Which phase of the nursing process is most foundational for delivery of care

Simply put, the nursing process is a guide to everything that nurses do. Have you ever thought about it? 

The American Nurses Association defines the nursing process as the “essential core of practice for the registered nurse to deliver holistic, patient-focused care“ and consists of five different components: assessment, diagnosis, outcomes/planning, implementation, and evaluation.  

Although you probably remember seeing these five components during nursing school, the nursing process cannot be fully learned through memorization, but rather through practice and developmental experience. 

Let’s break it down.

Assessment

In order to be able to offer a potential diagnosis, the patient and all external factors must be assessed.

As we mentioned in our blog, listening to a patient and understanding their concerns and hopes for treatment must be the first step in the nursing process.

By doing so, we increase our chances of reaching a diagnosis, developing a treatment plan that meets the patient‘s needs, and increases the overall quality of care given.  

Diagnosis

This phase in the nursing process is one of the most important.

We must consider all external factors of the patient (environmental, socioeconomic, and physiological etc.) when developing a diagnosis, which can be challenging at times.

However, along with your experience and clinical knowledge, there are additional resources available in order to help you!

For example, the North American Nursing Diagnosis Association (NANDA) provides a continuously revised guide of all nursing diagnoses.

Outcomes/Planning

Once you have reached a diagnosis, care panning is the next essential step in the nursing process.

When considering a holistic care approach, it is necessary to factor in the already-determined external factors of the patient and their concerns when setting attainable health goals.

By utilizing resources such as the Nursing Outcomes Classification or Maslow’s Hierarchy of Needs, it can provide insight as to how you should develop a care plan specifically for your patient based on their goals and the level of urgency.

Implementation

This phase involves both direct and indirect patient care, whether that is administering medication, educating the patient, or continuously checking their vitals.

This point in the nursing process should actively follow the care plan that was developed in the previous step and should actively work toward accomplishing the patient‘s health goals.  

Evaluation

Lastly, the evaluation phase should be a direct assessment of if the implemented care plan was effective and if the intended outcomes were reached.

Implementation is the fifth step of the nursing process (and the fifth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse implements the identified plan.” The RN may delegate planned interventions after considering the circumstance, person, task, communication, supervision, and evaluation, as well as the state Nurse Practice Act, federal regulation, and agency policy.

Implementation of interventions requires the RN to use critical thinking and clinical judgment. After the initial plan of care is developed, continual reassessment of the patient is necessary to detect any changes in the patient’s condition requiring modification of the plan. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing safe care.

During the implementation phase of the nursing process, the nurse prioritizes planned interventions, assesses patient safety while implementing interventions, delegates interventions as appropriate, and documents interventions performed.

Prioritizing Implementation of Interventions

Prioritizing implementation of interventions follows a similar method as to prioritizing nursing diagnoses. Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation are used to establish top priority interventions. When possible, least invasive actions are usually preferred due to the risk of injury from invasive options. Read more about methods for prioritization under the “Diagnosis” subsection of this chapter.

The potential impact on future events, especially if a task is not completed at a certain time, is also included when prioritizing nursing interventions. For example, if a patient is scheduled to undergo a surgical procedure later in the day, the nurse prioritizes initiating a NPO (nothing by mouth) prescription prior to completing pre-op patient education about the procedure. The rationale for this decision is that if the patient ate food or drank water, the surgery time would be delayed. Knowing and understanding the patient’s purpose for care, current situation, and expected outcomes are necessary to accurately prioritize interventions.

Patient Safety

It is essential to consider patient safety when implementing interventions. At times, patients may experience a change in condition that makes a planned nursing intervention or provider prescription no longer safe to implement. For example, an established nursing care plan for a patient states, “The nurse will ambulate the patient 100 feet three times daily.” However, during assessment this morning, the patient reports feeling dizzy today, and their blood pressure is 90/60. Using critical thinking and clinical judgment, the nurse decides to not implement the planned intervention of ambulating the patient. This decision and supporting assessment findings should be documented in the patient’s chart and also communicated during the shift handoff report, along with appropriate notification of the provider of the patient’s change in condition.

Implementing interventions goes far beyond implementing provider prescriptions and completing tasks identified on the nursing care plan and must focus on patient safety. As front-line providers, nurses are in the position to stop errors before they reach the patient.

In 2000 the Institute of Medicine (IOM) issued a groundbreaking report titled To Err Is Human: Building a Safer Health System. The report stated that as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors. To Err Is Human broke the silence that previously surrounded the consequences of medical errors and set a national agenda for reducing medical errors and improving patient safety through the design of a safer health system. In 2007 the IOM published a follow-up report titled Preventing Medication Errors and reported that more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. This report emphasized actions that health care systems could take to improve medication safety.

Read additional information about specific actions that nurses can take to prevent medication errors; go to the “Preventing Medication Errors” section of the “Legal/Ethical” chapter of the Open RN Nursing Pharmacology textbook.

In an article released by the Robert Wood Johnson Foundation, errors involving nurses that endanger patient safety cover broad territory. This territory spans “wrong site, wrong patient, wrong procedure” errors, medication mistakes, failures to follow procedures that prevent central line bloodstream and other infections, errors that allow unsupervised patients to fall, and more. Some errors can be traced to shifts that are too long that leave nurses fatigued, some result from flawed systems that do not allow for adequate safety checks, and others are caused by interruptions to nurses while they are trying to administer medications or provide other care.

The Quality and Safety Education for Nurses (QSEN) project began in 2005 to assist in preparing future nurses to continuously improve the quality and safety of the health care systems in which they work. The vision of the QSEN project is to “inspire health care professionals to put quality and safety as core values to guide their work.” Nurses and nursing students are expected to participate in quality improvement (QI) initiatives by identifying gaps where change is needed and assisting in implementing initiatives to resolve these gaps. Quality improvement is defined as, “The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).”

Delegation of Interventions

While implementing interventions during the nursing process, includes components such as organizing the components of the plan, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and holistic care by the interprofessional team.

What is the most important phase of the nursing process?

Which step of the nursing process considers the effectiveness of nursing care?

Is the first major phase of the nursing process?

What are the 5 phases components of nursing process?