What activity is carried out during the implementation step of the nursing process?

Critical Thinking in Implementation

The delivery of nursing interventions is a complex decision-making process that involves critical thinking. The context in which you deliver care to each patient and the many interventions required result in decision-making approaches for each clinical situation. Critical thinking is necessary to consider the complexity of interventions, including the number of alternative approaches and the amount of time available to act.

Tonya indentified four relevant nursing diagnoses for Mr. Jacobs: acute pain related to incisional trauma, deficient knowledge regarding postoperative recovery related to inexperience with surgery, impaired physical mobility related to incisional pain, and anxiety related to uncertainty over the course of recovery. The diagnoses are interrelated, and sometimes a planned intervention (e.g., administering pain medication) treats or modifies more than one of the patient’s health problems (pain and impaired physical mobility). Tonya applies critical thinking and uses her time with Mr. Jacobs wisely by anticipating his priorities, applying the knowledge she has about his problems and the interventions planned, and implementing care strategies skillfully.

Before implementing a planned intervention, use critical thinking to confirm whether the intervention is correct and still appropriate for the patient’s clinical situation. Even though you have planned a set of interventions for a patient, you have to exercise good judgment and decision making before actually delivering each intervention. Always think before you act. Patients’ conditions often change minute to minute. You need to consider the scheduling of activities on a nursing unit, which often dictates when and how to complete an intervention. Thus many factors influence your decision on how and when to intervene. You are responsible for having the necessary knowledge and clinical competency to perform interventions for your patients safely and effectively. Some tips for making decisions during implementation follow.

• Review the set of all possible nursing interventions for the patient’s problem (e.g., for Mr. Jacobs’ pain Tonya considers analgesic administration, positioning and splinting, progressive relaxation, and other nonpharmacological approaches).

• Review all possible consequences associated with each possible nursing action (e.g., Tonya considers that the analgesic will either relieve pain; have little or insufficient effect; or cause an adverse reaction, including sedating the patient and increasing the risk of falling).

• Determine the probability of all possible consequences (e.g., if Mr. Jacobs’ pain has decreased with analgesia and positioning in the morning and there have been no side effects, it is unlikely that adverse reactions will occur, and the intervention will be successful; however, if the patient continues to remain highly anxious, his pain may not be relieved, and Tonya needs to consider an alternative).

• Make a judgment of the value of the consequence to the patient (e.g., if the administration of an analgesic is effective, Mr. Jacobs will likely become less anxious and more responsive to postoperative instruction and counseling about his anxiety).

The selection and performance of nursing interventions for a patient are part of clinical decision making. The critical thinking model described in Chapter 15 provides a framework for how to make decisions when implementing nursing care (Fig. 19-1). You learn how to implement nursing care using appropriate knowledge. For example, as you proceed with an intervention, you consider what you know about the purpose of the intervention, the steps in performing the intervention correctly, the medical condition of the patient, and his or her expected response. It is important to prepare well before first caring for any patient. With experience you become more proficient in anticipating what to expect in a given clinical situation and how to modify your approach. As you gain clinical experience, you are able to consider which interventions worked previously, which have not, and why. It also helps to know the clinical standards of practice for your agency. For example, one hospital has a different set of standards for patient education than another. The standards of practice offer guidelines for selection of interventions and their frequency and whether you are able to delegate the procedures.

As you perform a nursing intervention, apply intellectual standards, which are the guidelines for rational thought and responsible action. For example, before Tonya begins to teach Mr. Jacobs, she considers how to make her instructions relevant, clear, logical, and complete to promote patient learning. She knows that it will be helpful to involve Mrs. Jacobs so any instruction is relevant to their home situation. Using simple, clear explanations and repeated instructions promote learning for Mr. Jacobs, who is inexperienced with postoperative recovery. Making an instructional DVD on wound care available to the family is a valuable resource for repeated viewing in the home.

As a critical thinker, apply critical thinking attitudes when you intervene. For example, show confidence in performing an intervention. When you are unsure of how to perform a procedure, be responsible in seeking assistance from others. Confidence in performing interventions builds trust with patients. Creativity and self-discipline are attitudes that guide you in reviewing, modifying, and implementing interventions. As a beginning nursing student, seek out supervision from instructors or experienced nurses to guide you in the decision-making process for implementation.