Learning Objectives
By the end of this section, you will be able to:
- Explain the nurse’s role during the implementation phase
- Describe the goals of the implementation phase
- Identify the skills needed to complete the implementation phase
In this unit, the process of providing nursing care will be explained in detail. This process begins with assessment, as nurses collect comprehensive data about the patient, followed by the diagnosis when data are analyzed to identify the causes of health problems. Based on the diagnosis, the care team and patient collaborate to identify desired health outcomes, then develop a plan of care for achieving these goals through various interventions (any action intended to stop a harmful outcome or promote a healthful one). Each step in the nursing process is crucial and builds on the previous ones, all to ensure a holistic approach to patient care (American Nurses Association [ANA], n.d.).
The next phase of the nursing process is the implementation phase, when the plans and strategies formulated in earlier steps are put into action. The specifics of implementation describe how nurses translate care plans into practical, patient-centered actions. This section also covers the importance of effectively carrying out care plans, adapting interventions to patient responses, and ensuring continuity of care. Implementation is where theory meets practice, and the nurse’s skills, knowledge, and judgment come to the forefront to positively affect patient health.
Emphasis during the Implementation Phase
During the implementation phase of nursing care, nurses play a crucial role in translating the established plan of care into action, applying evidence-based practices, and ensuring continuity of care. This phase involves actively executing the plan, monitoring patient responses to interventions, and maintaining consistent care delivery—particularly when the patient transitions out of the facility.
Putting the Plan into Action
Nurses translate a patient’s established plan of care into action by delivering interventions, treatments, and therapies as outlined. This requires following evidence-based practices, adhering to protocols, and utilizing critical-thinking skills to adapt the plan to meet the patient’s immediate needs and changing conditions. By applying their clinical knowledge and critical-thinking skills, nurses adapt the plan to meet the unique needs of each patient, striving to achieve optimal outcomes and promote recovery.
Gauging Patient Response
Gauging the patient’s response to interventions is a critical aspect of the implementation phase. It involves continuously observing and interpreting how the patient physically, mentally, and emotionally reacts to the care plan. This process is essential for ensuring that interventions are effective and align with the patient’s needs and comfort levels.
Nurses assess responses through various means, including direct feedback from the patient, clinical observations, and monitoring vital signs or other relevant health indicators. This ongoing assessment allows the nurse to make timely adjustments to the care plan, ensuring it remains responsive and patient-centered. The implementation phase focuses on actively carrying out the established care plan, making real-time adjustments based on patient feedback, and ensuring that interventions are administered in a way that promotes the patient’s immediate well-being. In contrast, the evaluation phase systematically assesses the overall effectiveness of the care plan after interventions have been administered. It involves reviewing patient data and outcomes to determine if the goals and objectives of the care plan were met, making long-term adjustments based on a thorough analysis, and documenting the results for continuous improvement of future care plans.
Providing Continuity of Care
Providing continuity of care is pivotal in the implementation phase, particularly as the patient prepares to transition from the hospital to home or another care setting. This aspect of care ensures that the patient receives consistent and uninterrupted support throughout their recovery. Continuity of care requires effective communication, thorough documentation, and coordinated handoffs among healthcare professionals. It also involves preparing the patient and their family for what to expect after discharge, which may include education on medication management, physical therapy exercises, and wound care (Regis College, 2023).
Goals of the Implementation Phase
The implementation phase in nursing is driven by specific goals tailored to each patient’s care plan. These goals are derived from the patient’s diagnosis and desired outcomes, which are determined in earlier steps of the nursing process. Achieving goals requires a strategic approach, ensuring that each action by nursing staff contributes meaningfully to a patient’s recovery and overall well-being.
Ongoing Assessment
Ongoing assessments, discussed in Chapter 12 Assessment: Recognizing Cues, are a vital, continuous part of the implementation phase. They involve regular monitoring and evaluation of a patient’s condition and responses to interventions. Through these assessments, nurses can detect subtle changes in the patient’s status that may indicate either improvement or deterioration. As a result, care remains dynamic and responsive, adjusting to the patient’s evolving needs. For nurses, ongoing assessment encompasses an array of activities, from measuring physiological parameters to observing behavioral responses, all contributing to a comprehensive understanding of the patient’s health (Lloyd-Davies, n.d.). Through diligent ongoing assessment, the care team can ensure the patient’s care plan is continuously aligned with their needs, making modifications as necessary to optimize outcomes.
Establishing Priorities
Establishing priorities is deciding which patient needs are the most urgent and addressing them first (Marymount University, 2022). Prioritizing is especially important when resources are limited or when a patient has multiple needs. It’s always vital for effective and efficient care delivery. Priority setting is often guided by frameworks such as Maslow’s hierarchy of needs or specific clinical guidelines, helping nurses focus their attention and resources where they are most needed. Review Establishing Priorities during Assessment for more information about priorities and assessment. By continually evaluating and establishing priorities, the nursing team can ensure that a patient’s care is streamlined and targeted and that their needs are addressed in a logical, effective order.
Resource Allocation
Resource allocation involves strategically distributing and utilizing available resources to ensure optimal patient outcomes. Careful planning and organization are required to ensure that every aspect of patient care is adequately supported. Effective resource allocation means that the right personnel, equipment, and materials are available when needed, ensuring that the patient’s care proceeds smoothly and without unnecessary delays. This process includes both tangible resources such as medical supplies and staffing and intangible resources such as time and information.
Required Nursing Skills during the Implementation Phase
The implementation phase of the nursing process demands a specific set of skills to ensure effective and patient-centered care. These skills include clinical knowledge, critical thinking, and clinical judgment (Table 14.1), as well as psychomotor, interpersonal, and cognitive skills. Each skill plays a crucial role in translating a care plan into practical action and adapting it to the patient’s evolving needs. In nursing, these skills are not isolated competencies but interrelated aspects of a nurse’s ability to provide high-quality care.
| Definition | Description | Example | |
|---|---|---|---|
| Clinical knowledge | Understanding of health, disease processes, treatments, and nursing interventions | Foundation for care plans and informed decisions; gained through education and experience | Knowing the signs of hypoglycemia and how to respond to a patient with diabetes showing signs and symptoms of hypoglycemia |
| Critical thinking | Skillful reasoning to guide belief or action | Analyzing information, evaluating evidence, and making decisions; crucial in assessing situations and adapting care plans | Deciding to elevate a patient’s legs if they exhibit signs of fluid overload, even if the care plan does not explicitly mention this intervention |
| Clinical judgment | Using reasoning and thinking to draw conclusions and make decisions | Synthesizing information from various sources to prioritize interventions and make timely decisions based on patient needs and responses | Consulting with a wound care specialist on how to modify a patient’s care plan when treatment has not improved the surgical site infection |
Clinical Knowledge
A nurse’s understanding of health and disease processes, treatments, and nursing interventions is referred to as clinical knowledge. It is the foundation upon which nurses build their care plans and make informed decisions. Clinical knowledge is gained through education and experience and is vital in understanding the implications of different health conditions and how to manage them effectively. It is also a key component of clinical reasoning, the process by which a healthcare provider combines their knowledge and experience with data obtained through various patient assessments to diagnose a medical problem and determine an appropriate response (Gruppen, 2017).
Clinical Safety and Procedures (QSEN)
Using Clinical Knowledge to Develop Nursing Interventions
The Quality and Safety Education for Nurses (QSEN) competencies provide a framework for nursing education and practice, emphasizing key areas necessary for improving the quality and safety of patient care. Clinical knowledge is used to formulate nursing interventions using the QSEN competencies:
- Patient-centered care: Clinical knowledge enables nurses to develop nursing interventions tailored to each patient’s unique clinical presentation, medical history, and personal circumstances. By understanding the underlying pathophysiology of the patient’s condition, nurses can design interventions that address specific symptoms, promote healing, and enhance the patient’s overall well-being.
- Evidence-based practice (EBP): Clinical knowledge plays a crucial role in EBP by providing nurses with a solid foundation of understanding regarding the latest research findings, treatment modalities, and clinical guidelines relevant to their practice. Nurses use this knowledge to select and implement nursing interventions that are supported by evidence, ensuring that patients receive care that is both effective and safe.
- Quality improvement (QI): Clinical knowledge helps nurses identify areas for improvement within their practice settings by recognizing patterns of patient outcomes, adverse events, or system inefficiencies. By leveraging their understanding of disease processes, pharmacology, and best practices in nursing care, nurses can develop and implement targeted interventions to address identified areas of concern and optimize patient outcomes over time.
- Safety: Clinical knowledge is essential for identifying and mitigating potential risks to patient safety. Nurses draw upon their understanding of anatomy, physiology, pharmacology, and patient assessment techniques to anticipate and prevent adverse events while implementing nursing interventions. This may involve ensuring correct medication dosages and administration routes, implementing fall prevention strategies, or monitoring patients for signs of deterioration following interventions.
- Teamwork and collaboration: Clinical knowledge enables nurses to communicate effectively with interdisciplinary team members, such as physicians, pharmacists, and allied health professionals, by articulating rationales for nursing interventions based on sound clinical principles. By collaborating with other healthcare providers, nurses can ensure that interventions are implemented seamlessly and that patient care is well-coordinated across the continuum.
- Informatics: Clinical knowledge enables nurses to effectively utilize informatics tools, such as electronic health records (EHRs), clinical decision support systems, and telehealth platforms, to inform nursing interventions. By accessing patient data and evidence-based resources, nurses can make informed decisions about care delivery, monitor patient progress, and communicate effectively with interdisciplinary team members. Additionally, nurses use informatics to track outcomes, analyze trends, and identify opportunities for quality improvement, ultimately enhancing the safety, efficiency, and effectiveness of nursing interventions.
By integrating clinical knowledge into their practice, nurses uphold the core principles of the QSEN competencies and deliver high-quality, safe, patient-centered care (PCC).
Critical Thinking
When implementing a care plan, nurses should not simply “follow orders” without concern for how circumstances may change. Instead, they inform and reflect on decisions using critical thinking, the disciplined, systematic process of applying skillful reasoning to guide belief or action. Analyzing information, evaluating the available evidence, and making reasoned decisions is known as critical thinking (ANA, 2024). It is crucial in the implementation phase, as it allows nurses to assess situations, consider various options, and make decisions that best suit the patient’s needs. This process also ensures patients receive the most appropriate and effective care for their situation.
Clinical Judgment
Using clinical reasoning and critical thinking to draw conclusions or make decisions about a case is referred to as clinical judgment. It involves synthesizing information from various sources, including patient assessments, clinical knowledge, and the nurse’s experience (Tanner, 2006). Nurses utilize clinical judgment to prioritize nursing interventions, considering factors such as the patient’s condition, preferences, and response to treatment. By drawing upon their clinical knowledge and experience, nurses make timely and appropriate decisions regarding selecting and implementing interventions to promote optimal patient outcomes. The nurse’s clinical judgment will guide the decision to modify the treatment plan or consult with other healthcare professionals for further management.
Clinical Judgment Measurement Model
Take Action: Using Clinical Judgment to Initiate Nursing Interventions
Sarai, a registered nurse working in the emergency department, receives a new patient, Mr. Smith, a 63-year-old male presenting with chest pain and shortness of breath. Sarai begins by noticing the cues presented by Mr. Smith, including his chief complaint of chest pain and shortness of breath, as well as his pallor and diaphoresis. Sarai interprets the significance of the cues she has noticed, considering Mr. Smith’s age, medical history, and presenting symptoms. She recognizes that chest pain and shortness of breath could indicate a myocardial infarction (heart attack) and understands the urgency of the situation. Based on her interpretation of the cues, Sarai responds promptly by initiating appropriate nursing interventions per standing orders. She ensures that Mr. Smith is placed on continuous cardiac monitoring, administers oxygen therapy to improve his oxygenation, and establishes intravenous access for medication administration and fluid resuscitation.
Psychomotor Skills
The practical, hands-on abilities required to implement interventions effectively in nursing are known as psychomotor skills. These skills range from basic tasks such as taking vital signs to more complex procedures such as administering injections or performing wound care (University of San Francisco School of Nursing, 2011). Proficient psychomotor skills are essential for ensuring that physical interventions are carried out safely and correctly and with minimal patient discomfort. The precise execution of psychomotor skills contributes significantly to effectively implementing a patient’s care plan and their overall recovery experience.
Interpersonal Skills
Effective communication and interaction with patients, their families, and other healthcare professionals comprise interpersonal skills in nursing. These skills are crucial for building trust through open communication and mutual respect to build relationships and partnerships. They provide emotional support through empathy and compassion to acknowledge patients’ emotions and alleviate distress, promoting a sense of comfort and reassurance. Interpersonal skills also facilitate the exchange of information through active listening techniques to understand patients’ perspectives, preferences, and needs, allowing nurses to tailor interventions accordingly. These skills also involve collaboration—nurses collaborate with patients, families, and interdisciplinary team members to coordinate care, share information, and achieve common goals. Interpersonal skills must also encompass cultural sensitivity, which means being aware of and respecting a patient’s cultural background and beliefs. Nurses create a supportive environment that encourages patients to voice their concerns, ask questions, and express their preferences, ultimately enhancing the success of nursing interventions and promoting positive patient outcomes (ANA, 2023). Effective interpersonal skills help nurses better understand their patients’ needs and concerns, enabling more personalized care. By establishing a rapport and maintaining clear communication, the nurse can build trust and keep the patient and family informed and involved in care, enhancing the overall experience and adherence to the care plan.
Cognitive Skills
The mental processes involved in understanding patient needs, planning care, problem-solving, and decision-making in nursing are collectively known as cognitive skills. These skills are fundamental to processing patient information, applying clinical knowledge, and adapting care plans to meet individual patient needs. Cognitive skills enable nurses to think critically and apply clinical reasoning and judgment in practice. The nurse’s ability to process and integrate various pieces of information is key to adapting a patient’s care plan in response to changing needs, ensuring a smooth and effective recovery process.
Patient Conversations
A Skillful Conversation
Scenario: Nurse Ali is paying a home visit to Mrs. Dewi, who has been struggling with irritable bowel syndrome (IBS). Note how Nurse Ali utilizes the various nursing skills throughout the conversation.
Nurse: Good morning, Mrs. Dewi.
Mrs. Dewi: Good morning, Ali.
INTERPERSONAL SKILLS
Nurse: I see another beautiful drawing on your wall. Your grandchildren really keep your spirits up, don’t they?
Mrs. Dewi: Oh, yes. It’s from Lily. Her drawings are my little pieces of joy. She came over last night for dinner and made that one.
Nurse: How nice. What did you eat?
Mrs. Dewi: Don’t worry, I was good!
Nurse: I have no doubt.
CLINICAL KNOWLEDGE
Mrs. Dewi: I’ve been avoiding those high-fiber foods you mentioned. There’s been less bloating, but the discomfort is still there sometimes.
Nurse: That’s good to hear about the bloating. Remember, with irritable bowel syndrome, it can take some time to see the full benefits of dietary changes. Let’s keep monitoring this.
Mrs. Dewi: All right.
CRITICAL THINKING
Nurse: Besides diet, other factors such as stress can impact IBS. Have you noticed any patterns or specific times when the discomfort increases?
Mrs. Dewi: Now that you mention it, evenings are tougher. I tend to worry about things at night.
Nurse: That’s a helpful observation. Stress management can be a key part of managing IBS symptoms. Let’s explore some options to help you relax in the evenings.
Mrs. Dewi: I know, I should probably stay off the internet.
CLINICAL JUDGMENT
Nurse: Definitely before bed. But I’d recommend trying some relaxation techniques as well, such as guided imagery or deep-breathing exercises. It could help ease your symptoms.
Mrs. Dewi: I haven’t tried those before. How do they work?
Nurse: I can show you some techniques and provide resources. We can practice a few together to get you started.
PSYCHOMOTOR SKILLS
Nurse: Now, let’s do a quick abdominal check. Please let me know if you feel any discomfort.
Nurse Ali performs a gentle abdominal examination.
Mrs. Dewi: It’s a little tender but not painful.
Nurse: That’s normal. I’m checking for any unusual signs.
Mrs. Dewi: Nothing unusual?
COGNITIVE SKILLS
Nurse: Nothing unusual. You know, your feedback is important. Have we talked about keeping a symptom diary? You can note down your meals, stress levels, and when you experience discomfort.
Mrs. Dewi: That sounds like a plan. I can track what I eat and how I feel each day.
Nurse: Exactly. This diary will help us both see the bigger picture and adjust your care plan more effectively.