AS THE WORK of nursing becomes increasingly more complex and significantly more technical in nature, nurses are beginning to find that those basic nursing interventions that were once the hallmark of good nursing care are being left behind. Backrubs have been replaced by expensive alternating pressure mattresses and specialty beds, and bed baths have been replaced by microwavable disposable bathing kits. Acute care nurses are not only required to maintain a myriad of clinical competencies to care for today's patients, but they are also expected to be skilled in nursing informatics to navigate through highly complex electronic medical record systems. Documentation requirements have exploded in recent years because of increased patient safety standards from regulatory agencies such as The Joint Commission and the Centers for Medicare & Medicaid Services. Many nurses are becoming frustrated by the inability to provide some of the simpler, more basic nursing interventions that serve to put the "care" into nursing care. On the basis of the feedback from many of the nurses throughout the organization, the department of nursing decided to look at how we defined the practice of nursing to bring new energy and a new emphasis on providing those nursing interventions that were considered, less glamorous, but were of prime importance to our patients and their families.

Several years ago, our organization adopted Jean Watson's Theory of Human Caring (Watson 2009)1 as our model for nursing practice. This culture of intentional caring is evident across all care settings, both inpatient and throughout all the ambulatory care settings. However, in Watson's spirit of "cocreating" the theory, nursing services wanted to continue to create and sustain an environment in which the patient felt extraordinarily cared for. Although our organization has continued to achieve outstanding patient satisfaction scores, we were looking to take patient satisfaction to the next level. We knew that we delivered high-quality and technically safe care for our patients. But occasionally we also heard patients tell us that they had not received a bath, and we observed that patient rooms were sometimes cluttered and fresh water was not always available. We wanted our patients to know what kind of nursing care they could expect to receive and that this care would be delivered not only safely but also in a caring and compassionate manner by providing the "basics" in nursing care. The compelling issues that caused us to turn our attention to the essentials of patient care included the following:

* There were inconsistent standards for providing basic care.

* Expectations about specific aspects of basic care were unclear and not well defined (eg, how frequently to change linens, bathe patients).

* The department of nursing lacked standardized definitions about care essentials.

* There were many challenges in managing patient expectations about patient care and standardized care practices.

* There was considerable confusion about whether certain tasks were part of the RN role or the patient care assistant role.

* A larger population of new nursing graduates is being incorporated into the existing workforce, meaning that we needed to clearly and consistently define our care expectations to guide their transition from novice nurse to competent care provider.

THE STARTING POINT

Our goal was to develop a clearly defined set of consensus-driven expectations about those basic elements of nursing care that nurses strive for and which should be universal within our organization, no matter where the patient receives care. We also wanted a document that embraced our vision of providing the best nursing care in the world, as well as one that encompassed both the tasks of nursing care and the compassionate environment in which the care is delivered. Adding to the complexity of this goal was the recognition that we would be much more successful in meeting these standards consistently if the expectations were explicitly described and intentionally specified. The desire was to strike a balance between spelling out a unified and high level of professional performance without being overly prescriptive. The document therefore needed to be crafted in such a way that it left room for individual nurses to express their nursing care in ways that were personalized, yet still meeting or exceeding a high level of quality.

Using Jean Watson's Theory of Human Caring (Watson 2009) as our theoretical framework, the Patient Care Essentials document was designed to be primarily focused on the patient, reflecting on the patients' needs and perspectives at all junctures of their care (eg, procedural areas, acute care, ambulatory/office visits). Another important goal was to involve a large group of nurses in the developmental stage of the document in order to capture the unique nursing perspectives at all points across the nursing care continuum. This part of the process highlighted the challenge of creating a document that would be specific enough to be meaningful, but not be restricted or limited by the setting of care. For example, the Patient Care Essentials of "Patient Education: Medication" might be operationalized very differently in the inpatient setting as compared with the procedural areas, yet it remains an important aspect of nursing care in both settings. The challenge of creating one unified document that spoke to the essentials of nursing care across all of our practice sites was daunting. How would we be able to narrow the focus and be able to describe those essential nursing care expectations that would encompass all nurse-patient care encounters? How would we be able to optimize collaboration and consensus to create a meaningful document that nurses would embrace, internalize, and implement in their unique practice settings?

THE IMPLEMENTATION PROCESS THE JOURNEY

The journey to define patientcare essentials began as a collaborative effort between staff nurses (both inpatient and ambulatory), nursing leadership, and the nursing subcommittees (practice, education, research, and ambulatory nursing practice). Each of the subcommittees had a unique role to play in defining patient care essentials. The nursing research subcommittee was given the task of looking at the process using an evidence-based approach. They felt that it was important to review the literature and identify those elements that are important to both nurses and patients. The results demonstrated that there was general consensus among both groups on the care essentials that are most valued. Of special interest was the finding that listening and caring behaviors were at the top of the list.

The next step involved a partnership between the nursing practice subcommittee and the nursing research subcommittee. A joint brainstorming session was held and during that meeting 8 specific areas of emphasis were identified. The ambulatory nursing subcommittee reviewed the list focusing on the needs of the ambulatory patient and provided critical feedback, which included the important addition of a psychosocial element.

The nursing education subcommittee reviewed the results of the brainstorming session and looked at current academic nursing education and the content that nursing students are being taught regarding the basic essentials of patient care. We wanted to make sure that what we considered an essential patient care element was not in conflict with what new graduate nurses were learning. A small task force was created from members of each of the subcommittees and nursing administration. The task force reviewed the data submitted by each of the nursing subcommittees. During this process, the task force focused on the following 2 primary goals: (1) to incorporate Jean Watson's Theory of Human Caring and (2) to clearly define those basic elements of patient care that any patient could expect to receive by a Mayo Clinic nurse, regardless of the practice setting.

On the basis of the data, and with a focus on the 2 goals, a document was created with a list of 9 essential care elements. Assumptions, definitions, and goals of the patient care essentials document were also drafted. However, the task force wanted to ensure that the 9 essential care elements, which had been identified this far, were not just what nursing leadership defined as nursing essentials. It was critical to obtain input from staff nurses who were at the bedside or caring for patients in the ambulatory setting on a daily basis. Therefore, to accomplish this task, focus groups were held. A total of 24 staff nurses participated from a wide variety of practice settings, inpatient, acute care, and ambulatory. The valuable information that was obtained from these focus groups led to the development of the final document (Appendix).

The final Patient Care Essentials document was designed with assumptions that apply to all Mayo Clinic Arizona nurses in every patient interaction, regardless of setting, position, or title. The outcomes are overarching expectations with concrete examples that have been provided for each major area of nursing. This framework sets the basic expectations for nursing care at Mayo Clinic Arizona, and all departments and patient care units were encouraged to use this list to further define exactly what these patient care essentials mean in their unique practice setting. Each nursing area was encouraged to identify ways that the nursing care that is delivered in their practice setting actually exemplifies the tenets of the Patient Care Essentials document.

Putting it into practice: Not always a smooth road

Although nurses throughout the organization were involved in each stage of the development of the Patient Care Essentials document, communicating it to all nurses so they could truly integrate it into their daily practice was not a simple task. Some nurses had the perception that the initiative was too prescriptive and linear in nature. They viewed it as just one more checklist of tasks to be completed. Some nurses believed that it would add more work on top of their already overloaded daily assignment. Other nurses reported feeling defensive that they would need to be told how to take care of patients. It was clear that if this project was to succeed, the misconceptions would need to be acknowledged and managed in a positive way.

Nursing leadership took this as a signal to pause, listen to the nurses' concerns, and seek to understand their perspective. As members of the leadership team reflected on the current stage of the patient care essentials journey, they began to visualize what the document might look like as a living and breathing entity. They felt it was important to understand how each inpatient unit and each ambulatory site would interpret the document and implement the process for their unique patient population and setting. The leadership team also recognized that the methods used to communicate to the nursing staff the purpose and the importance of the document would determine whether the nurses were willing to internalized the patient care essential tenets and made them their own or whether they considered them just one more task imposed by nursing administration.

The implementation

A communication plan was created to guide the "roll-out" of the Patient Care Essentials initiative across the organization. Responsibility of designing the rollout plan was given to the nursing education subcommittee, in collaboration with member of the clinical and patient education department. The steps of the rollout plan are listed as follows:

* The nursing executive council, with advice from the nurse managers, made the decision to separate the rollout of the patient care essentials from Nurses Week celebration events. The nursing leadership team felt it was important to convey that patient care essentials was an ongoing approach to care rather than linking it to a special celebration such as Nurses Week.

* An article was included in the nursing newsletter, which described the process that was used to develop the document and all the decisions that led to the creation of the final product. This article was the debut of the final Patient Care Essentials document.

* For ready accessibility, the document was also posted on the nursing Web site to view or to download and print.

* Posters were developed so the document could be placed in strategic areas on each patient care unit. Brochures were also formatted and each Mayo Clinic Arizona nurse was given a copy of the document. The brochure was also included as a part of the orientation packet given to new nurses and was used by human resources at recruitment events.

Each of the unit-based nursing educators was asked to highlight the patient care essentials during staff meetings and team days. Examples that were pertinent to the individual unit were discussed with the idea of bringing the words to life. Each nursing unit was asked to answer the following question: "How do we incorporate the patient care essentials into the daily care of our patients?"

BRINGING THE ESSENTIALS TO LIFE

To understand how each nursing unit and each ambulatory setting answered the question of how this document was brought to life in their areas, nurses from each unit were given the opportunity to present their implementation model to the nursing executive council. The result of these presentations demonstrated that Mayo Clinic nurses had not only embraced the document but many nursing units also had created some unique best practice models based on the patient care essentials philosophy of care. In addition, giving nurses an opportunity to individualize and define how patient care essentials were implemented at the unit level was the beginning of a broader acceptance and understanding. This document embodies the expectations and promise that we offer our patients. It is nursing care defined by Mayo Clinic nurses. It is caring made visible.

Lessons learned

There were many lessons learned from the process of creating and implementing the patient care essentials. Learning continues because the process of bringing the essentials to life is a dynamic and ongoing process. One of the lessons we learned from a nursing leadership perspective is that this process is very time intensive. It would have been far easier and shorter to create and mandate the essentials from the boardroom. However, the perspective of nurses in all roles and settings is highly valued in our organization and we intentionally committed to devoting the time necessary to gather input at several junctures along the way and to provide forums for healthy discussion and debate. This approach is consistent with Watson's spirit of cocreating her theory and empowering nurses to create a dynamic approach to caring. The time commitment continues as we host presentations from nurses on various units describing how they have implemented the patient care essentials in unique and creative ways.

In addition to the time involvement, there is energy expenditure. This type of consensus requires great patience because discussion can be repetitive, circular, and seemingly nonproductive at times. There was deliberate thought put into how the committees and focus groups would be facilitated and input sought and incorporated. Because our organization also values theory-driven and evidence-based practice, we worked mindfully to make sure that we were aligned with our theoretical model (Jean Watson's Theory of Human Caring) and with the emerging scientific literature. This alignment is something that requires ongoing attention, particularly as the evidence regarding nursing practices is changing and growing.

As with any creative endeavor, the document required many revisions. Each round of communication and dialogue meant more changes. We had to be vigilant to ensure that the document kept up with the incoming input and that we did not have multiple versions of the document being distributed simultaneously. In addition, we wanted to capture the richness of the ideas that came from nurses balanced with the need to keep the document size manageable for users.

We learned early on that we needed to proceed with caution about how the Patient Care Essentials process was communicated. Much care was taken so that nurses did not perceive this as just one more "edict from above" and instead felt empowered to take time on the details of caring. On the positive side, nurses enjoyed being a part of the focus groups and appreciated having their voice heard. Also, nurses who attended the focus groups raised awareness on other issues, which needed to be addressed through other forums.

IMPLICATIONS AND RECOMMENDATIONS FOR FUTURE ACCOUNTABILITY

Future directions for our organization include exploring ways of evaluating whether the formal incorporation of the Patient Care Essentials has made tangible differences. Some metrics we are exploring include patient satisfaction scores, patient complaints, nursing satisfaction, and some of our quality metrics. Formative evaluation is also ongoing. Formative evaluation strategies included having representatives of the nursing work units present their initiatives at the nursing executive council. Another approach was to have nurses present posters highlighting their Patient Care Essentials work during Nurses Week. Abstracts for several of these posters have been submitted for presentations external to our organization.

We are in the process of modifying our curriculum for nursing orientation, our new nursing graduate program, and our nurse preceptor program to include an emphasis on patient care essentials. Creating the document was relatively easy-keeping it alive and well at the point of care will be an ongoing challenge that we cannot accomplish without our preceptors' help. Modeling competent delivery of the patient care essentials will require diligence and commitment on the part of the preceptors but will be the most memorable tool for nurses.

Perhaps the most difficult element of any change initiative is the sustainability phase. We are in active discussions relative to how to keep the Patient Care Essentials a vibrant part of how nurses approach patient care. The language of the document has become a part of nursing culture, yet there are still improvements to make in terms of keeping Patient Care Essentials in the forefront of nursing awareness. In many ways, revisiting the "basics" of nursing has allowed us to rededicate our work and deepen our resolve to the essential principles that brought us into the field of nursing.

Patient Care Essentials: The Final Document

The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary. - -William J. Mayo, MD

These patient care essentials, developed through a collaborative effort between staff nurses, both inpatient and ambulatory, and nursing leadership, reflect our patient care expectations for all Mayo Clinic Arizona Nurses. It is our shared belief that the elements outlined in this document will create an optimal environment for keeping the spoken and unspoken promises we make to our patients and each other.

APPENDIX EXPECTATIONS

* All nurse-patient, nurse-family, and nurse-nurse interactions are conducted with sensitivity toward human dignity, respect, privacy, and cultural diversity.

* Intentional caring is a part of every nursing intervention.

* The nurse is an essential part of the patient's care environment.

* The nurse will learn from the patient.

* It is every Mayo Clinic nurse's responsibility to assist and respond to the patient's needs regardless of the environment or the setting.

* The nurse will collaborate with members of the health care team to meet the needs of the patient.

OUTCOMES

Patient environment

The patient care environment will be safe, uncluttered, clean, quiet, and private to provide optimal healing as evidenced by the following actions:

* Orient the patient to the environment through a 2-way exchange of information; for example, welcome packets, DVDs, way-finding signage, escorts with minimal patient-caregiver handoffs, and/or other educational materials.

* Provide appropriate equipment and supplies and ensure that linens/gowns/examination table covers are clean, and patients have the means to call for assistance when needed.

Patient education

The patient and family will have the information necessary to participate and understand their care through an individualized culturally and age-appropriate approach.

Involve the patient and family in their plan of care through:

* Assessment of the learner's readiness to learn and identification of barriers to learning.

* Mutual goal setting.

* Pre- and postprocedure and discharge education.

* Medication education.

* Participation in decision making.

* Use of a variety of Mayo Clinic approved modalities; for example, individual, group discussion, printed materials, Web-based or online, tele-health, video, and DVD.

Psychosocial and spiritual care

The patient's and family's needs will be recognized and acted upon as follows:

* Provide for the patients spiritual and psychosocial needs by being a patient advocate who is engaged, supportive, and caring.

* Facilitate appropriate referrals; for example, chaplains, volunteers, social workers, and hospice.

* Accept the patient's positive and negative views.

* Ensure that diverse ethical and cultural issues will be addressed and respected.

Nutritional care

Nutritional assessment and intervention that supports healing in ways that are culturally and age appropriate and individualized to the patient will be demonstrated by the following actions:

* Perform accurate I&O and calorie counts.

* Monitor NPO status daily.

* Assess patient's understanding of dietary needs for healing or on-going management of chronic disease; for example, specialized diets for CHF, diabetes, diet restrictions.

* Identify and monitor for food/drug interactions.

* Provide individualized patient choices for meals and snacks.

* Identify and monitor for significant weight change or deviation from standard growth charts.

* Facilitate appropriate referrals to dieticians.

Hygiene

The patient's hygiene needs will be met on a consistent basis, through collaboration with nursing, to promote independence, and ensure a clean body as evidenced by the following actions:

* Monitor and maintain skin cleanliness and integrity.

* Perform a comprehensive skin assessment; for example, removal of TED hose and a complete skin assessment upon admission, each shift and during appropriate ambulatory encounters (preoperatively/office visits), including removal of shoes and socks for every office visit for diabetic patients.

* Provide daily and as needed bathing and gown change.

* Administer caring touch; for example, backrub and holding a hand.

* Provide patient hand hygiene; for example, after toileting and prior to meals.

* Promote oral hygiene.

* Provide oral cleansing and lip care each shift and as needed.

* Provide appropriate elimination/peri-care.

* Assess bladder function and bowel movement daily.

* Monitor and measure accurate I&O.

* Provide daily and as needed peri-care.

* Provide assistance as needed with appropriate peri-care following procedures; for example, Papanicolaou test, other gynecological, or urological procedures.

* Ensure the availability of supplies.

* Provide needed assistance to enhance safety and prevent falls.

Postoperative care, procedure care, and general care

The care, monitoring, and communication necessary to stabilize the patient and prevent complications postoperatively and postprocedurally will be manifested by the following actions:

* Provide appropriate pulmonary hygiene.

* Perform DVT prophylaxis.

* Perform hemodynamic monitoring; for example, vital signs-especially respirations.

* Assess level of consciousness.

* Ensure accurate, timely, and safe hand-offs; utilizing SBAR.

* Assess and manage pain.

* Ensure adequate mobilization; for example, ambulation and turning.

* Assess and manage incision wound care.

* Monitor and ensure appropriate elimination patterns are established/maintained.

* Provide information for postoperative/procedure care and ensure that results are provided to the patient in a timely manner.

Used with permission from Mayo Foundation for Medical Education and Research. Copyright 2011.

Abbreviations: CHF, congestive heart failure; DVT, deep venous thrombosis; I&O, intake and output; NPO, nothing by mouth; SBAR, situation-background-assessment-recommendation. [Context Link]

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