The plan of care developed in the previous three standards is actualized through the implementation standard. In this phase of the nursing process, nurses continue to use clinical judgment and critical thinking to prepare
themselves, the healthcare consumer, and the environment for action. Planned interventions are carried out to help the client achieve identified outcomes.

Implementation requires nurses to combine thinking and doing, as well as feeling, sensing, and valuing. Nurses select and implement interventions that promote client goal achievement. The interventions may be delegated, independent, or interdependent actions. Independent nursing actions are autonomous and occur when the nurse conducts assessments and interventions for the purpose of promoting health and healing. The focus is on the client’s response to actual or potential health problems.

Nurses also implement delegated interventions, such as those that are required standard or protocol or are ordered by other providers such as physicians or nurse practitioners. Nurses carry out those delegated functions when their knowledge, experience, and judgment confirm that the order is appropriate and safe for the client. (Koularatis, 2004). In interdependent practice, nurses collaborate with other disciplines to jointly identify and implement specialized interventions.

Implementation involves direct client care as well as indirect care. Direct care includes the use of cognitive skills (critical thinking, reflection, clinical judgment, creativity, etc.); interpersonal skills (caring, communication, comforting, advocacy, counseling, etc.); and technical or psychomotor skills (lifting, giving injections, repositioning, etc.). Indirect care interventions are those carried out away from the client, such as managing the environment or consulting with a specialist.

Implementation may involve delegation of actions to other nurses or healthcare workers. The nurse is accountable for the quality of care provided directly, indirectly, or through delegation. Professional and legal standards for delegation must be followed. Nurse administrators, educators, and others in graduate-level specialty prepared roles use implementation as they carry out the plans and goals developed in prior steps of the process.

It is during implementation of the plan that nurses demonstrate the art and science of nursing practice. The science of nursing is based on principles of the biological, physical, behavioral, and social sciences. Nurses integrate evidence with the practice-generated data, the clinical expertise, and the values and preferences of their clients to achieve goals. New knowledge is constantly used to inform practice and promote effective interventions (ANA, 2010a).

The art of nursing is based on caring and respect for human dignity. Caring is central to nursing practice and is demonstrated in the personal relationship that the nurse enters into with the client (ANA 2010b, p. 23). In a holistic framework for implementation, the nurse establishes an active partnership with the client; performs care with purposeful, focused intention; and recognizes the importance of the client’s humanness. The presence of the caring nurse is, in and of itself, a therapeutic intervention (Potter & Frisch, 2009).

Nurses are responsible and accountable for maintaining and demonstrating their competence when implementing the plan of care. Knowledge, skills, abilities, and judgment, all of which are based on established science and current practice expectations, must be integrated in the nurse’s actions (AACN, 2008). Nurses must assess their own competence and seek consultation or collaboration from appropriate sources if the client’s needs are beyond their capabilities (ANA, 2001).

Implementation of interventions will generate patient responses and, therefore, inherently involve ongoing assessment and evaluation. Assessment information discovered during implementation informs evaluation and provides feedback on all other steps of the nursing process (ANA, 2010b). Nurses critically reflect during and after the implementation of interventions; the plan is constantly reassessed and modified to promote goal achievement.

A wealth of work has been done to identify and classify nursing interventions. The Center for Nursing Classification and Clinical Effectiveness at the University of Iowa’s College of Nursing was established in 1995 to facilitate the ongoing research of the Nursing Interventions Classification (NIC). NIC is a comprehensive, research-based, standardized classification of interventions that nurses perform. The classification includes the interventions that nurses do on behalf of patients, both independent and collaborative interventions, both direct and indirect care.

The following examples demonstrate the broad range of interventions nurses implement, including strategies to promote health and a safe environment (Standard 5B), physiological (e.g., Acid-Base Management), psychosocial (e.g., Anxiety Reduction), illness treatment (e.g., Hyperglycemia Management), illness prevention (e.g., Fall Prevention), and health promotion (e.g., Exercise Promotion). Those interventions are all included in NIC. Most of the interventions are for
use with individuals, but many are for use with families (e.g., Family Integrity Promotion) and some are for use with entire communities (e.g., Environmental Management—Community).

Indirect care interventions (e.g., Supply Management) are also included. The classification is continually updated with an ongoing process for feedback and review (University of Iowa, n.d.). The nurse uses knowledge and critical thinking to select and prioritize individualized interventions. Effective planning and implementation of appropriate interventions enhance client outcomes.

In practice, nurses demonstrate the implementation competencies when providing interventions in partnership with the healthcare consumer. Nurses demonstrate a caring approach in all interventions. Nurses introduce themselves and inform clients of the nurse’s role in their care. They discuss the planned interventions and ensure client understanding. Clients are familiarized with their environment, and the purpose of any equipment used in their care is explained. Caring is demonstrated when nurses ensure client comfort (physical, emotional, and spiritual), privacy, and dignity while implementing interventions. Interventions are not initiated without the healthcare consumer or surrogate decision-maker’s knowledge and consent. Great consideration is given to the healthcare consumer’s readiness and ability to participate.

Interventions are implemented in a manner that respects client diversity. A nurse uses nonverbal communication and an interpreter when working with a client whose language he or she does not speak. He or she uses touch respectfully and cautiously for a client who is anxious or fearful. Religious and cultural beliefs regarding health care are honored in the nurse’s approach to implementation of interventions.

Nurses use critical thinking skills as they determine how to implement interventions. All clients are individuals with diverse needs. A client’s age, educational level, functional ability, and cultural and spiritual beliefs are but a few examples of individual characteristics that a nurse will consider when providing care. For example, an intervention such as skin care will be approached differently for an infant than for an older adult. How a client is taught to self-administer medications will vary according to a client’s communication, language, and learning style preferences. Nurses use evidence-based interventions that are specific to a client’s diagnosis; they also use the best evidence available to guide care delivery.

Nurses become expert at determining when interventions need to be modified on the basis of diverse client needs. Nurses apply a holistic framework to their thinking and recognize that effective implementation of interventions requires attention to the human dimensions of their clients. Wound care may go more smoothly when a loving parent holds the young child being cared for on his or her lap during the procedure. A client’s anxiety may be eased when the spouse walks next to her or him on the ride to the operating room. Respect for privacy and confidentiality may promote honest dialogue when counseling a teenager. Multiple nursing theories and frameworks describe the personal relationships between client and nurse as well as caring processes and specific techniques (ANA, 2010a).

Recommendations from multiple organizations provide the nurse with guidance for timeliness and safety regarding implementation practices. Highrisk activities such as medication administration are also guided by regulatory standards, as well as the nurse’s knowledge, skills, and abilities. For example, The Joint Commission National Patient Safety Goals recommends that the nurse should use two ways to identify patients correctly. Before administering medication, the nurse will properly identify the patient. The nurse may ask the adult hospitalized client to state his or her name and date of birth and then may verify this information against the client’s medical record and name band. This method of implementing correct identification of the client would vary in a nonverbal or cognitively impaired client (The Joint Commission, 2011).

Nurses may use technology to implement and enhance nursing practice, to coordinate client care, and to maximize client independence. Technology may be used in direct client care to collect physiologic data (cardiac monitors) or to provide support for physiologic function (mechanical ventilators). Nursing care is provided in highly technological environments, such as emergency departments, operating rooms, and intensive care units. In addition to effectively using the technology to optimize client outcomes, nurses manage the interface between the client and the technology. The use of technology may be frightening or threatening for a client. Nurses implement interventions to ensure that client safety and dignity are respected.