Standard 3: Outcomes Identification “The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.” Competencies concentrate on engaging the entire healthcare team, including patients and families, in the identification of realistic outcomes. The nurse engages with the healthcare consumer, interprofessional team, and others to identify expected outcomes and collaborates with the healthcare consumer to define expected outcomes, integrating the healthcare consumer’s culture, values, and ethical considerations. From this information, the nurse formulates expected outcomes Standard 4: Planning “The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes.” Competencies involve developing an individualized, holistic, evidence- based plan of care in partnership with the patient, family, and interprofessional team. The RN develops an individualized, holistic, evidence-based plan in partnership with the healthcare consumer, family, significant others, and interprofessional team And designs innovative nursing practices that can be incorporated into the plan. The RN prioritizes elements of the plan based on the assessment of the healthcare consumer’s level of safety needs to include risks, benefits, and alternatives. The RN establishes the plan priorities with the healthcare consumer, family, significant others, and interprofessional team and advocates for compassionate, responsible, and appropriate use of interventions to minimize unwarranted or unwanted treatment, and healthcare consumer suffering, or both. The RN includes strategies designed to address each of the identified diagnoses, Standard 5: Implementation “The registered nurse implements the identified plan.” Competencies include use of evidence-based practice and partners with the healthcare consumer to implement the plan. Demonstrates caring behaviors to develop therapeutic relationships. Provides care that focuses on the healthcare consumer. Advocates for the needs of diverse populations across the life span. Uses critical thinking and technology solutions to implement the nursing process to collect, measure, record, retrieve, trend, and analyze data and information to enhance healthcare consumer outcomes and nursing practice. Partners with the healthcare consumer to implement the plan in a safe, effective, efficient, timely, and equitable manner. Engages interprofessional team partners in implementation of the plan through collaboration and communication across the continuum of care. Uses evidence-based interventions and strategies to achieve mutually identified goals and outcomes specific to the problem or needs. Delegates according to the health, safety, and welfare of the healthcare consumer. Delegates after considering the circumstance, person, task, direction or communication, supervision, and evaluation, as well as the state nurse practice act (ANA, 2021a; Kindle location 1945-1954). Standard 5A: Coordination of Care “The registered nurse coordinates care delivery.” Competencies focus on coordinating care with the interprofessional team. “Collaborates with the healthcare consumer and the Standard 6: Evaluation “The registered nurse evaluates progress toward attainment of goals and outcomes.” Competencies concentrate on conducting ongoing, criterion-based evaluation of patient goals and outcomes. “Uses applicable standards and defined criteria (e.g., Quality and Safety Education for Nurses [QSEN], Quadruple Aim, Institute for Healthcare Improvement [IHI]). Conducts a systematic, ongoing, and criterion-based evaluation of the goals and outcomes in relation to the structure, processes, and timeline prescribed in the plan. Collaborates with the healthcare consumer, stakeholders, interprofessional team, and others involved in the care or situation in the evaluation process. Determines, in partnership with the healthcare consumer and other stakeholders, the person-centeredness,
derived from assessments and diagnoses. They then integrate evidence and best practices to identify expected outcomes and develop expected outcomes that facilitate coordination of care. The nurse next identifies a time frame for the attainment of expected outcomes, documents expected outcomes as measurable goals, and identifies the actual outcomes in relation to expected outcomes, safety, and quality standards. If needed, the nurse then modifies expected outcomes based on the evaluation of the status of the healthcare consumer and situation (ANA, 2021a, Kindle Location 1864-1872). health challenges, issues, or opportunities. These strategies may include but are not limited to maintaining health and wellness; promotion of comfort; promotion of wholeness, growth, and development; promotion and restoration of health and wellness; prevention of illness, injury, disease, complications, and trauma; facilitation of healing; alleviation of suffering; supportive care; and mitigation of environmental or occupational risks. The RN incorporates an implementation pathway that describes an overall timeline, steps, and milestones. The RN provides for the coordination and continuity of care and identifies cost and economic implications of the plan. The RN develops a plan that reflects compliance with current statutes, rules and regulations, and standards and modifies the plan according to the ongoing assessment of the healthcare consumer’s response and other outcome indicators. The RN documents the plan using standardized language or recognized terminology (ANA, 2021a, Kindle location 1898-1913). interprofessional team to help manage healthcare based on mutually agreed-upon outcomes. Organizes the components of the plan with input from the healthcare consumer and other stakeholders. Manages the healthcare consumer’s care to reach mutually agreed-upon outcomes. Engages healthcare consumers in self-care to achieve preferred goals for quality of life” (ANA, 2021a, Kindle Location 1993-1997) Standard 5B: Health Teaching and Health Promotion “The registered nurse employs strategies to promote health and a safe environment.” RN competencies focus on effective patient/family education. Provides opportunities for the healthcare consumer to identify needed health promotion, disease prevention, and self-management topics such as: - Healthy lifestyles - Self-care and risk management - Coping, adaptability, and resiliency. Uses health promotion and health teaching methods in collaboration with the healthcare consumer’s values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status. Uses feedback from the healthcare consumer and other assessments to determine the effectiveness of the employed strategies. Uses technologies to communicate health promotion and disease prevention information to the healthcare consumer (ANA, 2021a, Kindle Locations 2031-2038). effectiveness, efficiency, safety, timeliness, and equitability of the strategies in relation to the responses to the plan and attainment of outcomes. Uses ongoing assessment data, other data and information resources and benchmarks, research, and meta-analysis for the analytic activities to revise the diagnoses, outcomes, plan, implementation, and evaluation strategies as needed. Documents the results of the evaluation. Reports evaluation data in a timely fashion. Shares evaluation data and conclusions with the healthcare consumer and other stakeholders to promote clarity and transparency in accordance with state, federal, organizational, and professional requirements” (ANA, 2021a, Kindle Location 2066-2077).
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