Learning Objectives
By the end of this section, you will be able to:
- Define the need to research evidence to support the plan of care
- Recognize how to establish priorities during the implementation of care
- Analyze the importance of outcome identification
- Explain the nurse’s role in the planning phase
The primary focus of the outcome identification and planning phases is to develop with the patient a plan of care for the patient. This section discusses creating a plan of care and the nurse’s role in implementing that plan. To create a plan, first consider what research the plan is based on and what evidence is available to support positive patient outcomes. Once those questions are answered, the nurse can determine how to establish priorities while implementing a care plan. Finally, the nurse must identify outcomes and evaluate the effectiveness of the plan.
The nurse is involved in every step of the planning phase, from the first stage of identifying the needs to thinking through the priorities, designing the plan, and putting the plan into action. To perform their role in the planning process, nurses must understand the importance of developing interpersonal competence, recognize the stages of comprehensive planning, and understand their role as care coordinators in the implementation phase.
Research Evidence to Support Plan of Care
An evidence-based practice (EBP) is the responsible and thoughtful use of current and best evidence to guide the implementation of patient care. Everything nurses say and do must be supported and validated by evidence-based research. Nursing research provides the evidence needed to support the implementation of specific nursing actions to facilitate patient recovery.
EBP has freed nurses from relying on anecdotal or historical healthcare practices that may have been based on less-than-favorable conditions, such as the availability of supplies. Nursing care that is based on evidence provides a more solid foundation for manageable and predictable outcomes. This section will discuss the most common EBP guidelines, including clinical pathways and core measures set forth by government bodies and widely known healthcare organizations.
Clinical Pathways
A clinical pathway is an evidence-based practice guideline used to develop plans of care. A clinical pathway is an example of a multidisciplinary care plan that translates policy, guidelines, and/or evidence into a standardized structure (Figure 13.5). Examples of clinical pathways include algorithms or hospital protocols for commonly treated conditions. Utilization of a common set of standard guidelines or protocols allows more research to be conducted on effective treatment plans. The overall aim of clinical pathways is to translate research into practice.
Clinical pathways are designed based on clinical research and evidence. Another widely known example of a clinical pathway is the advanced cardiac life support (ACLS) algorithm. The ACLS pathway outlines the multiple steps to treat patients who need advanced cardiac life support (ACLS). Specific medication and identified steps are implemented based on the patient’s response to treatment.
Core Measures
A core measure is an evidence-based standard of care or practice guidelines established by The Joint Commission (TJC) and the Centers for Medicare & Medicaid Services (CMS), agencies that aim to improve healthcare quality and patient safety by establishing evidence-based standards of care.
Core measures incorporate EBP guidelines to care for specific conditions or diagnoses. Examples include stroke protocols or acute coronary system (ACS) protocols associated with signs and symptoms that point to a particular clinical situation. In these scenarios, core measures help the nurse articulate what to do, what else to look for, what might be causing the problem, and even what diagnostic tests to consider. Particularly important is the relationship between core measure protocols and clear standards of performance guidelines set forth by the accrediting agencies.
The CMS primarily oversees the organization of most core measures. This responsibility stems from CMS’s pivotal role in establishing and enforcing healthcare quality benchmarks, ensuring that healthcare providers participating in Medicare and Medicaid adhere to these standards. According to CMS (2021), core measures are quality guidelines that healthcare providers are to follow, such as
- promotion of measurement that is evidence-based and generates valuable information for quality improvement;
- consumer decision-making;
- value-based payment and purchasing;
- reduction in the variability in measure selection; and
- decreased provider’s collection burden and cost.
Establishing Priorities
The means of identifying what steps need to be implemented first and why is called establishing priorities. Prioritization in nursing is a decision-making process in which a nurse considers the determined patient’s care needs, applies decision-making guidelines, and determines an order of importance for the patient’s health and well-being. Commonly used formats for clinical reasoning when establishing priorities include ABCs, Maslow’s hierarchy (see 4.2 Models of Health for more information), and the identification of actual versus potential problems, acute versus chronic problems, patient preferences, and anticipation of future problems. The importance of establishing priorities during assessment are detailed in Establishing Priorities during Assessment.)
ABCs
In the clinical setting, steps needed for life are considered the most important and should be considered above all else. Patient ABCs—airway, breathing, and circulation—are the highest priorities. The nurse must ensure a patient has an effective and functioning airway, is breathing efficiently, and is adequately circulating or has sufficient cardiac perfusion. If the ABCs are identified as a need, protocols such as basic or advanced life support should be initiated.
Actual versus Potential Problem
When prioritizing interventions or steps of care, the nurse must consider whether the problem they are addressing is an actual or potential problem. The nurse will prioritize an actual problem over a potential one.
Consider the following scenario: The nurse enters a room and finds the patient sitting in bed crying, emotionally distraught over an argument they’ve had with their significant other. The patient states, “I may not even be able to eat lunch today because I am too upset to think about food.” Applying the priority decision tree to the patient’s situation, the nurse can rule out an ABC problem. However, the patient’s problem does fall within Maslow’s hierarchy of needs. First, the nurse considers the patient’s emotional well-being, as the patient is crying and visibly upset. Second, the nurse considers the patient’s statement that they “might not be able to eat lunch today.” According to Maslow, eating is the priority—but the nurse will consider it a potential problem for now. The priority in this situation is what is happening right now—the patient’s emotional state.
Acute versus Chronic Problem
If the application of ABC, Maslow’s, and actual versus potential problems do not apply, the next step is to consider whether the problem is acute or chronic. Acute or chronic problems depend on what is going on with the patient. The nurse needs to determine which interventions or applied care should take priority.
As nurses come to understand disease processes, they will learn that certain conditions or problems are associated with specific signs and symptoms. For example, an acute episode of rheumatoid arthritis is more of a priority than a patient’s chronic constipation problem. Acute problems will take precedence over chronic problems when prioritizing care.
Expected versus Unexpected Problem
Finally, the nurse will apply the prioritization of expected versus unexpected related to identified problems or needs. Consider a patient with chronic asthma. The nurse realizes it is expected that the patient will have wheezing even with minimal exertion or activity. It is not expected, however, that a patient without a chronic lung disease will experience wheezing with minimal activity or exertion of activity.
Another example of applying prioritization is when patients are prescribed certain treatments by the provider. For example, the nurse knows that a patient prescribed a diuretic is going to produce more urine and will need to go to the bathroom more often. The nurse expects the outcome and plans the patient’s care accordingly. The nurse also knows that the patient should not experience increased heart rate, hives, and shortness of breath after administration of the medicine. These would be unexpected outcomes and would take priority over other interventions when planning care.
Outcome Identification
An outcome is the desired result or goal after the implementation of the patient’s individualized plan of care. Identified outcomes may be long-term or short-term goals and should all follow the SMART goal format. The nurse considers several factors related to outcome identification. These factors include
- specific measurements to determine the success of outcomes;
- relevance of the outcomes for the specific patient with their unique qualities and needs; and
- attainability of the outcome based on the outlined timeline.
Realistic Outcomes
The nurse will determine whether the outcome identified is realistic, meaning reasonable and attainable for this specific patient. For example, it is expected that patients undergoing minor surgical procedures will begin to move and possibly walk within a day (or even the same day) as the surgery. However, this would not be realistic for all patients. Consider a patient who is paraplegic who undergoes a minor surgical procedure—they could not walk before the surgery, so it is not realistic to expect them to walk after the surgery.
Another example is a patient who has been prescribed physical therapy to gain muscle coordination and strength training. On the day of therapy, it is realistic and attainable to expect the patient to walk a few steps in the room with therapy assistance. However, it is not realistic or attainable to expect the patient to walk 500 feet (150 meters) to the nurse’s station and back without assistance. While common sense helps with outcome identification, a strong use of critical thinking is also needed.
Expected Time Frame for Completion
As with any goal or expectation, a time frame for completion must be set. Having a set time frame enables the nurse to implement the interventions and evaluate the effectiveness of the intervention at the end of the time frame. The identified outcome time frame is set by the nurse and the healthcare team, as well as the patient’s input, when possible. There are two types of outcome identification regarding time frames: short-term and long-term.
Patient Conversations
Setting Short-Term and Long-Term Goals
Scenario: Luisa is being discharged from the hospital with a new diagnosis of type 2 diabetes. She is a bit overwhelmed with her diagnosis, but she is very motivated to stay well for the sake of her children and grandchildren. Minh is the nurse doing her discharge teaching.
Nurse: Luisa, let’s talk about setting some short- and long-term goals for your diabetes care. That might help you focus on what you need to do to stay well.
Patient: Yes! My short-term goals are to eat better and exercise more, and my long-term goal is to lose thirty pounds (fourteen kilograms) in six months.
Nurse: Those are ambitious goals! Let’s plan on how you’re going to go about achieving them.
Patient: Well, that’s where I get worried because thirty pounds is a lot of weight, and I really don’t know how to change my diet. When my family gets together, we love to make food and eat and it’s going to be hard. Plus, I don’t live near a gym, and I couldn’t afford one even if I did. Can I still achieve these goals?
Nurse: I think if we look at your goals more closely and maybe modify them to better suit your life and resources it might be a bit easier to approach. What if we change the long-term goal to five pounds (two kilograms) in one month? That is a realistic amount of weight to lose in a month, and you won’t need a gym. Do you live near any parks?
Patient: Yes, there’s a park about half a mile from my house where I take my grandchildren to play.
Nurse: That’s great! Let’s set a short-term goal of walking to the park and back once a day, five days a week. Does that sound doable?
Patient: Yes. My grandchildren will be so happy!
Nurse: (laughs) I’m so glad! Now let’s talk about diet goals.
Scenario follow-up: By helping Luisa modify her long-term goal into a more realistic one, she has helped her get a plan in place for living a healthier lifestyle.
Short-Term Goals
Short-term goals have a time frame of days to a week—some are even within the nurse’s assigned shift. Most short-term goals are to be achieved before the patient is discharged. This allows the healthcare team to evaluate the effectiveness of a newly prescribed treatment, medication, or specific intervention. For example, a patient with an indwelling Foley catheter may have a goal or outcome identified as “The patient will void (urinate) within two hours after removal of the Foley catheter.” This outcome allows the healthcare team to ensure the patient regains bladder function.
Another example of a short-term goal might be a patient who has recently been diagnosed with diabetes. The outcome identified would be “The patient will demonstrate how to check their own blood sugar using the return demonstration method before discharge.” This allows the healthcare team to ensure the patient can self-monitor their blood sugar upon discharge.
Long-Term Goals
Long-term goals generally have time frames longer than a few days and can be several weeks or even months. These goals often involve ongoing activities or interventions that continue long after the patient is discharged. Examples of long-term goals include cardiac, respiratory, or physical rehabilitation as well as wound care and long-term medication protocols. Long-term goals often are set to improve a patient’s quality of life.
The Nurse’s Role in Planning
The nurse has an integral role in the planning phase. Nurses are responsible for tasks that start with identifying the patient’s needs through establishing priorities, implementing the plan, and evaluating the outcomes. To execute their role effectively and efficiently, the nurse must understand the importance of developing interpersonal competence, the steps involved in comprehensive planning, and the role of being a care coordinator.
Interpersonal Competence
The nurse’s interpersonal competence is a crucial step that starts with their very first interaction with a patient. If the patient perceives the nurse as unknowledgeable or lacking the skills needed to provide care, they may not trust the entire team—especially if they are new to the healthcare environment. Patients may judge all nurses by that one encounter and be resistant to any future attempts at education or treatments performed by nurses.
There are several things the nurse can do to promote and demonstrate interpersonal competence. Techniques the nurse can utilize to accomplish effective communication and display personal competence include active listening, clear verbal communication, patience, and a teamwork mentality. The nurse must display knowledge and professionalism when speaking with the patient. They should use evidence to support communication, not opinion. Nurses must establish a trusting relationship with patients to facilitate active participation and cooperation with the plan of care. Nurses need effective communication with patients and their families, as well as the skills to communicate clearly and effectively with other members of the healthcare team.
A multitude of factors contribute to patient needs, and nurses must develop a strong sense of interpersonal competence to recognize them. Nurses use their clinical knowledge, experience, and social and cultural awareness to assess patients. They also need to understand how patient needs differ from family needs. Aspects such as a patient’s culture, age, and family dynamics need to be considered as the nurse develops competence.
Nurses must understand that patients and families may find it difficult to manage the expectations placed on them. Clear communication and asking direct questions about expectations help the nurse identify needs and lead to more competent decision-making.
At every stage, the nurse’s interpersonal competence drives their decision-making. The nurse needs to recognize the patient may have fears associated with the healthcare process and should plan accordingly. Addressing patient and family fears in the planning phase of care is an essential part of the process. Ensuring the patient and family are as well-educated and prepared as possible allays fears and provides a solid starting place. However, the nurse should avoid focusing too much on fears, as it can halt progress.
Comprehensive Planning
The planning stage of the nursing process is defined by the ANA as developing a “collaborative plan” in conjunction with the healthcare consumer, family, significant others, and the interprofessional team. A plan is termed comprehensive because it includes all relevant and affected parties. The planning phase can be broken into three main categories: initial planning, ongoing planning, and discharge planning (Table 13.3).
| Type | Description |
|---|---|
| Initial planning | Addresses each problem in a nursing diagnosis format, prioritizes interventions in order of implementation, and identifies patient outcomes |
| Ongoing planning | Addresses the patient’s ongoing needs, identifying which parts of the plan of care need revision, are marked as completed, or need new areas developed based on condition changes |
| Discharge planning | Addressed by the entire interdisciplinary team but implemented by the nurse, the discharge plan identifies what will happen after the patient is discharged from the facility. It can include identification of community resources or need for further health care such as home health. |
Nurse’s Role as Care Coordinator
Nurses are in the unique position of being at the center of the patient’s care. They see the patient the most frequently and get to know them and their family the best. So, when it comes to coordinating what the patient needs, the nurse is usually the one to make that happen. Almost like a manager or a quarterback of a football team, the nurse sees the whole picture for the patient and helps organize the different team members.
As a coordinator of care, the nurse plays many roles, including communicator, educator, counselor, and interdisciplinary team member (Table 13.4).
| Role | Description | Example |
|---|---|---|
| Communicator | Uses clear, concise, and therapeutic communication techniques with the patient, family and other healthcare team members | The nurse explains to the patient that based on their current lab results, the provider would like to start checking their blood glucose levels before each meal. |
| Educator | Uses knowledge, skill, or competency to help facilitate someone else’s learning | The nurse teaches the patient how to perform a blood glucose test. |
| Counselor | Assists the patient with making decisions that promote overall health and well-being, and provides encouragement and support for patient-centered care | The nurse listens as the patient decides which foods from a list are appropriate for their diagnosis of diabetes. Then the nurse offers praise when the patient selects the correct foods. |
| Interdisciplinary team member | Identifies and meets the needs of the patient by performing as an active team member | The nurse recognizes the patient’s blood sugar is above the normal range (264). Then the nurse notifies the provider and receives new medication (insulin) and diet orders (diabetic). The nurse then notifies the pharmacy and nutritionist of the newly received orders and communicates the newly developed plan to the patient. |
Patient Conversations
Nurse as a Care Coordinator
Scenario: Augusto has been admitted to the cardiac unit to be worked up for an aortic valve replacement. He has never been hospitalized before this and didn’t even know that anything could be wrong with his heart valves. Augusto was admitted at 6:00 a.m. Max is his day shift nurse.
Nurse: Good morning, Augusto. My name is Max, and I’ll be your nurse today. How are you feeling?
Patient: Freaked out, man. I’ve never been in the hospital before, and this place is crazy busy.
Nurse: I understand, there is a lot going on here. I know it can all seem overwhelming.
Patient: They say that I need a valve replaced. What are “valves” in my heart, and why does mine need to be replaced? Is this why I’ve been having more and more trouble walking without getting out of breath?
Nurse: Those are all good questions. Your heart valve is the source of your shortness of breath when walking. I’ve got some info for you at the nurse’s station regarding the normal anatomy of the heart, and about heart valve replacement surgery. I also have an informational video the hospital made. I can show you it on your TV screen. There are a lot of reasons why a heart valve needs to be replaced. I will ask the doctor when he comes by on rounds shortly to come in and discuss your reasons for needing the surgery.
Patient: Wow, thanks! I had no idea there were so many resources to help teach me about what’s going on. Yeah, I think I’d prefer to watch a video first before getting into any reading material. This way I’ll know questions to ask the doctor too.
Nurse: No problem, Augusto. I’ll do my morning assessment right now, and I’ll pull up the video for you to watch while I’m getting your morning medications.
Scenario follow-up: Max got the patient to talk about their concerns and found out how the patient likes to learn. He has developed a positive therapeutic relationship with Augusto and has started an important discussion about his disease process that allows Augusto to ask questions. Max can coordinate with the doctor or other members as Augusto’s questions and needs arise.