of the implementation phase of the nursing process, as with the other phases of the process, requires a broad base of clinical knowledge, careful planning, critical thinking and analysis, and judgment on the part of the nurse.
This chapter discusses the purposes of implementation, the specific skills associated with effectively implementing the nursing plan of care, and the activities involved in this process. Although identified as the fourth step of the nursing process, the implementation phase begins with assessment and continually interacts with the other steps in the process to reflect the changing needs of the client and the response of the nurse to those needs.
PURPOSES OF IMPLEMENTATION
Implementation is directed toward a fulfillment of client needs that results in health promotion, prevention of illness, illness management, or health restoration in a variety of settings including acute care, home health care, ambulatory clinics, or extended care facilities.
It also involves the delegation of tasks to staff members and assistive personnel and documentation of the specific activities executed by the nurse and the client’s response to these activities.
The American Nursing Association (1998), in its Standards of Clinical Nursing Practice, describes the standards applicable to implementation in terms of both a standard of care and standards of professional performance.
Adherence to these standards requires that the nurse have a current knowledge base, be proficient with technical and communication skills, and use sound judgment in determining safe and efficient use of personnel and materials.
REQUIREMENTS FOR EFFECTIVE IMPLEMENTATION
The implementation phase of the nursing process requires cognitive (intellectual), psychomotor (technical), and interpersonal skills. These skills serve as competencies through which effective nursing care can be delivered and are used either in conjunction with each other or individually as required by the client and the specific needs of the situation.
Cognitive skills enable nurses to make appropriate observations, understand the rationale for the activities performed, and appreciate the differences among individuals and how they influence nursing care. Critical thinking is an important element within the cognitive domain because it helps nurses to analyze data, organize observations, and apply prior knowledge and experiences to current client situations.
Proficiency with psychomotor skills is necessary to safely and effectively perform nursing activities. Nurses must be able to handle medical equipment with a high degree of competency and to perform skills such as administering medications and assisting clients with mobility needs (e.g., positioning and ambulating).
The use of interpersonal skills involves communication with clients and families as well as with other health care professionals. The nurse-client relationship is established through the use of therapeutic communication that helps ensure a beneficial outcome for the client’s health status. Interaction between members of the health care team promotes collaboration and enhances holistic care of the client.
IMPLEMENTATION ACTIVITIES
Nursing implementation activities include:
• Ongoing assessment
• Establishment of priorities
• Allocation of resources
• Initiation of nursing interventions
• Documentation of interventions and client response
These activities are interactive and each is discussed in further detail.
Ongoing Assessment
The nursing plan of care is based on the initial assessment data collected by the nurse and the nursing diagnoses derived from those data. Because a client’s condition can change rapidly, or new data may become available through interaction with the client, ongoing assessment is necessary to validate the relevance of proposed interventions. Goals, expected outcomes, and interventions may need to be altered as new data are collected or progress toward outcomes is evaluated.
Although a focused assessment should be completed during the initial interaction with the client, continuous observations during the implementation process allow for adaptations to be made to better individualize care.
It is not unusual for nursing diagnoses to change or to be resolved in a short period of time. For example, the nursing care plan for Mrs. Cline, a preoperative client, might include an intervention to teach her about the use of a patient-controlled analgesia (PCA) pump. As the use of this equipment is being demonstrated, the nurse observes that Mrs. Cline is unable to depress the button easily with the fingers of her right hand. Mrs. Cline informs the nurse that she forgot to mention that her joints swell occasionally and she has very little strength in her hand during these times. This information is essential for both developing a nursing diagnosis concerning Mrs. Cline’s impaired physical mobility and determining appropriate teaching methods for use of the PCA pump.
Ongoing assessment demands attention to verbal and nonverbal cues from the client and requires knowledge of expected responses to specific interventions. If nurses observe that responses are different from those expected, this assessment data can lead to a change in expected outcomes and accompanying interventions.
Ongoing assessment is of equal importance in home health care or extended care settings when contact with skilled health care providers might occur less frequently and the length of time that the care is required varies (see the accompanying display). The nurse’s assessment and clinical judgment often determine whether the client needs continued care or referral to other health care providers.
Establishment of Priorities
Following ongoing assessment and review of the problem list, priorities are determined for implementation of care. Priorities are based on:
• Which problems are deemed most important by the nurse, the client, and family or significant others
• Activities previously scheduled by other departments (e.g., surgery, diagnostic testing)
• Available resources
The change-of-shift report can also be a valuable tool in determining priorities. A client’s condition and variables in the clinical setting can change quickly and frequently—especially in acute care settings—requiring that the nurse exercise strong clinical judgment and maintain flexibility in organizing care. For example, the nursing care plan for Mr. Jenkins, who had hip replacement surgery, might reflect a priority nursing diagnosis of Impaired Physical Mobility with interventions focused toward learning to ambulate. When the nurse listens to Mr. Jenkins’ breath sounds on a particular morning, it is noted that his breathing is more labored and crackles can be auscultated in the lung bases. This assessment is noted on the change-of-shift report, and the priorities of interventions change to focus on this new development.
Time management is important whether the nurse is caring for one client or a group of clients. It is helpful to make a list of tasks that need to be accomplished throughout the day and to create a worksheet outlining a target time for these activities. Those activities with specified times for completion should be scheduled first. For example, medications usually allow a narrow time frame for administration and must be scheduled at specific times on the worksheet. An example of a worksheet that outlines a plan for activities is shown in Table 9-1.
The time allotted for activities depends on the complexity of the task and the amount of assistance required by the client. An example of a worksheet for a group of clients is presented in Table 9-2.
Allocation of Resources
Before implementing the nursing plan of care, the nurse reviews proposed interventions to determine the level of knowledge and the types of skills required for safe and effective implementation. The assessment provides data for determining if an activity can be performed independently by the client, can be completed with assistance from family, or requires assistance of health care personnel.
Delegation of Tasks
The registered nurse is legally responsible for all nursing care given. Whereas some interventions are complex and require the knowledge and skills of a registered nurse, other interventions are relatively simple and can be delegated to assistive personnel. Delegation is the process of transferring a selected nursing task in a situation to an individual who is competent to perform that specific task. It must be remembered that, although some activities can be assigned to other health care personnel, the registered nurse remains accountable for appropriate delegation and supervision of care provided by these individuals. In general, registered nurses are authorized by law to both provide nursing care to clients directly and supervise and instruct others to deliver this care. Further, the registered nurse is empowered to delegate selected tasks to either licensed or unlicensed nursing personnel (see Figure 9-1).
Decisions about delegation are guided by the needs of the client, the number and type of available personnel, and the nursing management system of the unit or agency. In performing delegated tasks, nursing students must either determine if the intervention is one that they have performed with supervision and can safely accomplish independently or is one for which assistance is needed.
The first consideration in determining the most appropriate nursing personnel to administer care is client safety. Nurse practice acts dictate to some extent which tasks can be legally delegated. For example, administration of blood or blood products is not an act that can be legally delegated to licensed practical nurses or unlicensed assistive personnel in most states.
Other activities, such as assisting clients with activities of daily living (ADL, those activities performed by a person usually on a daily basis), ordering supplies, or transcribing orders, can often be safely delegated to other personnel.
If delegation of a particular activity is legally allowed, the nurse should validate the knowledge and skill level of personnel before delegation. If uncertain about the level of competence of an individual to perform an activity, the nurse should not delegate the task even though it might be legally performed by that level of personnel.
The registered nurse is held accountable to delegate only such care that can safely be done by the other individual and would be performed with the same level of competency and respect for state laws and regulations as would be evident in the nurse’s performance of this care.
Types of Management Systems
Wise use of resources dictates that tasks be assigned to the most cost-effective level of personnel who can safely and proficiently perform the activity. The nursing management system often determines the numbers and types of personnel available. Changes in health care delivery in recent years have resulted in an increasing emphasis on cost containment and have subsequently created several unique management models. The redesign of the workplace in many health care agencies has included cross-training of employees, with nurses frequently assuming responsibilities formerly assigned to other health care providers. For example, nurses might draw blood for laboratory tests, perform electrocardiograms, or administer respiratory treatments, as care is focused around the client rather than the various departments in the agency. Nurses in community health settings have traditionally exercised a variety of roles in their practice.
As health care delivery continues to evolve in this country, a variety of innovative approaches will emerge to better meet the needs of clients. The most common management systems currently used include functional nursing, team nursing, primary nursing, total client care, modular nursing, and case management.
Functional Nursing
The functional nursing approach divides care into tasks to be completed and uses various levels of personnel depending on the complexity of the assignment. Each member of the staff performs his or her assigned task for each client. For example, one nurse may assess each client and document findings and another may give all medications and treatments. Another nurse may be assigned to complete client teaching or discharge planning (process that enables the client to resume self-care activities before leaving the health care environment).
One nursing assistant might serve all trays and collect intake and output records for each client while another is responsible for giving baths or making beds.
The advantage of this system is that a large number of clients can be cared for by a relatively small number of personnel. In addition, it allows the use of less skilled (and less expensive) personnel for some tasks and allows personnel to be used in areas for which they have special knowledge or skill. However, this system can also result in fragmented and depersonalized care and may invite omissions in care because no one person is responsible for the total care of the client.
Team Nursing
The team nursing approach uses a variety of personnel (professional, technical, and unlicensed assistants) in the delivery of nursing care. The registered nurse is leader of the team and is responsible for supervision of the team, as well as planning and evaluating the results of caregiving activities. This management system uses professional nurses for skilled observations and interventions and provision of direct care to acutely ill clients, while licensed practical nurses care for less acutely ill clients, and nursing assistants are responsible for serving trays, making beds, and assisting the nurses with other tasks. This management system is frequently used because it is cost-effective and provides more individualized care than the functional approach.
Primary Nursing
In the primary nursing management system, the professional nurse assumes full responsibility for total client care for a small number of clients. Although care may be delegated to nurse associates for shifts when the primary nurse is not in attendance, the primary nurse maintains responsibility for total client care 24 hours a day (see Figure 9-2).
The primary nurse sets health care goals with the client and plans care to meet those goals.
The principal advantage of this approach is the continuity of care inherent in the system. Primary nursing is most effective with a total staff of registered nurses, which makes this system expensive to maintain.
Total Client Care and Modular Nursing
Total client care and modular nursing are variations of primary nursing. Although these systems imply that one nurse is responsible for all the care administered to a client, responsibility for the client actually changes from shift to shift with the assigned caregiver. This system uses both registered nurses and licensed practical nurses; the registered nurses are assigned to more complex client situations. A unit manager or charge nurse typically coordinates activities on the unit. Modular nursing attempts to assign caregivers to a small segment or “module” of a nursing unit, ensuring that clients are cared for by the same personnel on a regular basis.
Case Management
In the case management system, the nurse assumes responsibility for planning, implementing, coordinating, and evaluating care for a given client, regardless of the client’s location at any given time. This approach is often used when care is complex and a number of health care team members are involved in providing care. Generally, a case management plan, or critical pathway, is developed (based on the norm or typical course of the condition), and the nurse evaluates the progress of the client in relation to what is expected, investigating and following up on any variance in the time required or the amount of improvement noted.
Although the case load for the individual nurse might be smaller (thus making this approach expensive), continuity of care and collaboration are enhanced.
Nursing Interventions
After reviewing the client’s current condition, verifying priorities, and examining resources, the nurse should be ready to initiate nursing interventions. A nursing intervention is an action performed by the nurse that help the client to achieve the results specified by the goals and expected outcomes.
All interventions must conform to standards of care. Nurses should understand the reason for any intervention, the expected effect, and any potential problems that may result. Understanding the reason for a nursing intervention is the hallmark of a professional nurse, in that the nurse is using logic and/or scientific reasoning as the basis of practice.
Nursing interventions are a blend of science (rational acts) and art (intuitive actions). It is important for novice nurses to identify the rationale (the fundamental principle) of all interventions in order to implement theory-based practice. Prior to implementation, it is necessary to determine exactly:
• What is to be done
• How it is to be done
• When it should be done
• Who will do it
• How long it should be done
Interventions are determined by and directed toward the cause of the problem or factors contributing to the nursing diagnosis and may vary for clients with similar nursing diagnoses depending on realistic expected outcomes for the individual. Consideration should be given to client preferences, the developmental level of the client, and availability of resources. In addition, the health care practitioner’s orders often have an impact oursing interventions by imposing restrictions on factors such as diet or activity.
Types of Nursing Interventions
Nursing interventions are written as orders in the care plan and may be nurse-initiated, health care practitioner-initiated, or derived from collaboration with other health care professionals. These interventions can also be categorized as independent, dependent, or interdependent, depending on the authority required for initiation of the activity.
Interventions can be implemented on the basis of standing orders or protocols. A standing order is a standardized intervention written, approved, and signed by a health care practitioner that is kept on file within health care agencies to be used in predictable situations or in circumstances requiring immediate attention. Nurses can implement standing orders in these situations after they have assessed the client and identified the primary or emerging problem. For example, nurses in an ambulatory clinic or home health care agency may have standing orders for administering certain medications or ordering laboratory tests when indicated, or a health care practitioner may establish standing orders on an inpatient unit that specify certain medications that can be administered for common complaints such as headache. Table 9-3 provides an example of standing orders used for client preparation for a barium enema.
A protocol is a series of standing orders or procedures that should be followed under certain specific conditions.
They define what interventions are permissible and under what circumstances the nurse is allowed to implement the measures. Health care agencies or individual health care practitioners frequently have standing orders or protocols for client preparation for diagnostic tests or for immediate interventions in life-threatening circumstances.
These protocols prevent needless duplication of writing the same orders repeatedly for different clients and often save valuable time in critical situations.
Nursing Interventions Classification
The Iowa Intervention Project has developed a taxonomy of nursing interventions that includes both direct and indirect activities directed toward health promotion and illness management (Iowa Intervention Project, 1993).
This taxonomy, the Nursing Interventions Classification (NIC), is a standardized language system that describes nursing interventions performed in all practice settings.
“NIC offers a standardized language that communicates the nature and worth of the work we do. Without it, nursing will remain in jeopardy” (Eganhouse, Comi-McCloskey, & Bulecheck, 1996). NIC is a method for linking nursing interventions to diagnoses and client outcomes (McCloskey, Bulechek, & Eoyang, 1999).
The format for each intervention is as follows: label name, definition, a list of activities that a nurse performs to carry out the intervention, and a list of background readings (McCloskey & Bulechek, 1996) (See Table 9-4).
NIC offers standardized language for research oursing interventions and is a promising tool for determining reimbursement for nursing services.
Nursing Intervention Activities
Nursing interventions include:
• Assisting with ADL
• Delivering skilled therapeutic interventions
• Monitoring and surveillance of response to care
• Teaching
• Discharge planning
• Supervising and coordinating nursing personnel
Implementing nursing interventions requires that consideration be given to client rights, nursing ethics, and the legal implications associated with providing care. Clients have the right to refuse any intervention.
However, the nurse must explain the rationale for the intervention and possible consequences associated with refusing treatment. If the intervention refused was health care practitioner-initiated, the health care practitioner should be informed of the refusal of care. Ethical standards require that clients be afforded privacy and confidentiality. Matters related to a client’s condition and care should be discussed only with individuals directly involved with the client’s care, and any discussion should be held in a location where information cannot be overheard by visitors or bystanders. From a legal standpoint, the nurse must ensure that the authority for prescribing any intervention has been satisfied and that applicable standards of care are maintained during implementation of all nursing interventions.
Activities of Daily Living
Clients frequently need assistance with ADL such as bathing, grooming, ambulating, eating, and eliminating.
The goal for most clients is to return to self-care or to regain as much autonomy as possible. The nurse’s role is to determine the extent of assistance needed and to provide support for ADL while at the same time fostering independence. Ongoing assessment is important for determining the appropriate balance between ensuring safety and promoting independence. For example, maintaining personal grooming is important for purposes of hygiene and comfort as well as for promoting self-esteem.
The nurse must always provide privacy when assisting clients with personal hygiene. If these tasks are assigned to other personnel, adequate supervision is imperative to ensure compliance with these principles.
Therapeutic Interventions
Therapeutic nursing interventions are those measures directed toward resolution of a current problem and include activities such as administration of medications and treatments, performing skilled procedures, and providing physical and psychological comfort. Written orders must be verified before implementing interventions requiring prescriptive authority. Reassessment of the client is also needed to determine if the intervention remains appropriate. In addition, a nurse must also understand the rationale, expected effects, and possible complications that could result from any intervention.
Monitoring and Surveillance
Observation of the client’s response to treatment is an integral part of implementation of any intervention.
Monitoring and surveillance of the client’s progress or lack of progress are essential in determining the effectiveness of the plan of care and for detection of potential complications. Specific interventions require specific monitoring activities; however, typical monitoring activities include observations such as vital signs measurement, cardiac monitoring, and recording of intake and output.
Teaching
A key element in health promotion and illness management is the counseling of clients to help them modify their behaviors in response to potential health risks and actual health alterations. As part of this teaching process, nurses must also discuss the rationales for the interventions that are included in the nursing plan of care.
Numerous opportunities arise every day for informal teaching related to client care. For example, teaching clients about the medications they are taking and possible side effects should occur routinely as medications are administered. Similarly, as nurses perform assessment activities, the sharing of observations with the client can be informative in terms of what characteristics are desirable and what observations are sources of concern.
This knowledge can be valuable to a client when self-monitoring.
Effective teaching requires insight into the client’s knowledge base and readiness to learn. Realistic teaching goals and learning outcomes should be set on the basis of these factors. It is also desirable to include the family or significant others in teaching plans. A suitable learning environment should be created that is nonthreatening and allows active participation by the client.
Nurses should be careful to use terminology easily understood by the client. It is important that learning outcomes are validated to be sure that clients can safely and effectively care for themselves on discharge.
Discharge Planning
Preparation for discharge begins at the time of admission to a health care facility. As the average length of stay in acute care settings continues to decrease, early discharge planning becomes imperative. Expected outcomes dictate the type of planning required and the interventions necessary to attain the desired outcomes.
Interventions directed toward discharge planning include activities such as teaching and consultation with other agencies (e.g., home health, rehabilitation facilities, nursing homes, social services) concerning followup care. Teaching related to any changes in diet, medications, or lifestyle must be implemented; any barriers or problems in the home environment must be resolved before discharge. Some agencies employ personnel with the primary responsibility of teaching or discharge planning for groups of clients; however, the nurse who is caring for the individual client is also responsible for ensuring that all appropriate interventions have been implemented before discharge.
Supervision and Coordination of Personnel
The management style and type of facility, as well as the needs of the client, determine the scope of interventions associated with supervision and coordination of client care. In a health care facility in which nurses are assigned clients within a total client care management system, responsibilities for supervision might be minimal, whereas facilities that use a variety of ancillary personnel for certain client activities might require a large percentage of time devoted to supervision of care. In home health care, for example, the primary role of the professional nurse might be supervision of personnel who provide assistance with ADL. Although a nurse might delegate certain tasks to other personnel, it is still the nurse’s responsibility to ensure that the task was completed according to standards of care and to note the response of the client in order to evaluate progress toward expected outcomes.
Regardless of management style or type of facility, coordination of client activities among various health care providers remains the nurse’s responsibility. For example, in acute care settings, the nurse needs to coordinate client activities around the schedule of diagnostic tests or physical therapy. Scheduling of procedures, therapy, treatments, and medications for a number of clients often requires considerable organizational skills, creativity, and resourcefulness.
Evaluating Interventions
An important step to assure the delivery of quality care is evaluation of nursing interventions. One approach to determining the efficacy of nursing interventions is by evaluating clients’ achievement of expected outcomes.
The Nursing Intervention Classification (NIC), previously described in this chapter, provides a systematic method for linking nursing activities to client outcomes. When treatment can be shown to directly improve client outcomes, both nursing and health care consumers benefit.
Another taxonomy, the Nursing Outcomes Classification (NOC) has been specifically designed to evaluate nursing interventions. NOC provides a common language for measuring client responses to nursing interventions.
Documentation of Interventions
Communication concerning implementation of interventions must be provided through written documentation and should also be verbally conveyed when responsibility of the client’s care is transferred to another nurse.
The nurse is legally required to record all interventions and observations related to the client’s response to treatment.
This not only provides a legal record but also allows valuable communication with other health care team members for continuity of care and for evaluating progress toward expected outcomes. In addition, written documentation provides data necessary for reimbursement for services and tracking of indicators for continuous quality improvement.
The recording of information can be in the form of either checklists, flow sheets, or narrative summaries. A complete description must be provided if there are any deviations from the norm or if any changes have occurred.
Verbal interaction among health care providers is also essential for communicating current information about clients. Nurses who delegate the delivery of client care to assistive personnel must be careful to elicit their feedback related to activities completed and the client’s response to any interventions. In addition, assistive personnel should be alerted as to what additional data are meaningful, and these data should be conveyed to the nurse responsible for the client’s care. For example, if a nursing assistant observes that Mrs. Robbins, hospitalized with a deep vein thrombosis of the left leg, is having difficulty swallowing and has eaten very little, this information should be reported to the nurse. This is especially important if the behavior is a new occurrence and not a part of the established problem list, because the nurse might not otherwise seek this information.
Communication betweeurses generally occurs at the change of shift, when the responsibility for care changes from one nurse to another. Nursing students must communicate relevant information to the nurse responsible for their clients when they leave the unit. Information that should be shared in the verbal report includes:
• Activities completed and those remaining to be completed
• Status of current relevant problems
• Any abnormalities or changes in assessment
• Results of treatments (i.e., client response)
• Diagnostic tests scheduled or completed (and results)
All communication—written and/or verbal—must be objective, descriptive, and complete. The communication includes observations rather than opinions and is stated or written so that an accurate picture of the client is conveyed. For example, if it is noted that a client is less alert today than yesterday, the behavior that led to that conclusion should be documented. This observation can be objectively and descriptively communicated by the statement: “Does not respond unless firmly touched; quickly returns to sleep.” This description results in a more complete picture of the client than simply stating: “Less alert today.” Thorough and detailed communication of implementation activities is fundamental to ensuring that client care and progress toward goals can be adequately evaluated.
KEY CONCEPTS
• The implementation step of the nursing process is directed toward meeting client needs and results in health promotion, prevention of illness, illness management, or health restoration and also involves delegation of nursing care activities to assistive personnel and documentation of the implementation activities performed.
• Implementation requires cognitive, psychomotor, and intellectual skills to accomplish goals and make progress toward expected outcomes.
• Implementation activities include ongoing assessment, establishment of priorities, allocation of resources, initiation of specific nursing interventions, and documentation of interventions and client responses.
• Ongoing assessment is necessary for determining effectiveness of interventions and for detection of new problems.
• Changing variables in clients and the environment demand clinical judgment and flexibility in organizing care.
• Time management skills are essential in implementing client care.
• The nurse maintains responsibility for care delegated to other health care personnel.
• The most common management systems currently used include functional nursing, team nursing, primary nursing, total client care, modular nursing, and case management.
• Interventions can be nurse-initiated, health care practitioner-initiated, or collaborative in origin, and thus are considered dependent, independent, or interdependent.
• Nursing Interventions Classification (NIC) is a system for sorting, labeling, and describing nursing interventions.
• Nursing interventions include assisting with activities of daily living, skilled therapeutic interventions, monitoring and surveillance of response to care, teaching, discharge planning, and supervision and coordination of nursing personnel.
• Communication concerning interventions should be provided verbally and in writing.
