Fundies chapter 15

The American Nurses Association (ANA) in 1975 developed a model quality-assurance program consisting of seven steps:

(1) identify values; (2) identify structure, process, and outcome standards and criteria; (3) measure the degree of attainment of criteria and standards; (4) make interpretations about strengths and weaknesses based on such measurements; (5) identify possible courses of action; (6) choose a course of action; and (7) take action.

The five classic elements of evaluation are

(1) identifying evaluative criteria and standards (what you are looking for when you evaluate, e.g., expected patient outcomes), (2) collecting data to determine whether these criteria and standards are met, (3) interpreting and summarizing findings, (4) documenting your judgment, and (5) terminating, continuing, or modifying the plan.

Examples of positive factors that influence outcome achievement

-a patient's strong motivation to learn new health behaviors, -a nurse who comes to work well rested and with a new care idea learned from a nursing journal, - a health care institution or agency that offers incentives for quality nursing and has an optimal nurse-to-patient ratio.

risks that are widely known but not discussed:

1) dangerous shortcuts, (2) incompetence, and (3) disrespect

After identifying the factors contributing to the outcomes not being achieved, use the evaluative statement to suggest necessary revisions in the plan of care

1) delete or modify the nursing diagnosis, (2) make the outcome statement more realistic, (3) increase the complexity of the outcome statement, (4) adjust time criteria in outcome statement, or (5) change the nursing intervention.

Discover a problem

Advance directives are a powerful legal tool for people to indicate their end-of-life care preferences. Nurses on an oncology unit are becoming frustrated because many of the patients on their unit lack advance directives. By the time decisions need to be made about ventilators, coding, dialysis, and so forth, patients are often no longer able to communicate their preferences. The hospital has a policy about advance directives, but no one seems to be taking responsibility for initiating discussions with patients when they are first admitted-or in the outpatient setting.

Institute for Healthcare Improvement (IHI)

An independent, not-for-profit organization founded in the 1980s to redesign health care into a system without errors, waste, delay, and unsustainable costs. IHI is a leading innovator in health and health care improvement worldwide. To accelerate the path to the health and care we need, IHI created the Triple Aim, a framework for optimizing health system performance by simultaneously focusing on the health of a population, the experience of care for people within that population, and the per capita cost of providing that care.

10 rules to redesign and improve care:

Care based on continuous healing relationships Customization based on patient needs and values The patient as the source of control Shared knowledge and the free flow of information Evidence-based decision making Safety as a system priority The need for transparency Anticipation of patient's needs Continuous decrease in waste Cooperation among clinicians

Implement a change

Case managers begin assuming this responsibility, and one nurse volunteers to monitor progress at 3-month intervals by checking charts for advance directive content and by speaking with the staff nurses who voiced the initial frustration about decision making.

steps crucial in improving performance

Discover a problem. Plan a strategy using indicators. Implement a change. Assess the change; if the outcome is not met, plan a new strategy.

Safety:

Errors in care will not harm you. You will be safe in the care system.

The major premises of quality improvement are

Focus on organizational mission Continuous improvement Customer orientation Leadership commitment Empowerment Collaboration/crossing boundaries Focus on process Focus on data and statistical thinking

Assess the change

If the goal is not met, plan a new strategy. At the end of 6 months, everyone seems satisfied that the new plan is working, but a decision is made to schedule a 6-month follow-up evaluation to prevent backsliding.

An older adult client has lost significant muscle mass during her recovery from a systemic infection. As a result, she has made no progress toward meeting any of the outcomes for mobility and activities of daily living that are specified in her nursing plan of care. How should her nurses best respond to this situation? Continue the plan of care with the aim of helping the client achieve the outcomes. Modify the plan of care to better reflect the client's current functional ability. Terminate the plan of care since it does not accurately reflect the client's abilities. Replace the client's individualized plan of care with a clinical pathway.

Modify the plan of care to better reflect the client's current functional ability.

National Quality Forum (NQF)

NQF operates under a three-part mission to improve the quality of American health care by: Building consensus on national priorities and goals for performance improvement and working in partnership to achieve them Endorsing national consensus standards for measuring and publicly reporting on performance Promoting the attainment of national goals through education and outreach programs To ensure that all patients are protected from injury while receiving care, NQF has developed and endorsed a set of Serious Reportable Events (SREs). This set is a compilation of serious, largely preventable, and harmful clinical events, designed to help the health care field assess, measure, and report performance in providing safe care.

Authentic Leadership

Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement.

Skilled Communication

Nurses must be as proficient in communication skills as they are in clinical skills.

Meaningful Recognition

Nurses must be recognized and must recognize others for the value each brings to the work of the organization

True Collaboration.

Nurses must be relentless in pursuing and fostering true collaboration

Effective Decision Making.

Nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.

Centers for Medicare and Medicaid Services

Set of assessment questions to collect clinical, financial, and administrative data in home health care agencies. Goals of OASIS: to improve quality of care delivered to home health care patients and to provide data to HCFA.

PROBLEM Assessing Inaccurate database → inaccurate nursing diagnoses and a distorted plan of care Database does not reflect changes in patient condition. Database is superficial: Fails to communicate uniqueness of patient Lacks sufficient detail on major problems or developments

Solution: a. Identify the patient or nurse variables responsible for inaccuracy. b. Revise the recorded database. Review with the entire nursing staff the importance of making assessment a priority in every patient interaction as well as the recording of the new data obtained. a. Rethink the critical relation between an adequate database and quality care. b. Develop interviewing and physical assessment skills. c. Begin to identify the key data that need to be collected for specific nursing diagnosis and medical diagnosis and to assess patient response to therapeutic regimen (use of a nursing diagnosis handbook may be helpful).

Problem: Diagnosing General sense that nursing diagnoses are "common sense" and, therefore, do not need to be put in writing → failure to address patient's real problems General sense that nurses are too busy doing treatments, "passing meds," and doing paperwork to develop nursing diagnoses carefully → independent dimension of nursing remains underdeveloped Nursing diagnoses are too vague to be helpful → routinized patient care

Solution: Carefully develop and record priority nursing diagnoses for several patients and fairly evaluate whether this makes a difference in terms of the continuity of quality care. Examine practice and see whether independent nursing has a place; what percentage of every day is devoted to independent nursing functions? If this percentage is nonexistent or small, there understandably may be no felt need for nursing diagnoses—but a desperate need to revise practice priorities. a. Revise the problem statement to describe more accurately what is unhealthy about the patient (the behavior that needs to be changed). b. Revise the etiology to more accurately identify what is making the problem a problem—this should be a guide to nursing intervention. c. Check NANDA-I lists. Have a process for periodically reviewing the plan of care to delete nursing diagnoses when problems have been resolved and to add a new diagnosis as needed.

Problem:Poor teamwork A particularly difficult family is splitting the team by choosing (and rewarding) favorites among the staff and complaining to them about other workers. The staff is encouraging this behavior.

Solution: Someone needs to call the team together and name the divisive behavior and get everyone working together again. If there is staff who are problematic, appropriate channels need to be used to address these behaviors.

Problem: Mistakes Nurse administers medication to the wrong patient and asks you to keep an eye on the patient for adverse reactions. She does not plan to report the error.

Solution: Tell your colleague that you'll be happy to help watch the patient but that a full report needs to be made. If appropriate, help your colleague identify what contributed to her giving the medication to the wrong patient.

Problem: Disrespect When a student nurse asks a physician if she has time to answer a few questions for her patient, the physician screams at her and tells her that she has more important things to do than babysit her patient and tells the student to find someone else to answer the questions.

Solution: The student should calmly tell the physician that her response is inappropriate and that she is entitled to respectful conversation, then seek the counsel of an experienced nurse. The physician's behavior should be reported.

Problem: Micromanagement A student asks her clinical preceptor, "Will you walk me through this procedure before I do it, since it's my first time?" The preceptor then takes over, doing the procedure for the student, and starts watching her every move.

Solution: The student should inform her preceptor that she merely wanted to review the steps of the procedure to make sure that she would perform it correctly and that it is essential for the student to gain experience by trying new procedures. If the preceptor's behavior does not change, the student should seek the counsel of her instructor.

Problem:Incompetence Nurse fails to correctly administer dialysis. She wasn't finished with her orientation to the unit and attempted a procedure before she was prepared to do it solo.

Solution: in addition to reporting the error, help the nurse identify that overconfidence in one's abilities can have deadly results for patients. The nurse manager will need to address the incompetence.

problem:Nurse who is bored

Solution:After reflection, write down personal objectives related to work. Explore avenues within work setting for professional growth and development: initiate changes in nursing unit to improve patient care and to stimulate peer development; join institutional committees; participate actively in staff development programs; develop patient and family support groups. Look for new position that offers new challenges within or outside the institution. Join professional organizations and participate actively. Evaluate educational goals and explore possibilities—continuing education programs and degree work.

Problem:Broken rules Colleague fails to wash hands.

Solution:Confront your colleague and tell her that you noticed that she failed to wash her hands and that this could be harmful to herself, the patient, or other patients. If the behavior continues, report your concerns to the nurse manager and work up the chain of command.

problem:inadequate staffing

Solution:Develop and use a patient classification system that incorporates an identification of the kind and amount of nursing services required. Record staffing patterns and relate to needs for nursing care and patient outcomes. Clearly demonstrate and document that adequate staffing makes a difference. Present these data to nursing administration with the request for additional staff. If necessary, use professional bargaining unit.

Problem:Lack of support Nurse refuses to help a colleague move an obese patient although she has time to do so.

Solution:Explain to this nurse that teamwork is essential to good outcomes and that her behavior is simply unacceptable. "When we have patients with special needs and need all hands on deck, everyone who's free is obligated to help out!" Develop and enforce zero tolerance for selfish behavior.

problem:Nursing administration has sold out nursing; insensitivity to nursing demands within the institution

Solution:It may be impossible to practice quality, progressive nursing in this environment. If there seems to be no hope for change after appropriate channels have been explored, look for a new practice setting. Evaluate the new setting on the basis of what experience has taught you.

Problem:Planning The plan of care contains only the standard knowledge most nurses would know without a written plan. The long-term goal is vague, standard; fails to make clear the discharge goal for this patient. The nursing outcomes, even if met, do not necessarily guarantee a resolution of the patient problem The outcomes are incorrectly developed; progress toward goal achievement is difficult to evaluate. Nursing orders are superficial → patient receives routinized care. The initial plan of care fails to be updated → plan of care will not be consulted by nurses—if used, it will be to patient's detriment. The plan of care addresses the immediate needs of the patient but fails to anticipate discharge needs → patient returns home unable to manage self-care activities.

Solution:Make use of standardized (computerized) plans as a basis for care planning. Devote nursing energies to individualizing this plan. Practice writing specific long-term goals that clarify for all nurses the aim toward which all nursing care is directed (e.g., patient returns home ambulatory with walker, right hip incision healing, able to manage activities of daily living with minimal assistance from spouse). When writing goals, it often helps to develop outcomes related to etiologic factors. Because the stated etiology may be incomplete or inaccurate, at least one outcome must be written so that if it is achieved, the problem in the nursing diagnosis is resolved. After writing outcomes, check them against the following criteria: Subject is the patient or some part of the patient. The patient behavior is stated in observable, measurable terms. Criteria of acceptable performance are specified. Time criteria are included in notes. Review nursing orders to ensure that they indicate the specific nursing strategies or interventions most likely to result in successful outcome achievement for this patient (e.g., particular comfort measures that are successful adjuncts to analgesic administration for a particular patient). In specifying the "who, what, when, where, how, and how much" of nursing interventions, be sure to list the type of equipment and supplies needed in various treatments. As new patient data are obtained, update nursing orders. Delete inappropriate or unnecessary orders. If personal accountability for updating plan fails, develop a process on the nursing unit to ensure care plan review and revision. Work hard at developing the ability to project yourself into the patient's home after discharge. Learn to anticipate problems and concerns and prepare the patient and family for these. Use all discharge resources in the institution. Learn from patients what their needs were after previous discharge.

Problem: Implementing Nurses are not aware of patient priorities and the plan of care; lack of continuity; inefficient use of nursing resources → patient fails to achieve goals/outcomes. Nursing care becomes routine and mechanized → patient never has the sense of being personally known by nurses. Documentation is inadequate → because there is no complete written record of nursing care, legally this care was never provided.

Solution:a. Use shift report to update staff on status of priority nursing diagnosis and concomitant nursing care. b. Review plan of care and nursing notes before beginning care. Explore creative strategies to make quality nursing care on this particular unit a challenge rather than a burden; use ongoing education, problem-solving strategies by the nursing team, gaming, and other incentives. a. Develop the philosophy that quality nursing care deserves to be documented. Review legal reasons for careful documentation. b. Become familiar with the flow sheets and note format used within the work setting so that charting can be done quickly and comprehensively.

Appropriate staffing

Staffing must ensure the effective match between patient needs and nurse competencies.

Based on the patient's responses to the plan of care, the nurse decides to:

Terminate the plan of care when each expected outcome is achieved Modify the plan of care if there are difficulties achieving the outcomes Continue the plan of care if more time is needed to achieve the outcomes

Control:

The care system will take control only if and when you freely give permission.

American Nurses Association (ANA) Standards of Practice: Standard 6, Evaluation

The registered nurse evaluates progress toward attainment of outcomes. Competencies The registered nurse: Conducts a systematic, ongoing, criterion-based evaluation of the outcomes in relation to the structures and processes prescribed by the plan of care and the indicated timeline. Collaborates with the healthcare consumer and others involved in the care or situation in the evaluative process. Evaluates, in partnership with the healthcare consumer, the effectiveness of the planned strategies in relation to the healthcare consumer's responses and the attainment of the expected outcomes. Uses ongoing assessment data to revise the diagnoses, outcomes, the plan, and the implementation as needed. Disseminates the results to the healthcare consumer, family and others involved, in accordance with the state and federal laws and regulations. Participates in assessing and assuring the responsible and appropriate use of interventions in order to minimize unwarranted or unwanted treatment and healthcare consumer suffering. Documents the results of the evaluation.

Cooperation:

Those who provide care will cooperate and coordinate their work fully with each other and with you. The walls between professions and institutions will crumble, so that your experiences will become seamless. You will never feel lost.

Information:

You can know what you wish to know, when you wish to know it. Your medical record is yours to keep, to read, and to understand. The rule is: "Nothing about you without you."

Individualization:

You will be known and respected as an individual. Your choices and preferences will be sought and honored. The usual system of care will meet most of your needs. When your needs are special, the care will adapt to meet you on your own terms.

Science:

You will have care based on the best available scientific knowledge. The system promises you excellence as its standard. Your care will not vary illogically from doctor to doctor or from place to place. The system will promise you all the care that can help you, and will help you avoid care that cannot help you.

Beyond patient visits:

You will have the care you need when you need it . . . whenever you need it. You will find help in many forms, not just in face-to-face visits. You will find help on the Internet, on the telephone, from many sources, by many routes, in the form you want it.

Transparency:

Your care will be confidential, but the care system will not keep secrets from you. You can know whatever you wish to know about the care that affects you and your loved ones.

Value:

Your care will not waste your time or money. You will benefit from constant innovations, which will increase the value of care to you.

The cultivation of evaluation as a critical component of the nursing process helps ensure

\nursing's continued success in achieving desired changes in patient health status.

The two-part evaluative statement includes

a decision about how well the outcome was met, along with patient data or behaviors that support this decision.

evaluative statement:

a judgment summarizing the nurse's findings after data have been collected and interpreted to determine patient outcome achievement

The purpose of evaluation is to

allow the patient's achievement of expected outcomes to direct future nurse-patient interactions.

Quality-assurance programs enable nursing to

be accountable to society for the quality of nursing care. They help ensure survival of the profession, encourage nursing's fidelity to its moral and ethical responsibilities, and assist nursing to comply with other external pressures.

A nurse uses the following classic elements of evaluation when caring for patients. Which item below places them in their correct sequence? (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting one's judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what one is looking for when evaluating, e.g., expected patient outcomes) 1, 2, 3, 4, 5 3, 2, 1, 4, 5 5, 2, 1, 3, 4 2, 3, 1, 4, 5

c. The five classic elements of evaluation in order are (1) identifying evaluative criteria and standards (what you are looking for when you evaluate, e.g., expected patient outcomes), (2) collecting data to determine whether these criteria and standards are met, (3) interpreting and summarizing findings, (4) documenting your judgment, and (5) terminating, continuing, or modifying the plan.

performance improvement:

commitment to healthier patients, quality care, reduced costs, and making a difference; accomplished by discovering a problem, planning a strategy, implementing a change, and assessing the change to see if the goal is met

A student health nurse is counseling a female college student who wants to lose 20 pounds. The nurse develops a plan to increase the student's activity level and decrease the consumption of the wrong types of foods and excess calories. The nurse plans to evaluate the student's weight loss monthly. When the student arrives for her first "weigh-in," the nurse discovers that instead of the projected weight loss of 5 pounds, the student has lost only 1 pound. Which is the best nursing response? Congratulate the student and continue the plan of care. Terminate the plan of care since it is not working. Try giving the student more time to reach the targeted outcome. Modify the plan of care after discussing possible reasons for the student's partial success.

d. Since the student has only partially met her outcome, the nurse should first explore the factors making it difficult for her to reach her outcome and then modify the plan of care. It would not be appropriate to continue the plan as it is since it is not working, and it is premature to terminate the plan of care since the student has not met her targeted outcome. The student may need more than time to reach her outcome, which makes (c) the wrong response.

While the nurse collects data in the nursing assessment to identify patient health problems, the data collected in the evaluation step are used to

determine whether the identified health problems have been or are being resolved through outcome achievement.

The ANA Safety & Quality Initiative has focused on

educating RNs about quality measurement; informing the public and purchasing/regulating constituencies about safe, quality health care; and investigating research methods and data sources to empirically evaluate the safety and quality of patient care.

Celebrating outcome attainment with the patient usually helps

encourage the patient and leads to further outcome achievement.

peer review:

evaluation at the closest point to the patient and an ongoing tool to use for professional growth

process evaluation

evaluation focusing on the nature and sequence of activities carried out by nurses implementing the nursing process

retrospective evaluation

evaluation of nursing care and patient outcomes after the patient has been discharged using postdischarge questionnaires, patient interviews, or chart review to collect data

outcome evaluation:

evaluation that focuses on measurable changes in the health status of the patient or the end results of nursing care

The decreased availability of resources to treat patients in hospitals and the unavailability of sufficient alternative treatment settings pose a strong challenge to the nursing profession to

find ways to avoid compromising quality of care.

Quality by inspection focuses on

finding deficient workers and removing them.

Quality as opportunity

focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned.

structure evaluation:

focuses on the environment in which care is provided; also known as an audit

When interpreting and summarizing findings, consider factors that

influence outcome achievement.

The Joint Commission

integrates use of outcomes and performance measures into accreditation process; requires accredited general medical/surgical hospitals to collect and transmit data on a minimum of six core measures.

ANA (American Nurses Association

is the only national nursing quality measurement program that provides hospitals with unit-level performance reports with comparisons to national averages, percentile rankings, and other important data. All indicator data are collected and reported at the nursing-unit level. NDNQI's nursing-sensitive indicators reflect the structure, process, and outcomes of nursing care. NDNQI's mission is to aid the nursing provider in patient safety and quality improvement efforts by providing research-based national comparative data on nursing care and the relationship to patient outcomes. The database collects and evaluates unit-specific nurse-sensitive data from hospitals in the United States.

the object of reflective practice is to

look at an experience, understand it, and learn from it.

After the data have been collected and interpreted to determine patient outcome achievement, the nurse

makes and documents a judgment summarizing the findings.

evaluating:

measurement of the extent to which the patient has achieved the goals specified in the plan of care; factors that positively or negatively influence goal achievement are identified, and the plan of care is terminated or revised

When evaluating patient outcome achievement, the nurse identifies factors that contribute to the patient's ability to achieve expected outcomes and, when necessary,

modifies the plan of care

evidence-based practice:

nursing care provided that is supported by sound scientific rationale

quality-assurance program:

ongoing evaluation program designed and implemented to secure the excellence of health care; may involve an assessment of structure, process, and outcome standards

Nurses write outcomes during the ________________ phase of the nursing process.

planning

The overall goal of QSEN Institute initiatives is to

prepare nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of their health care systems.

The goals of the National Database of Nursing Quality Indicators (NDNQI) are to

promote and facilitate the standardization of information submitted by hospitals across the United States on nursing quality and patient outcomes

Either directly or indirectly, the aim of all nursing evaluation is

quality nursing care that aids patient outcome achievement.

When evaluation reveals that the patient has made little or no progress toward outcome achievement, the nurse needs to

re-evaluate each preceding step of the nursing process to try to identify the contributing factors causing problems with the plan of care.

From the patient's point of view, one of the most important outcomes of quality improvement is the

recognition that patient satisfaction in health care is as important as customer satisfaction in retail business.

standards:

rules or guidelines that allow nurses to carry out professional roles, serving as protection for the nurse, the patient, and the institution where health care is given

problem:Evaluating It is not done → mastery of nursing process is stunted; severely limits accomplishment of nursing aims.

solution:Develop the belief that quality nursing care does not happen automatically and that only ongoing evaluation will identify needed areas of revision. Devise an evaluative strategy and carry it out. Study its effect on quality of care after 6 months' implementation.

problem:Nurse with overwhelming outside concerns: Preparation for marriage, childbirth, divorce Illness (self or family members) Role conflict (familial roles, school, work, and the like) New apartment, house

solution:During periods of peak demand, may need to accept less than optimal performance at work. If this becomes the norm rather than the exception, carefully evaluate priorities. May need to cut work hours rather than "cheat" patients.

problem: Patient who is physically and cognitively capable of self-care gives up—refuses to cooperate with therapeutic regimen or thwarts the regimen

solution:Identify one nurse who is able to develop a trusting relationship with the patient and determine the reason underlying the observed behavior: No longer finds meaning and purpose in life Overwhelming sense of powerlessness Previous history of being "hurt," "exploited," "cheated" by the health care system Inability to accept illness and related lifestyle changes Counsel appropriately. Use a team conference to develop a consistent plan of nursing care.

problem:Nurse who sincerely desires to give 150% all the time and who becomes quickly frustrated when observing substandard care; may feel alienated from other staff; excellent candidate for burnout

solution:Learn to give quality care during designated work period; leave on time; avoid the temptation to do the work of others; leave work concerns at work. After establishing a reputation for delivering quality nursing care, seek creative solutions for nursing problems (strategies to increase nursing resources, motivation, morale) and try them—hopefully with a support network. View concerns as challenges rather than overwhelming obstacles. Develop a realistic sense of how much nursing care and of what quality can be delivered with existing resources. If resources do not permit quality care, explore change strategies within the institution. If administration is not supportive, explore other practice settings.

problem:Patient who quietly accepts whatever is done or not done for him or her; seldom communicates needs or dissatisfaction

solution:Note on the plan of care the need to assess this patient thoroughly because the patient will probably not advocate for self. Educate the patient to become a more assertive health care consumer.

criteria:

specified behavior; for example, the measurable criteria in a patient goal specifies how the patient must perform the desired behavior

The ANA model directs attention to three essential components of quality care:

structure, process, and outcome.

Before the nurse can make a judgment about the patient's achievement of outcomes, it is necessary to

study and interpret the data collected

NCQA (National Committee for Quality Assurance)

targets these areas: effectiveness of care, access and availability of care, patient satisfaction, health plan stability, use of services, costs, and health plan descriptive information. Quality Compass reports (available on CD-ROM/electronic data file) include performance data on managed care plans.

quality improvement (QI):

the commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectations and outcomes—also known as continuous quality improvement (CQI) or total quality management (TQM)

concurrent evaluation:

the evaluation of nursing care and patient outcomes while the patient is receiving care, conducted by using direct observation of nursing care, patient interviews, and chart review to determine whether the specified evaluative criteria are met

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

the first national, standardized, publicly reported survey of patients' perspectives of hospital care.

Plan a strategy using indicators

the nurses call an interdisciplinary meeting with the oncologists, social workers, and spiritual caregivers, who decide that the nurse case manager will be responsible for working with patients on admission to see if they want help in preparing an advance directive. Each case manager will be responsible for documenting within 48 hours of admission the patient's decision regarding an advance directive. Staff nurses will be able to direct patient and family requests to do advance planning to the case manager and appropriate team members. The ethics committee was asked to do an in-service on advance directives for the team.

In the nursing process, evaluative criteria are

the patient outcomes developed during the planning step.

When failure to meet designated outcomes is detected early,

the plan of care can be modified to remedy the failure.

The most common mistake nurses make when evaluating in acute care settings is

waiting until the day the patient is to be discharged before evaluating outcome achievement. At that point, it is too late to revise the plan of care.

The nurse collects evaluative data to determine

whether or not the patient has met the desired outcomes.

Nursing care and patient outcomes may be evaluated

while the patient is receiving care (i.e., a concurrent evaluation) or after the patient has been discharged (i.e., a retrospective evaluation)

Anticipation:

your care will anticipate your needs and will help you find the help you need. You will experience proactive help, not just reactions, to help you restore and maintain your health.