Implementation & Evaluation

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Implementation Phase

Doing, delegating and documenting

Delegation and Supervision

Transferring responsibility while retaining accountability

Includes supervision

YOU CANNOT DELEGATE:

Any intervention that requires independent, specialized nursing knowledge, skill or judgement

Should not be doing anything independently

Requires your supervision

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Five Rights of Delegation

Right task

Examples of tasks you might assign to a NAP are bathing a stable patient, ambulating steady patients, obtaining routine vital signs, changing linens, assisting patients with meals, clerical duties, and transporting non-acute patients and specimens.

Right circumstance

Before deciding to delegate, assess your patient to be certain that her needs match the abilities of the NAP or LPN.

Right person (patient and assistant)

You must also be sure that the LPN or NAP is competent to perform the task and that his workload allows time to do the task properly. Consider the person’s experience, training, and cultural competence.

Right direction/communication = Make sure the other person understands and everything is coherent

(1) Explain exactly what the task is

(2) Include specific times and methods for reporting

(3) Explain the purpose or objective of the task

(4) Describe the expected results or

potential complications

(5) Be specific in your instructions

Right supervision

Supervision is the process of directing, guiding, and influencing the performance of the delegated task.

When you delegate tasks to a NAP or LVN/LPN, you or another RN must be available to answer questions and provide help, if necessary. You are responsible for providing supervision and evaluating the outcomes.

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Documentation

Important because if anything happens you need to report it

The final step of implementation

Records the nursing activities and the client's response = Includes what you did and the client's response

Should be able to look at the document and know everything about the patient

Documentation is a mode of communication among the members of the health team, and it provides the information you need to evaluate the patient’s health status and the nursing care plan.

Evaluation - Did it work or did it not work

The final step of the nursing process

Evaluation:

Client's progress toward goals

Effectiveness of nursing care plan

Quality of care in the healthcare setting

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Standards and Criteria in Evaluation

ANA standards include a set of criteria to help describe the standard

Represent expected or accepted levels of performance

Provide a model for what ought to be done

Used to describe quality nursing care

Criteria: Measurable characteristics, properties, attributes or qualities that describe the specific skills, knowledge, behaviors and attitudes that are desired or expected

Reliable = consistent results that yield the same results every time

Valid = if it is really measuring what it was intended to measure

What is being Evaluated?

Structure

Focuses on the setting in which care is provided

Explores the effect of organizational characteristics on the quality of care

Requires standards and data about policies, procedures, resources, facilities, equipment, and number and qualifications of personnel

Process

Focuses on the manner in which care is given

The activities performed by nurses

Explores whether the care was relevant to patient needs, appropriate, complete and timely

Outcomes

Focuses on observable/measurable changes in the client's health stays that result from the care given

Frequency and Time of Evaluations

Ongoing

Done while implementing

Immediately after an intervention

At each Patient contact

Intermittent

Performed at specified times

Terminal

Describes the client's health status and progress toward goals at the time of discharge

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Evaluating Client Progress

Review outcomes: review the goals/outcomes on the patient’s care plan.

The goals and indicators you identified in the planning outcomes phase suggest the kind of assessments you need to make and provide criteria by which to judge the data.

Collect reassessment data:

reassessments are always focused assessments and the care plan goals determine their focus.

Judge goal achievement:

Compare the reassessment data with the patient’s goals and ask are the responses (actual outcomes) the same as the expected or desired outcomes. If yes, the goal has been met. When some but not all of the desired behaviors are observed , or the desired response occurs only some of the time it is considered partial achievement. When the desired response did not occur the goal is labeled not achieved.

Record the evaluative statement

: It should include the conclusion about whether the goal was achieved and the reassessment data to support the judgment.

Evaluate collaborative problems:

compare the reassessment data to established norms and determine whether data are within an acceptable range.

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Evaluating and Revising the Care Plan

Relate outcome to interventions

Draw conclusions about problem status

Revise the Care Plan

Checklist for Evaluating the Care Plan

Review Assessment

The data may have change (change in client condition or new data may have been identified)

Review diagnosis

May need to revise or add new nursing diagnoses

Other diagnosis may not be clear or validated

Review planning outcomes

Will need to revise outcomes if data was revised

Outcomes could be unrealistic or broad

Change in client priorities

Review planning interventions

If you determine interventions were not effective

If you revised the diagnosis or outcomes

Review implementations

Goals were not met because of a failure to implement the nursing orders or the manner they were implemented

Get input from the client, significant others, caregivers and the client records

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Thinking about your Thinking

Inquiring

Is my evaluation statement clearly stated ? Were my information sources reliable? Did I jump to conclusions about goal achievement? Do I need any other data to validate my conclusion?

Noticing content

What was going on either before or during evaluation that might have influenced my ability to gather data or draw conclusions?What emotional responses influenced my conclusions about goal achievement?

Analyzing assumptions

What biases do I have that may have affected my ability to reassess or evaluate goal achievement?

Reflecting skeptically

Did I make evaluating a priority? Did I schedule time for it, the same as I do for interventions? Could I have done it better? What would I do differently next time?

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Common Errors of Evaluation

Failing to evaluate systematically

Failing to record results - Failure to document

Failing to use reassessment data to reexamine and modify the care plan

Evaluating Quality of Care in a Healthcare Setting

Quality assurance (QA) goal

To evaluate and improve care provided in the healthcare setting

QA involves evaluation of

Structures, outcomes, and processes.

QU makes sure that the client is getting the best care possible and makes sure caregivers are following standards of practice