14.

Implementing and Evaluating

LEARNING OUTCOMES

After completing this chapter, you will be able to:

1. Explain how implementing relates to other phases of the nursing process.

2. Describe three categories of skills used to implement nursing interventions.
3. Discuss the five activities of the implementing phase.
4. Identify guidelines for implementing nursing interventions.
5. Explain how evaluating relates to other phases of the nursing process.
6. Describe five components of the evaluation process.
7. Describe the steps involved in reviewing and modifying the client's care plan.
8. Differentiate quality improvement from quality assurance.
9. Name the two components of an evaluation statement.
10. Describe three components of quality evaluation: structure, process, and outcomes.

KEY TERMS

audit, 240
cognitive skills, 233
concurrent audit, 240
evaluating, 235
evaluation statement, 236
implementing, 233
interpersonal skills, 233
outcome evaluation, 239
process evaluation, 239
quality-assurance (QA) program, 239
quality improvement (QI), 240
retrospective audit, 240
root cause analysis, 240
sentinel event, 240
structure evaluation, 239
technical skills, 233

INTRODUCTION

The nursing process is action oriented, client centered, and outcome directed. After developing a plan
of care based on the assessing and diagnosing phases, the nurse implements the interventions and
evaluates the desired outcomes. On the basis of this evaluation, the plan of care is either continued,
modified, or terminated. As in all phases of the nursing process, clients and support persons are
encouraged to participate as much as possible.

IMPLEMENTING

In the nursing process, implementing is the action phase in which the nurse performs the nursing
interventions. Using NIC terminology, implementing consists of doing and documenting the
activities that are the specific nursing actions needed to carry out the interventions. The nurse
performs or delegates the nursing activities for the interventions that were developed in the planning
step and then concludes the implementing step by recording nursing activities and the resulting client
responses.

Although the nurse may act on the client's behalf (e.g., referring the client to a community health
nurse for home care), professional standards support client and family participation, as in all phases of
the nursing process. The degree of participation depends on the client's health status. For example, an
unconscious man is unable to participate in his care and therefore needs to have care given to him. By
contrast, an ambulatory client may require very little care from the nurse and carry out health care
activities independently.

Relationship of Implementing to Other Nursing Process Phases

The first three nursing process phasesassessing, diagnosing, and planningprovide the basis for the
nursing actions performed during the implementing step. In turn, the implementing phase provides the
actual nursing activities and client responses that are examined in the final phase, the evaluating
phase. Using data acquired during assessment, the nurse can individualize the care given in the
implementing phase, tailoring the interventions to fit a specific client rather than applying them
routinely to categories of clients (e.g., all clients with pneumonia).

While implementing nursing care, the nurse continues to reassess the client at every contact, gathering
data about the client's responses to the nursing activities and about any new problems that may
develop. A nursing activity on the client's care plan for the NIC intervention Airway Management
might read "Auscultate breath sounds q4h." When performing this activity, the nurse is both carrying
out the intervention (implementing) and performing an assessment. Some routine nursing activities
are, themselves, assessments. For example, while bathing an elderly client, the nurse observes a
reddened area on the client's sacrum. Or, when emptying a urinary catheter bag, the nurse measures
200 mL of offensive smelling, brown urine.

Implementing Skills

To implement the care plan successfully, nurses need cognitive, interpersonal, and technical skills.
These skills are distinct from one another; in practice, however, nurses use them in various
combinations and with different emphasis, depending on the activity. For instance, when inserting a
urinary catheter the nurse needs cognitive knowledge of the principles and steps of the procedure,
interpersonal skills to inform and reassure the client, and technical skill in draping the client and
manipulating the equipment.

The cognitive skills (intellectual skills) include problem solving, decision making, critical thinking,

and creativity. They are crucial to safe, intelligent nursing care (see Chapter 10).

Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting
directly with one another. The effectiveness of a nursing action often depends largely on the nurse' s
ability to communicate with others. The nurse uses therapeutic communication to understand the
client and in turn be understood. A nurse also needs to work effectively with others as a member of
the health care team.

Interpersonal skills are necessary for all nursing activities: caring, comforting, advocating, referring,
counseling, and supporting are just a few. Interpersonal skills include conveying knowledge, attitudes,
feelings, interest, and appreciation of the client's cultural values and lifestyle. Before nurses can be
highly skilled in interpersonal relations, they must have self-awareness and sensitivity to others (see

Chapters 25 and 39).

Technical skills are purposeful "hands-on" skills such as manipulating equipment, giving injections,
bandaging, moving, lifting, and repositioning clients. These skills are also called tasks, procedures, or
psychomotor skills. The term psychomotor refers to physical actions that are controlled by the mind,
not reflexive.
Technical skills require knowledge and, frequently, manual dexterity. The number of technical skills
expected of a nurse has greatly increased in recent years because of the pervasive use of technology,
especially in acute care hospitals.

Process of Implementing

The process of implementing (see Figure 14-1) normally includes the following:

• Reassessing the client

• Determining the nurse's need for assistance

• Implementing the nursing interventions

• Supervising the delegated care

• Documenting nursing activities

Reassessing the Client

Just before implementing an intervention, the nurse must reassess the client to make sure the
intervention is still needed. Even though an order is written on the care plan, the client's condition
may have changed. For example, a client has a nursing diagnosis of Disturbed Sleep Pattern related to
anxiety and unfamiliar surroundings. During rounds, the nurse discovers that she is sleeping and
therefore defers the back massage that had been planned as a relaxation strategy.

New data may indicate a need to change the priorities of care or the nursing activities. For example, a
nurse begins to teach a client who has diabetes, how to give himself insulin injections. Shortly after
beginning the teaching, the nurse realizes that he is not concentrating on the lesson. Subsequent
discussion reveals that he is worried about his eyesight and fears he is going blind. Realizing that the
client's level of stress is interfering with his learning, the nurse ends the lesson and arranges for a
primary care provider to examine the client's eyes. The nurse also provides supportive communication
to help alleviate the client's stress.

Determining the Nurse's Need for Assistance

When implementing some nursing interventions, the nurse may require assistance for one or more of
the following reasons:

• The nurse is unable to implement the nursing activity safely or efficiently alone (e.g., ambulating an
unsteady obese client).

• Assistance would reduce stress on the client (e.g., turning a person who experiences acute pain when
moved).

• The nurse lacks the knowledge or skills to implement a particular nursing activity (e.g., a nurse who
is not familiar with a particular model of traction equipment needs assistance the first time it is
applied).

Implementing the Nursing Interventions

It is important to explain to the client what interventions will be done, what sensations to expect, what
the client is expected to do, and what the expected outcome is. For many nursing activities it is also
important to ensure the client's privacy, for example by closing doors, pulling curtains, or draping the
client. The number and kind of direct nursing interventions are almost unlimited. Nurses also
coordinate client care. This activity involves scheduling client contacts with other departments (e.g.,
laboratory and x-ray technicians, physical and respiratory therapists) and serving as a liaison among
the members of the health care team.
When implementing interventions, nurses should follow these guidelines:

• Base nursing interventions on scientific knowledge, nursing research, and professional standards of
care (evidence-based practice) when these exist. The nurse must be aware of the scientific rationale,
as well as possible side effects or complications, of all interventions. For example, a client prefers to
take an oral medication after meals; however, this medication is not absorbed well in the presence of
food. Therefore, the nurse will need to explain why this preference cannot be honored.

• Clearly understand the interventions to be implemented and question any that are not understood.
The nurse is responsible for intelligent implementation of medical and nursing plans of care. This
requires knowledge of each intervention, its purpose in the client's plan of care, any contraindications
(e.g., allergies), and changes in the client's condition that may affect the order.

• Adapt activities to the individual client. A client's beliefs, values, age, health status, and
environment are factors that can affect the success of a nursing action. For example, the nurse
determines that a client chokes when swallowing pills, so consults with the physician to change the
order to a liquid form of the medication. Or, the nurse recognizes that many Asian persons prefer to
drink hot water rather than ice water and, after confirming it with a specific client, supplies this at the
bedside.

• Implement safe care. For example, when changing a sterile dressing, the nurse practices sterile
technique to prevent infection; when giving a medication, the nurse administers the correct dosage by
the ordered route.

• Provide teaching, support, and comfort. See Chapter 27 for details on client teaching and Box
27-3 for examples of verbs used in writing learning outcomes. The nurse should always explain the
purpose of interventions, what the client will experience, and how the client can participate. The client
must have sufficient knowledge to agree to the plan of care and to be able to assume responsibility for
as much self-care as possible. These independent nursing activities enhance the effectiveness of
nursing care plans (see Figure 14-2).

• Be holistic. The nurse must always view the client as a whole and consider the client's responses in
that context. For example, whenever possible, the nurse honors the client's expressed preference that
interventions be planned for times that fit with the client's usual schedule of visitors, work, sleep, or
eating.

• Respect the dignity of the client and enhance the client's self-esteem. Providing privacy and
encouraging clients to make their own decisions are ways of respecting dignity and enhancing self-
esteem.

• Encourage clients to participate actively in implementing the nursing interventions. Active

participation enhances the client's sense of independence and control. However, clients vary in the
degree of participation they desire. Some want total involvement in their care, whereas others prefer
little involvement. The amount of desired involvement may be related to the severity of the illness;
the client's culture; or the client's fear, understanding of the illness, and understanding of the
intervention.

Supervising Delegated Care

If care has been delegated to other health care personnel, the nurse responsible for the client's overall
care must ensure that the activities have been implemented according to the care plan. Other
caregivers may be required to communicate their activities to the nurse by documenting them on the
client record, reporting verbally, or filling out a written form. The nurse validates and responds to any
adverse findings or client responses. This may involve modifying the nursing care plan.
Documenting Nursing Activities
After carrying out the nursing activities, the nurse completes the implementing phase by recording the
interventions and client responses in the nursing progress notes. These are a part of the agency' s
permanent record for the client. Nursing care must not be recorded in advance because the nurse may
determine on reassessment of the client that the intervention should not or cannot be implemented.
For example, a nurse is authorized to inject 10 mg of morphine sulfate subcutaneously to a client, but
the nurse finds that the client's respiratory rate is 4 breaths per minute. This finding contraindicates
the administration of morphine (a respiratory depressant). The nurse withholds the morphine and
reports the client's respiratory rate to the nurse in charge and/or physician.

The nurse may record routine or recurring activities (e.g., mouth care) in the client record at the end
of a shift. In the meantime, the nurse maintains a personal record of these interventions on a
worksheet. In some instances, it is important to record a nursing intervention immediately after it is
implemented. This is particularly true of the administration of medications and treatments because
recorded data about a client must be up to date, accurate, and available to other nurses and health care
professionals. Immediate recording helps safeguard the client, for example, from receiving a duplicate
dose of medication.

Nursing activities are communicated verbally as well as in writing. When a client's health is changing
rapidly, the charge nurse and/or the physician may want to be kept up to date with verbal reports.
Nurses also report client status at a change of shift and on a client's discharge to another unit or health
agency in person, via a voice recording, or in writing. For information on documenting and reporting,

see Chapter 15.

Figure 14-1. Implementing. The fourth phase of the nursing process, in which the nurse
implements the nursing interventions and documents the care provided.
Figure 14-2. Amanda agrees to practice deep-breathing exercises q3h during the day. In
addition, she verbalizes awareness of the need to increase her fluid intake.

EVALUATING

To evaluate is to judge or to appraise. Evaluating is the fifth and last phase of the nursing process. In
this context, evaluating is a planned, ongoing, purposeful activity in which clients and health care
professionals determine (a) the client's progress toward achievement of goals/outcomes and (b) the
effectiveness of the nursing care plan. Evaluation is an important aspect of the nursing process
because conclusions drawn from the evaluation determine whether the nursing interventions should
be terminated, continued, or changed.

Evaluation is continuous. Evaluation done while or immediately after implementing a nursing order
enables the nurse to make on-the-spot modifications in an intervention. Evaluation performed at
specified intervals (e.g., once a week for the home care client) shows the extent of progress toward
goal achievement and enables the nurse to correct any deficiencies and modify the care plan as
needed. Evaluation continues until the client achieves the health goals or is discharged from nursing
care. Evaluation at discharge includes the status of goal achievement and the client's self-care abilities
with regard to follow-up care. Most agencies have a special discharge record for this evaluation.

Through evaluating, nurses demonstrate responsibility and accountability for their actions, indicate
interest in the results of the nursing activities, and demonstrate a desire not to perpetuate ineffective
actions but to adopt more effective ones.

Relationship of Evaluating to Other Nursing Process Phases

Successful evaluation depends on the effectiveness of the steps that precede it. Assessment data must
be accurate and complete so that the nurse can formulate appropriate nursing diagnoses and desired
outcomes. The desired outcomes must be stated concretely in behavioral terms if they are to be useful
for evaluating client responses. And finally, without the implementing phase in which the plan is put
into action, there would be nothing to evaluate.

The evaluating and assessing phases overlap. As previously stated, assessment (data collection) is
ongoing and continuous at every client contact. However, data are collected for different purposes at
different points in the nursing process. During the assessment phase the nurse collects data for the
purpose of making diagnoses. During the evaluation step the nurse collects data for the purpose of
comparing it to preselected goals and judging the effectiveness of the nursing care. The act of
assessing (data collection) is the same; the differences lie in (a) when the data are collected and (b)
how the data are used.

Process of Evaluating Client Responses

Before evaluation, the nurse identifies the desired outcomes (indicators) that will be used to measure
client goal achievement. (This is done in the planning step.) Desired outcomes serve two purposes:
They establish the kind of evaluative data that need to be collected and provide a standard against
which the data are judged. For example, given the following expected outcomes, any nurse caring for
the client would know what data to collect:

• Daily fluid intake will not be less than 2500 mL.

• Urinary output will balance with fluid intake.

• Residual urine will be less than 100 mL.

The evaluation process has five components (see Figure 14-3):

• Collecting data related to the desired outcomes (NOC indicators)

• Comparing the data with outcomes

• Relating nursing activities to outcomes

• Drawing conclusions about problem status

• Continuing, modifying, or terminating the nursing care plan

Collecting Data
Using the clearly stated, precise, and measurable desired outcomes as a guide, the nurse collects data
so that conclusions can be drawn about whether goals have been met. It is usually necessary to collect
both objective and subjective data.

Some data may require interpretation. Examples of objective data requiring interpretation are the
degree of tissue turgor of a dehydrated client or the degree of restlessness of a client with pain.
Examples of subjective data needing interpretation include complaints of nausea or pain by the client.
When interpreting subjective data, the nurse must rely upon either (a) the client's statements (e.g.,
"My pain is worse now than it was after breakfast") or (b) objective indicators of the subjective data,
even though these indicators may require further interpretation (e.g., decreased restlessness, decreased
pulse and respiratory rates, and relaxed facial muscles as indicators of pain relief). Data must be
recorded concisely and accurately to facilitate the next part of the evaluating process.

Comparing Data with Outcomes

If the first two parts of the evaluation process have been carried out effectively, it is relatively simple
to determine whether a desired outcome has been met. Both the nurse and client play an active role in
comparing the client's actual responses with the desired outcomes. Did the client drink 3000 mL of
fluid in 24 hours? Did the client walk unassisted the specified distance per day? When determining
whether a goal has been achieved, the nurse can draw one of three possible conclusions:

1. The goal was met; that is, the client response is the same as the desired outcome.

2. The goal was partially met; that is, either a short-term goal was achieved but the long-term goal
was not, or the desired outcome was only partially attained.

3. The goal was not met.

After determining whether a goal has been met, the nurse writes an evaluative statement (either on the
care plan or in the nurse' s notes). An evaluation statement consists of two parts: a conclusion and
supporting data. The conclusion is a statement that the goal/desired outcome was met, partially met,
or not met. The supporting data are the list of client responses that support the conclusion, for
example:

Goal met: Oral intake 300 mL more than output; skin turgor resilient; mucous membranes moist.

See the Nursing Care Plan at the end of the chapter for evaluation statements for Amanda Aquilini.
Data in the Evaluation Statements column on this table represent Ms. Aquilini's responses to care as
observed by the night nurse on the morning after her admission to the unit. In practice, care plans
usually do not have a column for evaluation statements; rather, these are recorded in the nurse' s
notes. If NOC indicators are being used with the outcomes, scores on the scales after intervention
would be compared with those measured at baseline to determine improvement. See Table 13-3 on

page 220 for an example of the NOC rating scales used for indicators of mobility. The column
explaining rationale for continuing or modifying the plan is included in a student care plan.

Relating Nursing Activities to Outcomes

The fourth aspect of the evaluating process is determining whether the nursing activities had any
relation to the outcomes. It should never be assumed that a nursing activity was the cause of or the
only factor in meeting, partially meeting, or not meeting a goal.

For example, a client was obese and needed to lose 14 kg (30 lb). When the nurse and client drew up
a care plan, one goal was "Lose 1.4 kg (3 lb) in 4 weeks." A nursing strategy in the care plan was
"Explain how to plan and prepare a 1200-calorie diet." Four weeks later, the client weighed herself
and had lost 1.8 kg (4 lb). The goal had been metin fact, exceeded. It is easy to assume that the
nursing strategy was highly effective. However, it is important to collect more data before drawing
that conclusion. On questioning the client, the nurse might find any of the following: (a) The client
planned a 1200-calorie diet and prepared and ate the food; (b) the client planned a 1200-calorie diet
but did not prepare the correct food; (c) the client did not understand how to plan a 1200-calorie diet,
so she did not bother with it.

If the first possibility is found to be true, the nurse can safely judge that the nursing strategy "Explain
how to plan and prepare a 1200-calorie diet" was effective in helping the client lose weight. However,
if the nurse learns that either the second or third possibility actually happened, then it must be
assumed that the nursing strategy did not affect the outcome. The next step for the nurse is to collect
data about what the client actually did to lose weight. It is important to establish the relationship (or
lack thereof) of the nursing actions to the client responses.

Drawing Conclusions about Problem Status

The nurse uses the judgments about goal achievement to determine whether the care plan was
effective in resolving, reducing, or preventing client problems. When goals have been met, the nurse
can draw one of the following conclusions about the status of the client's problem:
• The actual problem stated in the nursing diagnosis has been resolved, or the potential problem is
being prevented and the risk factors no longer exist. In these instances, the nurse documents that the
goals have been met and discontinues the care for the problem.

• The potential problem stated in the nursing diagnosis is being prevented, but the risk factors are still
present. In this case, the nurse keeps the problem on the care plan.

• The actual problem still exists even though some goals are being met. For example, a desired
outcome on a client's care plan is "Will drink 3000 mL of fluid daily." Even though the data may
show this outcome has been achieved, other data (dry oral mucous membranes) may indicate that
there is Deficient Fluid Volume. Therefore, the nursing interventions must be continued even though
this one goal was met.

When goals have been partially met or when goals have not been met, two conclusions may be drawn:

• The care plan may need to be revised, since the problem is only partially resolved. The revisions
may need to occur during assessing, diagnosing, or planning phases, as well as implementing.

OR

• The care plan does not need revision, because the client merely needs more time to achieve the
previously established goal(s). To make this decision, the nurse must assess why the goals are being
only partially achieved, including whether the evaluation was conducted too soon (see Figure 14-4).

Continuing, Modifying, and Terminating the Nursing Care Plan

After drawing conclusions about the status of the client's problems, the nurse modifies the care plan as
indicated. Depending on the agency, modifications may be made by drawing a line through portions
of the care plan, or marking portions using a highlighting pen, or writing "Discontinued" (dc'd), "goal
met," or "problem resolved" and the date.

Whether or not goals were met, a number of decisions need to be made about continuing, modifying,
or terminating nursing care for each problem. See Table 14-1 for a checklist to use when reviewing a
care plan. Although the checklist uses a closed-ended yes/no format, its only intent is to identify areas
that require the nurse's further examination.

Before making modifications, the nurse must determine if the plan as a whole was not completely
effective. This requires a review of the entire care plan and a critique of each step of the nursing
process involved in its development.

ASSESSING. An incomplete or incorrect database influences all subsequent steps of the nursing
process and care plan. If data are incomplete, the nurse needs to reassess the client and record the new
data. In some instances, new data may indicate the need for new nursing diagnoses, new goals, and
new nursing interventions.

DIAGNOSING. If the database was incomplete, new diagnostic statements may be required. If the
database was complete, the nurse needs to analyze whether the problems were identified correctly and
whether the nursing diagnoses were relevant to that database. After making judgments about problem
status, the nurse revises or adds new diagnoses as needed to reflect the most recent client data.

PLANNING: DESIRED OUTCOMES. If a nursing diagnosis was inaccurate, obviously the goal
statement will need revision. If the nursing diagnosis was appropriate, the nurse then checks if the
goals were realistic and attainable. Unrealistic goals require correction. The nurse should also
determine whether priorities have changed and whether the client still agrees with the priorities. For
example, the amount of time delineated for a specific amount of weight loss was possibly too short
and should be extended. Goals must also be written for any new nursing diagnoses.
PLANNING: NURSING INTERVENTIONS. The nurse investigates whether the nursing
interventions were related to goal achievement and whether the best nursing interventions were
selected. Even when diagnoses and goals were appropriate, the nursing interventions selected may not
have been the best ones to achieve the goal. New nursing interventions may reflect changes in the
amount of nursing care the client needs, scheduling changes, or rearrangement of nursing activities to
group similar activities or to permit longer rest or activity periods for the client. For example, for a
client who wishes to stop smoking, there are many potential interventions. If medication was
prescribed but the client is still smoking, possibly a behavioral intervention such as group counseling
needs to be added. If new nursing diagnoses have been written, then new nursing interventions will
also be necessary.

IMPLEMENTING. Even if all sections of the care plan appear to be satisfactory, the manner in
which the plan was implemented may have interfered with goal achievement. Before selecting new
interventions, the nurse should check whether they were carried out. Other personnel may not have
carried them out, either because the interventions were unclear or because they were unreasonable in
terms of external constraints such as money, staff, time, and equipment.

After making the necessary modifications to the care plan, the nurse implements the modified plan
and begins the nursing process cycle again. Refer to the Nursing Care Plan at the end of this chapter
to see how the plan for Amanda Aquilini was modified after evaluation of goal achievement and
review of the nursing process. A line has been drawn through portions the nurse wished to delete;
additions to the care plan are shown in italics.

Evaluating the Quality of Nursing Care

In addition to evaluating goal achievement for individual clients, nurses are also involved in
evaluating and modifying the overall quality of care given to groups of clients. This is an essential
part of professional accountability. In each of the processes described as follows, nurses and all other
health care providers work together as an interdisciplinary team focused on improving client care. The
activities both use and contribute to evidence-based practice.

Quality Assurance
A quality-assurance (QA) program is an ongoing, systematic process designed to evaluate and
promote excellence in the health care provided to clients. Quality assurance frequently refers to
evaluation of the level of care provided in a health care agency, but it may be limited to the evaluation
of the performance of one nurse or more broadly involve the evaluation of the quality of the care in an
agency, or even in a country.

Quality assurance requires evaluation of three components of care: structure, process, and outcome.
Each type of evaluation requires different criteria and methods, and each has a different focus.

Structure evaluation focuses on the setting in which care is given. It answers this question: What
effect does the setting have on the quality of care? Structural standards describe desirable
environmental and organizational characteristics that influence care, such as equipment and staffing.

Process evaluation focuses on how the care was given. It answers questions such as these: Is the care
relevant to the client's needs? Is the care appropriate, complete, and timely? Process standards focus
on the manner in which the nurse uses the nursing process. Some examples of process criteria are
"Checks client's identification band before giving medication" and "Performs and records chest
assessment, including auscultation, once per shift."

Outcome evaluation focuses on demonstrable changes in the client's health status as a result of
nursing care. Outcome criteria are written in terms of client responses or health status, just as they are
for evaluation within the nursing process. For example, "How many clients undergoing hip repairs
develop pneumonia?" or "How many clients who have a colostomy experience an infection that
delays discharge?"

Quality Improvement
There are currently strong national efforts at evaluating and improving the quality of health care based
on internal assessment by health care providers and increasing awareness by the public that medical
errors are not uncommon and can be lethal. The Quality of Health Care in America Committee of the
Institute of Medicine issued a landmark report: To Err Is Human: Building a Safer Health System in
2000. The entire report is available at the National Academies Press website. The emphases of the
report are increasing knowledge related to medical errors and establishing systems for enhancing safe
care. Since the report was issued, improved attention to these issues has come from a variety of
sources. However, the complexity of the health care system (including methods of reimbursement),
difficulties with leadership, and fear of threats to autonomy have limited progress (Leape & Berwick,
2005).

Clinical Alert

Bad systemsand not bad peoplelead to most errors.

The Center for Quality Improvement and Patient Safety (CQuIPS) within the Agency for Healthcare
Research and Quality (2004) has as its mission to "improve[s] the quality and safety of all Americans
through strategic partnerships. Specifically, CQuIPS:

1. Conducts and supports user-driven research on patient safety and health care quality measurement,
reporting, and improvement.

2. Develops and disseminates reports and information on health care quality measurement, reporting,
and improvement.

3. Collaborates with stakeholders across the health care system to implement evidence-based
practices, accelerating and amplifying improvements in quality and safety for patients.

4. Assesses our own practices to ensure continuous learning and improvement for the Center and its
members."

RESEARCH NOTE How Is Quality Improvement Being Conducted in Nursing Homes?

The purpose of this study, conducted in 35 nursing homes managed by the Veterans Administration,
was to examine the association between quality improvement (QI) and client outcomes. Over 1,000 of
the nursing staff completed surveys on the culture of the setting, satisfaction, and specific information
regarding implementation of pressure ulcer prevention guidelines. There were differences among the
nursing homes in their implementation of QI practices, and QI appeared to be associated with
employee satisfaction and the perception of providing better care. However, the results were
inconclusive in terms of demonstrating an effect of QI on quality of care.

IMPLICATIONS

The results demonstrated the need for continued study before QI is widely promoted as a means for
improving nursing home quality. The relationship between use of QI and satisfaction of the nursing
staff is an optimistic sign. Quality improvement, as well as other interventions to improve care, is
unlikely to be successfully implemented in nursing homes that are not suitably predisposed to making
the necessary changes in how care is delivered.

Note: From "Quality Improvement Implementation in the Nursing Home," by D. R. Berlowitz, G. J.

Young, E. C. Hickey, D. Saliba, B. S. Mittman, E. Czarnowski, et al., 2003, Health Services
Research, 38 (1 Part 1), pp. 65-83.

In addition, the mission of the Joint Commission on Accreditation of Healthcare Organizations

(JCAHO, 2005a) is: "To continuously improve the safety and quality of care provided to the public
through the provision of health care accreditation and related services that support performance
improvement in health care organizations." JCAHO has put great emphasis on the importance of what
are called "sentinel events." Although each agency must define sentinel events for itself, the definition
must be consistent with that given by JCAHO (2005b):

• A sentinel event is an unexpected occurrence involving death or serious physical or psychological

injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, "or
the risk thereof" includes any process variation for which a recurrence would carry a significant
chance of a serious adverse outcome.

• Such events are called "sentinel" because they signal the need for immediate investigation and
response.

The organization must respond to the sentinel event by assessing the cause, identifying a plan for
intervention, and evaluating the results of the plan. Often, assessment involves a root cause analysis.
Root cause analysis is a process for identifying the factors that bring about deviations in practices
that lead to the event. It focuses primarily on systems and processes, not individual performance. It
begins with examination of the single event but with the goal of determining which organizational
improvements are needed to decrease the likelihood of such events occurring again.

Unlike quality assurance, quality improvement (QI) follows client care rather than organizational
structure, focuses on process rather than individuals, and uses a systematic approach with the
intention of improving the quality of care rather than ensuring the quality of care. QI studies often
focus on identifying and correcting a system' s problems, such as duplication of services in a hospital.
QI is also known as continuous quality improvement (CQI), total quality management (TQM),
performance improvement (PI), or persistent quality improvement (PQI).

Nursing Audit
An audit means the examination or review of records. A retrospective audit is the evaluation of a
client's record after discharge from an agency. Retrospective means "relating to past events." A
concurrent audit is the evaluation of a client's health care while the client is still receiving care from
the agency. These evaluations use interviewing, direct observation of nursing care, and review of
clinical records to determine whether specific evaluative criteria have been met.

Another type of evaluation of care is the peer review. In nurse peer review, nurses functioning in the
same capacity, that is, peers, appraise the quality of care or practice performed by other equally
qualified nurses. The peer review is based on preestablished standards or criteria.

There are two types of peer reviews: individual and nursing audits. The individual peer review
focuses on the performance of an individual nurse. The nursing audit focuses on evaluating nursing
care through the review of records. The success of these audits depends on accurate documentation.
 LIFESPAN CONSIDERATIONS Evaluating

Evaluation of goals, selected outcomes, and interventions needs to be continuous, with ongoing
assessment and reassessment of the situation. Priority needs can change quickly and must be
reprioritized when problems occur. Infants and young children are vulnerable to rapid change in their
condition due to their small body size, disproportionate size of organs, and immaturity of body
systems. Also, they may not be able to verbalize how they are feeling. Older adults may have
conditions that impair communication, such as aphasia from a cerebrovascular accident, dementia,
multiple sclerosis, or other neurological conditions. In such cases, the nurse needs to be even more
astute in performing nonverbal assessments, being alert to potential problems, and detecting changes
in the client's condition. If evaluations are done often and thoroughly, changes can be made quickly to
intervene more effectively and improve outcomes. Constant assessment, communication, and
interpersonal skills are as essential in the evaluation phase as they are in the initial assessment.

NURSING CARE PLAN For Amanda Aquilini Modified Following Implementation and
Evaluation

NURSING DIAGNOSIS: Ineffective Airway Clearance related to viscous secretions and

shallow chest expansion secondary to deficient fluid volume, pain, and fatigue.

DESIRED OUTCOMES*/INDICATORS EVALUATION STATEMENTS NURSING

INTERVENTIONS** EXPLANATION FOR CONTINUING OR MODIFYING NURSING
INTERVENTIONS Respiratory status: gas exchange [0402], as evidenced by • Absence of pallor
and cyanosis (skin Partially met. Skin and mucous membranes not Monitor respiratory status q4h;
rate, depth, Retain nursing interventions to continue and mucous membranes) cyanotic, but still pale.
effort, skin color, mucous membranes, amount and to identify progress. Goal status color of sputum.
indicates problem not resolved. • Use of correct breathing/coughing Partially met. Uses correct
technique when Monitor results of blood gases, chest x-ray technique after instruction pain well
controlled by narcotic analgesics. studies, pulse oximetry, and incentive spirometer volume as
available. • Productive cough Met. Cough productive of moderate amounts of Monitor level of
consciousness. thick, yellow, pink-tinged sputum. Auscultate lungs q4h. • Symmetric chest excursion
of at Not met. Chest excursion = 3 cm. Vital signs q4h (TPR, BP, pulse oximetry). least 4 cm • Lungs
clear to auscultation within Not met. Scattered inspiratory crackles Instruct in breathing and coughing
techniques. Does not need to be reinstructed as 48-72 h auscultated throughout right anterior and
Remind to perform and assist q3h. Support and client demonstrates correct posterior chest.
encourage. (4/17/07, JW) techniques. May still need support and encouragement because of fatigue
and Administer prescribed expectorant; schedule for pain of breathing. maximum effectiveness. •
Respirations 12-22/min, pulse, 100 Partially met. Respirations 26/min, pulse 96. Maintain Fowler's or
semi-Fowler's position. beats/min • Inhaling normal volume of air on Not met. Tidal volume only 350
mL (Evaluated Administer prescribed analgesics. Notify primary incentive spirometer 4/17/07, JW)
care provider if pain not relieved. Administer oxygen by nasal cannula as prescribed. Provide portable
oxygen if client goes off unit (e.g., for x-ray examination). Assist with postural drainage daily at
0930. On 4/ As soon as client is hydrated and fever 17 teach to continue prn at home. (4/17/07, JW) is
controlled, she will probably be discharged to self-care at home. Administer prescribed antibiotic to
maintain constant blood level. Observe for rash and GI or other side effects. Anxiety control [1402],
as evidenced by • Listening to and following Met. Performed coughing techniques as When client is
dyspneic, stay with her; reassure instructions for correct breathing instructed during periods of
dyspnea. her you will stay. and coughing technique, even during periods of dyspnea Remain calm,
appear confident. • Verbalizing understanding of Met. See nurse's notes for 3-11 shift. Stated,
Encourage slow, deep breathing. condition, diagnostic tests, and "I know I need to try to breathe
deeply even treatments (by end of day) when it hurts." Demonstrated correct use of When client is
dyspneic, give brief explanations of incentive spirometer and stated treatments and procedures.
understanding of the need to use it. Understands IV is for hydration and antibiotics. (Evaluated
4/17/07, JW) • Decrease in reports of fear and Met. Stated, "I know I can get enough air, but anxiety it
still hurts to breathe." • Voice steady, not shaky Met. Speaks in steady voice. • Respiratory rate of 12-
22 min Not met. Rate 26-36/min. When acute episode is over, give detailed Detailed information has
been given. information about nature of condition, Because client shows understanding, treatments,
and tests. Reassess whether client there is no need to repeat needs any information on condition,
treatments, information. or tests. (4/17/07, JW). • Freely expresses concerns and Partially met.
Discussed only briefly on 3-11 As client can tolerate, encourage to express and It is important that
this assessment be possible solutions about work and shift. Not done on 11-7 shift because of expand
on her concerns about her child and her made right away, so child care can be parenting roles client's
need to rest. (Evaluated 4/17/07, work. Explore alternatives as needed. arranged if needed. JW) Note
whether husband returns as scheduled. If he does not, institute care plan for actual Interrupted Family
Process. (Do on 4/17, day shift) (4/17/07, JW) *The NOC # for desired outcomes is listed in brackets
following the appropriate outcome. Outcomes are only a sample of those suggested by NOC and
should be further individualized for each client. **In this care plan, a line has been drawn through
portions the nurse wished to delete; additions to the care plan are shown in italics.

APPLYING CRITICAL THINKING

1. From reviewing Amanda Aquilini's nursing care plan, what general conclusions can you make
about the desired outcomes for Ineffective Airway Clearance and Anxiety? 2. Despite some of the
outcomes being only partially met or not met, no new interventions were written for several
outcomes. What reasons might there be for this? 3. For the nursing diagnosis of Anxiety, most of the
outcomes are fully met. Would you delete this diagnosis from the care plan at this time? Why or why
not? 4. Since the Evaluation Statements column is generally not used on written care plans, where
would auditors or persons conducting quality assessments find these data?

See Critical Thinking Possibilities in Appendix A.

Figure 14-3. Evaluating. The final phase of the nursing process, in which the nurse determines
the client's progress toward goal achievement and the effectiveness of the nursing care plan. The
plan may be continued, modified, or terminated.
Figure 14-4. Upon assessment of respiratory excursion, Nurse Medina detects failure of the
client to achieve maximum ventilation. She and Amanda reevaluate the care plan and modify it
to increase coughing and deep-breathing exercises to q2h.

CHAPTER 14 REVIEW

CHAPTER HIGHLIGHTS

• Implementing is putting planned nursing interventions into action.

• Reassessing occurs simultaneously with the implementing phase of the nursing process.

• Successful implementing and evaluating depend in part on the quality of the preceding phases of
assessing, diagnosing, and planning.
• Cognitive, interpersonal, and technical skills are used to implement nursing strategies.

• Before implementing an order, the nurse reassesses the client to be sure that the order is still
appropriate.

• The nurse must determine whether assistance is needed to perform a nursing intervention
knowledgeably, safely, and comfortably for the client.

• The implementing phase terminates with the documentation of the nursing activities and client
responses.

• After the care plan has been implemented, the nurse evaluates the client's health status and the
effectiveness of the care plan in achieving client goals.

• The desired outcomes formulated during the planning phase serve as criteria for evaluating client
progress and improved health status.

• The desired outcomes determine the data that must be collected to evaluate the client's health status.

• Reexamining the client care plan is a process of making decisions about problem status and
critiquing each phase of the nursing process.

• Professional standards of care hold that nurses are responsible and accountable for implementing
and evaluating the plan of care.

• Quality assurance evaluation includes consideration of the structures, processes, and outcomes of
nursing care.

• Quality improvement is a philosophy and process internal to the institution, and does not rely on
inspections by an external agency.

TEST YOUR KNOWLEDGE

1. When initiating the implementation phase of the nursing process, the nurse performs which of the
following steps first?

1. Carrying out nursing interventions

2. Determining the need for assistance
3. Reassessing the client
4. Documenting interventions

2. Under what circumstances is it considered acceptable practice for the nurse to document a nursing
activity before it is carried out?

1. When the activity is routine (e.g., raising the bed rails)

2. When the activity occurs at regular intervals (e.g., turning the client in bed)
3. When the activity is to be carried out immediately (e.g., a stat medication)
4. It is never acceptable

3. Which of the following is the primary purpose of the evaluating phase of the care-planning process
to determine whether:

1. Desired outcomes have been met.

2. Nursing activities were carried out.
3. Nursing activities were effective.
 4. Client's condition has changed.

4. The client has a high-priority nursing diagnosis of Risk for Impaired Skin Integrity related to the
need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and finds the
skin integrity is not impaired. When the care plan is reviewed, the nurse should perform which of the
following?

1. Delete the diagnosis since the problem has not occurred.

2. Keep the diagnosis since the risk factors are still present.
3. Modify the nursing diagnosis to Impaired Mobility.
4. Demote the nursing diagnosis to a lower priority.

5. If the nurse planned to evaluate the length of time clients must wait for a nurse to respond to the
client need reported over the intercom system on each shift, which of the following processes does
this reflect?

1. Structure evaluation
2. Process evaluation
3. Outcome evaluation
4. Audit

See Answers to Test Your Knowledge in Appendix A.

EXPLORE MEDIALINK WWW.PRENHALL.COM/BERMAN

COMPANION WEBSITE

• Additional NCLEX Review

• Case Study: Treating a Client for Pain

• Application Activity:

Analyzing Effective Quality Assurance

• Links to Resources

READINGS AND REFERENCES

SUGGESTED READINGS

Dochterman, J., Titler, M., Wang, J., Reed, D., Pettit, D., Mathew-Wilson, M., et al. (2005).
Describing use of nursing interventions for three groups of patients. Journal of Nursing Scholarship,
37, 57-66.

This article describes the nursing interventions implemented most frequently during an acute hospital
stay for clients with heart failure, hip fractures, or fall risk by use of the Nursing Interventions
Classification (NIC).

QI project cuts patients' chronic pain dramatically: Facility earns Codman Award from JCAHO.
(2003). Healthcare Benchmarks and Quality Improvement, 10(8), 94-96.

A quality improvement project at a Michigan long-term care facility resulted in a decrease in the
prevalence of chronic pain among its residents from 33% to 18%. The reduction is even more
significant given that the assessment of an individual's pain is a highly complex procedure,
particularly among the elderly, who may experience cognitive or communication difficulties. For this
work, the facility earned the Ernest A. Codman Award, which recognizes excellence in the use of
outcomes measurement by health care organizations to achieve improvements in the quality and
safety of health care from the Joint Commission on Accreditation of Healthcare Organizations.

RELATED RESEARCH

Cavendish, R., Konecny, L., Mitzeliotis, C., Russo, D., Luise, B., Lanza, M., et al. (2003). Spiritual
care activities of nurses using nursing interventions classification (NIC) labels. International Journal
of Nursing Terminologies and Classifications, 14, 13-24.

Wallace, T., O' Connell, S., & Frisch, S. R. (2005). Community psychiatric practice: What do nurses
do when they take to the streets? An analysis of psychiatric and mental health nursing interventions in
the community. Community Mental Health Journal, 41, 481-496.

REFERENCES

Agency for Healthcare Research and Quality. (2004). Mission statement: Center for Quality
Improvement and Patient Safety. Rockville, MD. Retrieved April 16, 2006, from
http://www.ahrq.gov/about/cquips/cquipsmiss.htm

Berlowitz, D. R., Young, G. J., Hickey, E. C., Saliba, D., Mittman, B. S., Czarnowski, E., et al.
(2003). Quality improvement implementation in the nursing home. Health Services Research, 38(1
Part 1), 65-83.

Dochterman, J., & Bulechek, G. B. (Eds.). (2004). Nursing interventions classification (NIC) (4th
ed.). St. Louis, MO: Mosby.

Joint Commission on Accreditation of Healthcare Organizations. (2005a). Mission statement.

Retrieved April 16, 2006, from
http://www.jointcommission.org/AboutUs/joint_commission_facts.htm

Joint Commission on Accreditation of Healthcare Organizations. (2005b). Sentinel event policy and
procedures. Retrieved April 16, 2006, from http://www.jointcommission.org/SentinelEvents/

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer
health system. Washington, DC: Committee on Quality of Health Care in America, Institute of
Medicine National Academy Press. Retrieved June 21, 2006, from
http://books.nap.edu/books/0309068371/html/index.html

Leape, L. L., & Berwick, D. M. (2005). Five years after To Err Is Human: What have we learned?
Journal of the American Medical Association, 293, 2384-2390.

Moorhead, S., Johnson, M., & Maas, M. (Eds.). (2004). Nursing outcomes classification (NOC) (3rd
ed). St. Louis, MO: Mosby.

NANDA International. (2005). NANDA nursing diagnoses: Definitions and classification 2005-2006.
Philadelphia: Author.

SELECTED BIBLIOGRAPHY

Alfaro-LeFevre. R. A. (2005). Applying the nursing process: Promoting collaborative care (6th ed.).
Philadelphia: Lippincott Williams & Wilkins.

American Nurses Association. (1999). Nursing quality indicators: Guide for implementation.
Washington, DC: Author.
American Nurses Association. (2000). Nursing quality indicators beyond acute care: Literature
review. Washington, DC: Author.

Burkhart, L., Konicek, D., Moorhead, S., & Androwich, I. (2005). Mapping parish nurse
documentation into the Nursing Interventions Classification: A research method. CIN: Computers
Informatics Nursing, 23, 220-229.

Johnson, M., Bulechek, G. B., Butcher, H., Dochterman, J., Moorhead, S., Maas, M., et al. (Eds.).
(2005). NANDA, NOC and NIC linkages: Nursing diagnoses, outcomes, and intervention (2nd ed.).
St. Louis, MO: Elsevier Health Sciences.

von Krogh, G., Dale, C., & Naden, D. (2005). A framework for integrating NANDA, NIC, and NOC
terminology in electronic patient records. Journal of Nursing Scholarship, 37, 275-281.

Wilkinson, J. M. (2005). Nursing diagnosis handbook: With NIC interventions and NOC outcomes
(8th ed.). Upper Saddle River, NJ: Prentice Hall.

Wilkinson, J. M. (2007). Ν υ ρ σ ι ν γ προ χ ε σ σ & critical thinking (4th ed.). Upper

Saddle River, NJ: Prentice Hall.