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Nursing Care Plans (NCP): Ultimate Guide and List

Writing the  best   nursing care plan  requires a step-by-step approach to complete the parts needed for a care plan correctly. This tutorial will walk you through developing a care plan. This guide has the ultimate database and list of nursing care plans (NCP) and nursing diagnosis samples  for our student nurses and professional nurses to use—all for free! Care plan components, examples, objectives, and purposes are included with a detailed guide on writing an excellent nursing care plan or a template for your unit. 

Table of Contents

Standardized care plans, individualized care plans, purposes of a nursing care plan, three-column format, four-column format, student care plans, step 1: data collection or assessment, step 2: data analysis and organization, step 3: formulating your nursing diagnoses, step 4: setting priorities, short-term and long-term goals, components of goals and desired outcomes, types of nursing interventions, step 7: providing rationale, step 8: evaluation, step 9: putting it on paper, basic nursing and general care plans, surgery and perioperative care plans, cardiac care plans, endocrine and metabolic care plans, gastrointestinal, hematologic and lymphatic, infectious diseases, integumentary, maternal and newborn care plans, mental health and psychiatric, musculoskeletal, neurological, pediatric nursing care plans, reproductive, respiratory, recommended resources, references and sources, what is a nursing care plan.

A  nursing care plan (NCP)  is a formal process that correctly identifies existing needs and recognizes a client’s potential needs or risks. Care plans provide a way of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost.

Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to the client’s changes in condition and evaluation of goal achievement. Planning and delivering individualized or patient-centered care is the basis for excellence in nursing practice.

Types of Nursing Care Plans

Care plans can be informal or formal: An informal nursing care plan is a strategy of action that exists in the nurse ‘s mind. A  formal nursing care plan is a written or computerized guide that organizes the client’s care information.

Formal care plans are further subdivided into standardized care plans and individualized care plans:  Standardized care plans specify the nursing care for groups of clients with everyday needs.  Individualized care plans are tailored to meet a specific client’s unique needs or needs that are not addressed by the standardized care plan.

Standardized care plans are pre-developed guides by the nursing staff and health care agencies to ensure that patients with a particular condition receive consistent care. These care plans are used to ensure that minimally acceptable criteria are met and to promote the efficient use of the nurse’s time by removing the need to develop common activities that are done repeatedly for many of the clients on a nursing unit.

Standardized care plans are not tailored to a patient’s specific needs and goals and can provide a starting point for developing an individualized care plan .

Care plans listed in this guide are standard care plans which can serve as a framework or direction to develop an individualized care plan.

An individualized care plan care plan involves tailoring a standardized care plan to meet the specific needs and goals of the individual client and use approaches shown to be effective for a particular client. This approach allows more personalized and holistic care better suited to the client’s unique needs, strengths, and goals.

Additionally, individualized care plans can improve patient satisfaction . When patients feel that their care is tailored to their specific needs, they are more likely to feel heard and valued, leading to increased satisfaction with their care. This is particularly important in today’s healthcare environment, where patient satisfaction is increasingly used as a quality measure.

Tips on how to individualize a nursing care plan:

• Perform a comprehensive assessment of the patient’s health, history, health status, and desired goals.
• Involve the patient in the care planning process by asking them about their health goals and preferences. By involving the client, nurses can ensure that the care plan is aligned with the patient’s goals and preferences which can improve patient engagement and compliance with the care plan.
• Perform an ongoing assessment and evaluation as the patient’s health and goals can change. Adjust the care plan accordingly.

The following are the goals and objectives of writing a nursing care plan:

• Promote evidence-based nursing care and render pleasant and familiar conditions in hospitals or health centers.
• Support holistic care, which involves the whole person, including physical, psychological, social, and spiritual, with the management and prevention of the disease.
• Establish programs such as care pathways and care bundles. Care pathways involve a team effort to reach a consensus regarding standards of care and expected outcomes. In contrast, care bundles are related to best practices concerning care for a specific disease.
• Identify and distinguish goals and expected outcomes.
• Review communication and documentation of the care plan.
• Measure nursing care.

The following are the purposes and importance of writing a nursing care plan:

• Defines nurse’s role. Care plans help identify nurses’ unique and independent role in attending to clients’ overall health and well-being without relying entirely on a physician’s orders or interventions.
• Provides direction for individualized care of the client.  It serves as a roadmap for the care that will be provided to the patient and allows the nurse to think critically in developing interventions directly tailored to the individual.
• Continuity of care. Nurses from different shifts or departments can use the data to render the same quality and type of interventions to care for clients, therefore allowing clients to receive the most benefit from treatment.
• Coordinate care. Ensures that all members of the healthcare team are aware of the patient’s care needs and the actions that need to be taken to meet those needs preventing gaps in care.
• Documentation. It should accurately outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require. If nursing care is not documented correctly in the care plan, there is no evidence the care was provided.
• Serves as a guide for assigning a specific staff to a specific client.  There are instances when a client’s care needs to be assigned to staff with particular and precise skills.
• Monitor progress. To help track the patient’s progress and make necessary adjustments to the care plan as the patient’s health status and goals change.
• Serves as a guide for reimbursement.  The insurance companies use the medical record to determine what they will pay concerning the hospital care received by the client.
• Defines client’s goals. It benefits nurses and clients by involving them in their treatment and care.

A nursing care plan (NCP) usually includes nursing diagnoses, client problems, expected outcomes, nursing interventions, and rationales. These components are elaborated on below:

• Client health assessment , medical results, and diagnostic reports are the first steps to developing a care plan. In particular, client assessment relates to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic, and environmental. Information in this area can be subjective and objective.
• Nursing diagnosis . A nursing diagnosis is a statement that describes the patient’s health issue or concern. It is based on the information gathered about the patient’s health status during the assessment.
• Expected client outcomes. These are specific goals that will be achieved through nursing interventions. These may be long and short-term.
• Nursing interventions . These are specific actions that will be taken to address the nursing diagnosis and achieve expected outcomes . They should be based on best practices and evidence-based guidelines.
• Rationales. These are evidence-based explanations for the nursing interventions specified.
• Evaluation . These includes plans for monitoring and evaluating a patient’s progress and making necessary adjustments to the care plan as the patient’s health status and goals change.

Care Plan Formats

Nursing care plan formats are usually categorized or organized into four columns: (1) nursing diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation. Some agencies use a three-column plan where goals and evaluation are in the same column. Other agencies have a five-column plan that includes a column for assessment cues.

The three-column plan has a column for nursing diagnosis, outcomes and evaluation, and interventions.

This format includes columns for nursing diagnosis, goals and outcomes, interventions, and evaluation.

Below is a document containing sample templates for the different nursing care plan formats. Please feel free to edit, modify, and share the template.

Download: Printable Nursing Care Plan Templates and Formats

Student care plans are more lengthy and detailed than care plans used by working nurses because they serve as a learning activity for the student nurse.

Care plans by student nurses are usually required to be handwritten and have an additional column for “Rationale” or “Scientific Explanation” after the nursing interventions column. Rationales are scientific principles that explain the reasons for selecting a particular nursing intervention.

Writing a Nursing Care Plan

How do you write a nursing care plan (NCP)? Just follow the steps below to develop a care plan for your client.

The first step in writing a nursing care plan is to create a client database using assessment techniques and data collection methods (physical assessment, health history, interview, medical records review, and diagnostic studies). A client database includes all the health information gathered . In this step, the nurse can identify the related or risk factors and defining characteristics that can be used to formulate a nursing diagnosis. Some agencies or nursing schools have specific assessment formats you can use.

Critical thinking is key in patient assessment, integrating knowledge across sciences and professional guidelines to inform evaluations. This process, crucial for complex clinical decision-making, aims to identify patients’ healthcare needs effectively, leveraging a supportive environment and reliable information

Now that you have information about the client’s health, analyze, cluster, and organize the data to formulate your nursing diagnosis, priorities, and desired outcomes.

Nursing diagnoses are a uniform way of identifying, focusing on and dealing with specific client needs and responses to actual and high-risk problems. Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses.

We’ve detailed the steps on how to formulate your nursing diagnoses in this guide:  Nursing Diagnosis (NDx): Complete Guide and List .

Setting priorities involves establishing a preferential sequence for addressing nursing diagnoses and interventions. In this step, the nurse and the client begin planning which of the identified problems requires attention first. Diagnoses can be ranked and grouped as having a high, medium, or low priority. Life-threatening problems should be given high priority.

A nursing diagnosis encompasses Maslow’s Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate to all individuals. Basic physiological needs/goals must be met before higher needs/goals can be achieved, such as self-esteem and self-actualization. Physiological and safety needs are the basis for implementing nursing care and interventions. Thus, they are at the base of Maslow’s pyramid, laying the foundation for physical and emotional health.

Maslow’s Hierarchy of Needs

• Basic Physiological Needs: Nutrition (water and food), elimination (Toileting), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABCs), sleep , sex, shelter, and exercise.
• Safety and Security: Injury prevention ( side rails , call lights, hand hygiene , isolation , suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and safety ( therapeutic relationship ), patient education (modifiable risk factors for stroke , heart disease).
• Love and Belonging: Foster supportive relationships, methods to avoid social isolation ( bullying ), employ active listening techniques, therapeutic communication , and sexual intimacy.
• Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of control or empowerment, accepting one’s physical appearance or body habitus.
• Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point of view of others, reaching one’s maximum potential.

The client’s health values and beliefs, priorities, resources available, and urgency are factors the nurse must consider when assigning priorities. Involve the client in the process to enhance cooperation.

Step 5: Establishing Client Goals and Desired Outcomes

After assigning priorities for your nursing diagnosis, the nurse and the client set goals for each determined priority. Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions derived from the client’s nursing diagnoses. Goals provide direction for planning interventions, serve as criteria for evaluating client progress, enable the client and nurse to determine which problems have been resolved, and help motivate the client and nurse by providing a sense of achievement.

One overall goal is determined for each nursing diagnosis. The terms “ goal outcomes “ and “expected outcome s” are often used interchangeably.

According to Hamilton and Price (2013), goals should be SMART . SMART stands for specific, measurable, attainable, realistic, and time-oriented goals.

• Specific. It should be clear, significant, and sensible for a goal to be effective.
• Measurable or Meaningful. Making sure a goal is measurable makes it easier to monitor progress and know when it reaches the desired result.
• Attainable or Action-Oriented. Goals should be flexible but remain possible.
• Realistic or Results-Oriented. This is important to look forward to effective and successful outcomes by keeping in mind the available resources at hand.
• Timely or Time-Oriented. Every goal needs a designated time parameter, a deadline to focus on, and something to work toward.

Hogston (2011) suggests using the REEPIG standards to ensure that care is of the highest standards. By this means, nursing care plans should be:

• Realistic. Given available resources. 
• Explicitly stated. Be clear about precisely what must be done, so there is no room for misinterpretation of instructions.
• Evidence-based. That there is research that supports what is being proposed. 
• Prioritized. The most urgent problems are being dealt with first. 
• Involve. Involve both the patient and other members of the multidisciplinary team who are going to be involved in implementing the care.
• Goal-centered. That the care planned will meet and achieve the goal set.

Goals and expected outcomes must be measurable and client-centered.  Goals are constructed by focusing on problem prevention, resolution, and rehabilitation. Goals can be short-term or long-term . Most goals are short-term in an acute care setting since much of the nurse’s time is spent on the client’s immediate needs. Long-term goals are often used for clients who have chronic health problems or live at home, in nursing homes, or in extended-care facilities.

• Short-term goal . A statement distinguishing a shift in behavior that can be completed immediately, usually within a few hours or days.
• Long-term goal . Indicates an objective to be completed over a longer period, usually weeks or months.
• Discharge planning . Involves naming long-term goals, therefore promoting continued restorative care and problem resolution through home health, physical therapy, or various other referral sources.

Goals or desired outcome statements usually have four components: a subject, a verb, conditions or modifiers, and a criterion of desired performance.

• Subject. The subject is the client, any part of the client, or some attribute of the client (i.e., pulse, temperature, urinary output). That subject is often omitted in writing goals because it is assumed that the subject is the client unless indicated otherwise (family, significant other ).
• Verb. The verb specifies an action the client is to perform, for example, what the client is to do, learn, or experience.
• Conditions or modifiers. These are the “what, when, where, or how” that are added to the verb to explain the circumstances under which the behavior is to be performed.
• Criterion of desired performance. The criterion indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior. These are optional.

When writing goals and desired outcomes, the nurse should follow these tips:

• Write goals and outcomes in terms of client responses and not as activities of the nurse. Begin each goal with “Client will […]” help focus the goal on client behavior and responses.
• Avoid writing goals on what the nurse hopes to accomplish, and focus on what the client will do.
• Use observable, measurable terms for outcomes. Avoid using vague words that require interpretation or judgment of the observer.
• Desired outcomes should be realistic for the client’s resources, capabilities, limitations, and on the designated time span of care.
• Ensure that goals are compatible with the therapies of other professionals.
• Ensure that each goal is derived from only one nursing diagnosis. Keeping it this way facilitates evaluation of care by ensuring that planned nursing interventions are clearly related to the diagnosis set.
• Lastly, make sure that the client considers the goals important and values them to ensure cooperation.

Step 6: Selecting Nursing Interventions

Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the priority nursing problem or diagnosis. As for risk nursing problems, interventions should focus on reducing the client’s risk factors. In this step, nursing interventions are identified and written during the planning step of the nursing process ; however, they are actually performed during the implementation step.

Nursing interventions can be independent, dependent, or collaborative:

• Independent nursing interventions are activities that nurses are licensed to initiate based on their sound judgement and skills. Includes: ongoing assessment, emotional support, providing comfort, teaching, physical care, and making referrals to other health care professionals.
• Dependent nursing interventions are activities carried out under the physician’s orders or supervision. Includes orders to direct the nurse to provide medications, intravenous therapy , diagnostic tests, treatments, diet, and activity or rest. Assessment and providing explanation while administering medical orders are also part of the dependent nursing interventions.
• Collaborative interventions are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, dietitians, and therapists. These actions are developed in consultation with other health care professionals to gain their professional viewpoint.

Nursing interventions should be:

• Safe and appropriate for the client’s age, health, and condition.
• Achievable with the resources and time available.
• Inline with the client’s values, culture, and beliefs.
• Inline with other therapies.
• Based on nursing knowledge and experience or knowledge from relevant sciences.

When writing nursing interventions, follow these tips:

• Write the date and sign the plan. The date the plan is written is essential for evaluation, review, and future planning. The nurse’s signature demonstrates accountability.
• Nursing interventions should be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. Action verb starts the intervention and must be precise. Qualifiers of how, when, where, time, frequency, and amount provide the content of the planned activity. For example: “ Educate parents on how to take temperature and notify of any changes,” or “ Assess urine for color, amount, odor, and turbidity.”
• Use only abbreviations accepted by the institution.

Rationales, also known as scientific explanations, explain why the nursing intervention was chosen for the NCP.

Rationales do not appear in regular care plans. They are included to assist nursing students in associating the pathophysiological and psychological principles with the selected nursing intervention.

Evaluation is a planned, ongoing, purposeful activity in which the client’s progress towards achieving goals or desired outcomes is assessed, and the effectiveness of the nursing care plan (NCP). Evaluation is an essential aspect of the nursing process because the conclusions drawn from this step determine whether the nursing intervention should be terminated, continued, or changed.

The client’s care plan is documented according to hospital policy and becomes part of the client’s permanent medical record, which may be reviewed by the oncoming nurse. Different nursing programs have different care plan formats. Most are designed so that the student systematically proceeds through the interrelated steps of the nursing process , and many use a five-column format.

Nursing Care Plan List

This section lists the sample nursing care plans (NCP) and nursing diagnoses for various diseases and health conditions. They are segmented into categories:

Miscellaneous nursing care plans examples that don’t fit other categories:

Care plans that involve surgical intervention.

Nursing care plans about the different diseases of the cardiovascular system :

Nursing care plans (NCP) related to the endocrine system and metabolism:

Care plans (NCP) covering the disorders of the gastrointestinal and digestive system :

Care plans related to the hematologic and lymphatic system :

NCPs for communicable and infectious diseases:

All about disorders and conditions affecting the integumentary system :

Nursing care plans about the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:

Care plans for mental health and psychiatric nursing:

Care plans related to the musculoskeletal system:

Nursing care plans (NCP) for related to nervous system disorders:

Care plans relating to eye disorders:

Nursing care plans (NCP) for pediatric conditions and diseases:

Care plans related to the reproductive and sexual function disorders:

Care plans for respiratory system disorders:

Care plans related to the kidney and urinary system disorders:

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care  Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health   Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

Recommended reading materials and sources for this NCP guide: 

• Björvell, C., Thorell-Ekstrand, I., & Wredling, R. (2000). Development of an audit instrument for nursing care plans in the patient record.   BMJ Quality & Safety ,  9 (1), 6-13. [ Link ]
• DeLaune, S. C., & Ladner, P. K. (2011).  Fundamentals of nursing: Standards and practice . Cengage learning.
• Freitas, F. A., & Leonard, L. J. (2011). Maslow’s hierarchy of needs and student academic success .  Teaching and learning in Nursing ,  6 (1), 9-13.
• Hamilton, P., & Price, T. (2007). The nursing process, holistic.  Foundations of Nursing Practice E-Book: Fundamentals of Holistic Care , 349.
• Lee, T. T. (2004). Evaluation of computerized nursing care plan: instrument development .  Journal of Professional Nursing ,  20 (4), 230-238.
• Lee, T. T. (2006). Nurses’ perceptions of their documentation experiences in a computerized nursing care planning system .  Journal of Clinical Nursing ,  15 (11), 1376-1382.
• Rn, B. O. C., Rn, H. M., Rn, D. T., & Rn, F. E. (2000). Documenting and communicating patient care: Are nursing care plans redundant?.  International Journal of Nursing Practice ,  6 (5), 276-280.
• Stonehouse, D. (2017). Understanding the nursing process .  British Journal of Healthcare Assistants ,  11 (8), 388-391.
• Yildirim, B., & Ozkahraman, S. (2011). Critical thinking in nursing process and education .  International journal of humanities and social science ,  1 (13), 257-262.

65 thoughts on “Nursing Care Plans (NCP): Ultimate Guide and List”

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What is a nursing care plan a mother in second stage of labour?

Please see: 36 Labor Stages, Induced and Augmented Labor Nursing Care Plans

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Hi! You can download it here: Nursing Care Plan Template

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Matt, this page is very informative and I especially appreciate seeing care plans for patients with neurological disorders. I notice, though, that traumatic brain injury is not on your list. Might you add a care plan page for this?

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Hi Paul, on your browser go to File > Print > Save as PDF. Hope that helps and thanks for visiting Nurseslabs!

Matt, I’m a nursing instructor looking for tools to teach this. I am interested in where we can find “rules” for establishing “related to” sections…for example –not able to utilize medical diagnosis as a “related to” etc. Also, resources for nursing rationale.

Hello, please check out our guide on how to write nursing diagnoses here: https://nurseslabs.com/nursing-diagnosis/

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Hi Abbas, Thank you so much! Really glad to hear you found the nursing care plans guide useful. If there’s a specific area or topic you’re keen on exploring more, or if you have any suggestions for improvement, feel free to share. Always aiming to make our resources as helpful as possible!

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What is ncp for acute pain

For everything you need to know about managing acute pain, including a detailed nursing care plan (NCP), definitely check out our acute pain nursing care plan guide . It’s packed with insights on assessment, interventions, and patient education to effectively manage and alleviate acute pain.

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Nursing Student's Ultimate Guide to Writing a Nursing Care Plan

Knowing how to write a good nursing care plan is critical for nursing students and practicing nurses. Care plans act as a tool that helps nursing students and nurses strategically manage the nursing process to solve different problems affecting a patient. Nursing care plans also allow effective communication within a nursing team for collaborative or individual decision-making.

In this guide, we take you through the basics of nursing care plans and steps to create the best and give examples/illustrations to make it simpler. With the best practices we outline in this guide, you can write a nursing care plan without worrying that your end product will be subpar.

This guide is valuable to nursing students as it comprehensively addresses what matters. Besides, it is written by professional nurse researchers collaborating with top talents/brains in the nursing industry. It is also updated regularly to capture any new developments as far as nursing care planning is concerned.

What is a Nursing Care Plan?

A nursing care plan, abbreviated as NCP, refers to a document that details the relevant information about the history and diagnosis of the patient, their current or potential care needs, treatment goals, risks, treatment priorities, and evaluation plan.

Nursing care plans are usually updated depending on the patient's stay at a facility, preferably during and after every shift.

As a nursing student, you will be assigned to write a nursing care plan based on a scenario. For example, your preceptor could also ask you to write a care plan based on a real patient hospitalized in a clinical center where you are doing your internship or practicum.

The process of care planning begins during admission. As we have said above, it gets updated throughout the patient's stay depending on the changes they exhibit and report and based on evaluation of the achievement of the set goals. When you can plan and execute a patient-centered care plan, you have mastered the art of giving quality and excellent nursing services to your patient.

Let's peek at why nursing care plans are written with a view of their professional and academic importance.

Reasons for Writing Nursing Care Plans

You must note that there are different types of nursing care plans, either formal or informal. The formal nursing care plans are roughly documented or exist in the minds of the nurse. On the other hand, formal nursing care plans are either written on paper or computerized to guide the nursing process. Formal nursing care plans can also be standardized or individualized/patient-centered. While the standardized care plans focus on a specific population or group of patients, say those with cardiac arrest or osteoporosis, the individualized or patient-centered care plans are customized to the unique needs of a specific patient that cannot be addressed through a standardized care plan.

Given the understanding of the typologies of nursing care plans, let's now look at why we write them. Nursing care plans are written, or they exist for different reasons, including:

• To promote the use of evidence-based practices in nursing care to address different healthcare needs of the patients
• Holistically caring for patients in recognition of the nursing metaparadigm (health, people, environment, and nursing)
• Enabling nursing teal collaboration through information sharing and collaborative decision-making
• Measuring the effectiveness of care and documenting the nursing process for care efficiency and compliance
• Offering patient-centered or individualized care to improve outcomes
• Identifying the unique roles of nurses in attending to the needs of the patient without constant consultation with physicians
• Allowing for continuity of care by allowing nurses from different shifts to render quality interventions to patients optimizes care outcomes.
• Guide for delegating duties and assigning specific staff to a patient, especially in cases of specialized care.
• Defining a patient's goals helps involve them in decision-making regarding their care.

The Main Components of a Nursing Care Plan

A well-written nursing care plan must have specific components. The main components of a nursing care plan (NCP) are:

• Expected outcomes
• Interventions
• Evaluations

Let's elaborate on these five main components of a nursing care plan.

• Assessment. Assessments are akin to data collection. It entails a detail of the physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic, and environmental. Nursing assessments, combined with the results of medical findings and diagnostic studies, are documented in the client database and form the foundation for developing the client's care plan. The assessment is facilitated through observations for objective data and interviews with patients and their significant others or family for subjective data.
• Diagnosis. With a correct assessment, a nursing care plan details the clinical judgment that helps nurses determine the care plan or interventions for the specific patient.
• Expected outcomes. The outcomes entail the specific, measurable actions for a patient to be achieved within a specific time. The outcomes can be short, medium and long-term depending on the patient's condition.
• Interventions. This entails planning for actions to be taken to achieve the set goals of the patients and expected outcomes, including the rationale behind them. The rationale is evidence-based practices drawn from clinical guidelines, standard operating procedures, evidence-based guidelines, and best practices.
• Evaluations. This section of a nursing care plan entails a set of steps to determine the effectiveness of a nursing intervention or nursing interventions to assess whether the expected outcomes have been met.

What makes a good nursing care plan?

A good nursing care plan contains information about the patient's diagnosis, immediate and changing care needs, treatment goals, specific nursing interventions, and an evaluation plan to determine the effectiveness of care. Such a nursing care plan document can only be achieved through observing certain care plan fundamentals.

• The care plan must answer the questions of what, why, and how.
• A successful care plan uses the fundamental aspects of critical thinking to come up with a patient-centered approach to care
• Follows evidence-based practice guidelines when developing interventions or explaining the rationale for actions
• Has SMART goals for the patients
• Allows for effective communication
• Sharable and easily accessible. If written, it should be legible to everyone else. If you are typing it, use a readable font and good formatting.
• Up to date. It entails the latest information about the patient and changes in their conditions.

Steps for Writing a Nursing Care Plan

You will be assigned a patient scenario or case study as a student. These can be actual case studies from real cases happening on hospital floors or cases created to facilitate teaching and learning. As a professional nurse, you will write the case study based on your patient's condition. Given the understanding of the five main components of a nursing care plan, we also say that nursing care plans follow a five-step framework.

1. Assessment

The first step of writing a nursing care plan is to practice critical thinking skills and perform data collection. During this phase, you collect subjective and objective data. The source of subjective data is an interview with the caretakers, family members, or friends of the patient and the patient. The objective data are observed or measured by you, such as weight, height, heart rate, and respiratory rates. In this section of your nursing care plan, you will include the following:

• Verbal statements from the patient and those accompanying them
• Vital signs (heart rate, blood pressure, respiration, temperature, oxygen saturation)
• Physical complaints (headache, vomiting, nausea, pain, swelling)
• Body conditions (head-to-toe assessments)
• Medical history
• Physical features (height and weight)
• Concerns, perceptions, and feelings of the patient
• Lab findings
• Diagnostic tests (EKG, X-ray, echocardiogram, etc.)

2. Diagnosis

The success of this section depends on the accuracy of the data collected from the first part. Next, you need to select a nursing diagnosis that fits the goals and objectives of hospitalization. The diagnosis step entails analyzing the data from the first step or assessment. Writing good nursing diagnoses is a step in the right direction toward choosing nursing strategies targeting specific desired outcomes.

According to NANDA , nursing diagnosis is a clinical judgment about the human response to life processes or conditions. It also refers to vulnerability to that response by an individual, group, community, or family.

When writing a nursing diagnosis, it is essential to formulate it based on Maslow's Hierarchy of Needs Pyramid so that you can prioritize treatments and interventions. For instance, you need to prioritize the basic physiological needs before the higher needs, such as self-actualization and self-esteem. The rationale for first addressing the physiological/safety needs is that they form the foundations for nursing processes (care and intervention planning).

A good diagnosis identifies a problem (current health problem and the nursing interventions required), the risk factors or etiology (reasons for the problem/condition), and the characteristics of the problem (signs and symptoms).

Nursing diagnoses can be categorized into:

• Problem-focused diagnoses . The problems that present during the assessment of the patient. This is the actual diagnosis based on signs and symptoms. It could include shortness of breath, anxiety, acute pain, impaired skin integrity, etc.
• Risk nursing diagnoses . These are clinical judgments that a problem does not exist. However, the presence of risk factors predisposes the patient to the problem unless specific interventions are taken. Examples can include the risk of falls as evidenced by weak bones, the risk of injury as evidenced by altered mobility, the risk of infection as evidenced by immunosuppression, etc.
• Health Promotion or wellness diagnosis is a clinical judgment about the desire and motivation to increase well-being or reach one's health potential.
• Syndrome diagnoses . The clinical judgment concerns and combination of risk nursing diagnoses or problems that can occur due to specific events. Examples include chronic pain syndrome, frail elderly syndrome, etc.

You can read more from Nightingale College concerning nursing diagnosis .

Note that the nursing diagnoses will change as the client progresses through various stages of illness or maladaptation to resolve the problem or to the conclusion of a condition. Therefore, every decision must be time-bound, given that decisions might change as additional information is gathered.

When writing a student nursing care plan, you must provide a rationale for a specific diagnosis. This means including in-text citations from peer-reviewed nursing journal articles.

3. Outcomes

After writing the diagnosis section, you need to develop SMART (specific, measurable, achievable, relevant, and time-bound) goals based on evidence-based practice (EBP) guidelines and client-centered. To do this, you must consider the patient's overall condition, relevant information, and diagnosis.

The goals and desired outcomes describe what you expect to achieve by implementing specific nursing interventions or actions based on the diagnoses. The goals direct the intervention planning process and serve to evaluate the client's progress. When writing the goals, consider the medical diagnosis made by ad advanced healthcare practitioner or physician. It could include COPD, chronic kidney disease, heart failure, diabetes mellitus, diabetes ketoacidosis, obesity, thyroidectomy, hyper/hypothyroidism, cancer, Alzheimer's disease, endocarditis, eating disorders, acid-based balance disorders, fluid/electrolyte imbalance, etc.

The goals of the patient and expected outcomes can be short-term or long-term. Short-term goals immediately focus on the shift in behavior, mainly within a few hours or days. Long-term goals are objectives to be met over a long period, months or weeks.

When writing the goals and desired outcomes, you must include the subject, verb, conditions or modified, and criterion. Usually, they are written in the future tense.

Let's explore the four components:

• Subject. This refers to the client, any part of the client, or some attribute of the client. It could be vitals (temperature, urinary output, blood pressure)
• Verb. This specifies the specific action that the client will perform.
• Conditions or modifiers. These are the "what, where, when, and how?" added to the verb to explain the situations under which behavior is performed.
• Criterion . These are indicators of the standard by which a performance is measured and evaluated or the level at which the patient can comfortably and efficiently perform a given behavior or action.

Examples of goals and outcomes

• The patient will demonstrate adequate cardiac output as evidenced by vital signs within acceptable limits, no symptoms of heart failure, and absence of dysrhythmias.
• The client will identify individual nutritional needs within 36 hours
• The client will ambulate using a cane within 24 hours of surgery

4.  Nursing Interventions

Planning for nursing interventions or strategies is also called the implementation stage. You will be performing various nursing interventions, including following doctor's orders. Every intervention should be developed using evidence-based practice guidelines.

Interventions are classified into seven domains: family, physiological, community, complex physiological, safety, health system, and behavioral interventions. They can be implemented during shifts. Some interventions include pain assessment, listening, preventing falls, administering fluids, etc.

Nursing interventions refer to a set of activities or actions undertaken by a nurse in response to the diagnosis to achieve expected outcomes and meet a patient's goals.

The interventions majorly focus on eliminating or reducing the etiology of the nursing diagnosis. There are different types of nursing interventions:

• Independent nursing interventions . These are activities that the nurses can initiate based on their licensing, clinical judgment, and skills. They include ongoing assessments, emotional support, empathy, providing comfort, patient education, and referrals to other healthcare professionals.
• Dependent nursing interventions . These are activities undertaken through orders from physicians or supervisors. These can be orders to give specific medications, perform diagnostic tests, treatments, diets, or activities.
• Collaborative nursing interventions . Nurses undertake these actions in collaboration with other healthcare team members such as dietitians, physicians, social workers, and therapists.

When selecting a nursing intervention, it should be evidence-based, safe, appropriate for the client's age, health, and condition, and achievable. Every nursing intervention is followed with rationales, which are specific explanations about why a nursing intervention is the most appropriate given the diagnosis and the goals. When giving the rationales, you are expected to refer to your pathophysiological and psychological principles as a student. This means including in-text citations from peer-reviewed journals or clinical practice guidelines to support the choice of a specific intervention.

Nursing interventions are based on your identified needs during data collection or assessment. The timelines for the outcomes should reflect the anticipated length of stay and the individualized nurse-client expectations. You can create a mind map when conceptualizing the needs of the patient/client. The tool helps visualize the link between symptoms and interventions. It is why you will sometimes be asked by an instructor to do a NANDA concept or mind map before writing a nursing care plan assignment.

When writing a nursing strategy or intervention, you should be very specific. You should begin with an action verb that indicates what you are expected to do. You should also include qualifiers expressing how, when, where, time, amount, and frequency of the planned activity. For example:

• "Assist as needed with self-care activities each morning."
• "Record respiratory and pulse rates before, during, and after ambulating."
• "instruct the family in post-discharge care."

5. Evaluation and Documentation

This is the last step of the nursing care plan. As nursing care is provided, you will undertake ongoing assessments to evaluate the client's response to therapy and achieve the expected outcomes.

You should document the response to interventions, which is pretty much what evaluation is about. You can then adjust the care plan based on the information.

Evaluation helps identify the effectiveness of the nursing care plan. It also helps determine if the nursing processes were effective or if there is a need to terminate, continue, or change them.

When evaluating outcomes, you must label them as met, ongoing, or not. You can then decide whether the goals of the intervention need to be altered.

In most cases, all the goals are expected to be met by the time of discharge. However, you must prepare for that transition if a patient is discharged to a long-term care facility, nursing home, or hospice.

If everything is okay, you should document the nursing care plan (NCP) per the hospital's policy or standard operating procedure.

Nursing Care Plan Template for Nursing Students

Your instructor will give you a case study or patient scenario to write a nursing care plan. Some instructors also allow you to develop a nursing case study and write an appropriate nursing care plan. You can also use a real case from your shadowing, internship, or practicum experience. Whichever the case, you can use the template below if none is given. You should organize the nursing care plan into columns for easier entry and organization.

Your introduction should briefly revisit the case study. If requested, expound on the etiology of the medical diagnosis in the background section. The next section is your nursing care plan with columns of assessment, diagnosis, goals and outcomes, interventions, and evaluation, making it 5 columns . Some instructors only want three columns for nursing diagnosis, outcomes and evaluation, and interventions, while others insist on four columns for nursing diagnosis, goals and outcomes, interventions, and evaluation. Below is an example of the nursing care plan section:

The next section can include discharge planning, medication management, rest and activities, diet planning, ongoing care, sleeping, and follow-up.

Finally, write a conclusion that summarizes the entire nursing care plan and include a list of the references you used when writing the nursing care plan.

Sample Nursing Care Plan for Schizophrenia

Nursing Diagnosis : Ineffective coping skills and risk for hematologic side effects of Clozapine

Goals and expected outcomes

• To remain stable on medication and to transition into a less restrictive environment.
• Adequate rest and nutritional intake
• Establish communication and build trust, and encourage patients to participate in the therapeutic community.
• Increase ability to communicate with others.
• Symptom management; decrease in hallucination, delusions, and other psychotic features such as self-talk
• Increase self-esteem
• Subjective and Objective reduction of psychotic symptoms (an irrational behavior)
• Adhere to recommended therapy, including medications, psychotherapy, and lab appointments for hematology.

Nursing Interventions

• Assist the patient in identifying strengths and coping abilities ( nursing interventions) . Strength-based approaches help better recover schizophrenic patients (Xie, 2013). Emphasis on strength is a positive coping mechanism proven to buffer the impact of negative symptoms and promote rehabilitation of patients with schizophrenia (Tian et al., 2019). ( rationale)
• Meet monthly with the clinical team. Interprofessional teams help in the effective management of psychotic disorders such as schizophrenia. Psychiatrists and pharmacists can help improve the patient's status (Farinde, 2013).
• Obtain weekly Vital Signs. Interprofessional teams help in the effective management of psychotic disorders such as schizophrenia. Psychiatrists and pharmacists can help improve the patient's status (Farinde, 2013).
• Encourage all medications as prescribed. Adherence to pharmacological treatment helps alleviate the psychotic symptoms of schizophrenia, v. Non-adherence could lead to deterioration of the symptoms (El-Mallakh & Findlay, 2015).
• Provide opportunities for self-reflection, self-care, positive self-image, and effective communication. Encouraging healthy habits among schizophrenic patients helps optimize functioning, such as drug adherence, maintenance of sleep, reduced stress levels, self-care maintenance, and anxiety (Tian et al., 2019).
• Encourage outings and identify opportunities to reduce anxiety -enjoy music, poetry, and creative writing, and connect with a church spiritual group. Empathy helps the patient perceive the caregivers as caring and makes them feel accepted. It also helps the patients maintain positive coping mechanisms (Peixoto, Mour'o, & Serpa Junior, 2016).
• Monitor lab results (WBC and ANC) and report significant changes per Clozapine guidelines. Patients taking Clozapine must be monitored frequently as they are more predisposed to serious blood dyscrasias. In addition, discontinuing WBC monitoring after 6 months of starting the drug could lead to mortality and accidents (Kar, Barreto & Chandavarkar, 2016).
• Monitor for hematologic side effects: Neutropenia, leukopenia, agranulocytosis, and thrombocytopenia (secondary to bone marrow suppression caused by Clozapine). Clozapine has serious side effects such as seizures, cardiomyopathy, myocarditis, cardiomyopathy, neutropenia, ad agranulocytosis (Dixon & Dada, 2014).
• Instruct patient to report any side effects, illness, s/s of infection, fatigue, or bruising without apparent cause. Constant monitoring of psychotic symptoms helps change treatment (Holder, 2014). For instance, it can help determine if the antipsychotic medication is not working and include evidence-based psychosocial interventions (Stroup & Marder, 2015).
• Monitor anticholinergic effects; dry mouth, difficulty urinating, constipation.
• Monitor for reduction/increase of psychotic symptoms
• Discourage caffeine. Caffeine interacts with Clozapine and can lead to toxicosis. It increases the plasma concentrations of Clozapine (De Berardis et al., 2019). Caffeine inhibits the metabolism of Clozapine through the inhibition of CYP1A2 (Delacr�taz et al., 2018)
• The patient will have reduced symptoms, adhere to medication, and show improvement.
• The patient will control his feelings, perceptions, and thought processes.
• Social increasing ease of communication since starting Clozaril (date). The patient will easily interact with caregivers, family, and other patients.
• The patient will acknowledge the importance of medication in lowering suspicion.
• Self-talk has diminished since admission. The patient will also exhibit high self-esteem levels.
• The patient will have reduced anxiety and violent behavior and have remission.

Brekke, I. J., Puntervoll, L. H., Pedersen, P. B., Kellett, J., & Brabrand, M. (2019). The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review. PloS one , 14 (1), e0210875. https://doi.org/10.1371/journal.pone.0210875

De Berardis, D., Rapini, G., Olivieri, L., Di Nicola, D., Tomasetti, C., Valchera, A., ... & Serafini, G. (2018). Safety of antipsychotics for the treatment of schizophrenia: a focus on the adverse effects of Clozapine. Therapeutic advances in drug safety, 9(5), 237-256.

Delacr'taz, A., Vandenberghe, F., Glatard, A., Levier, A., Dubath, C., Ansermot, N.,  Eap, C. B. (2018). Association Between Plasma Caffeine and Other Methylxanthines and Metabolic Parameters in a Psychiatric Population Treated with Psychotropic Drugs Inducing Metabolic Disturbances. Frontiers in psychiatry , 9 , 573. https://doi.org/10.3389/fpsyt.2018.00573

Dixon, M., & Dada, C. (2014). How clozapine patients can be monitored safely and effectively.  The Pharmaceutical Journal, 6 (5), 131.

El-Mallakh, P., & Findlay, J. (2015). Strategies to improve medication adherence in patients with schizophrenia: the role of support services. Neuropsychiatric disease and treatment, 11 , 10771090. https://doi.org/10.2147/NDT.S56107

Farinde, A. (2013). Interprofessional Management of Psychotic Disorders and Psychotropic Medication Polypharmacy.  Health and Interprofessional Practice, 1 (4), 4.

Holder, D., S. (2014). Schizophrenia. American Family Physician, 90 (11), 775-782.

Kar, N., Barreto, S., & Chandavarkar, R. (2016). Clozapine Monitoring in Clinical Practice: Beyond the Mandatory Requirement. Clinical psychopharmacology and neuroscience: the official scientific journal of the Korean College of Neuropsychopharmacology, 14 (4), 323�329. https://doi.org/10.9758/cpn.2016.14.4.323

Lantta, T., H�t�nen, H. M., Kontio, R., Zhang, S., & V�lim�ki, M. (2016). Risk assessment for aggressive behavior in schizophrenia.  The Cochrane database of systematic reviews, 2016 (10). https://doi.org/ 10.1002/14651858.CD012397

Peixoto, M. M., Mour�o, A. C. D. N., & Serpa Junior, O. D. D. (2016). Coming to terms with the other's perspective: empathy in the relation between psychiatrists and persons diagnosed with schizophrenia.  Ciencia & saude coletiva, 21 (3), 881-890.

Stroup, T. S., & Marder, S. (2015). Pharmacotherapy for schizophrenia: Acute and maintenance phase treatment.  UpToDate .

Tian, C. H., Feng, X. J., Yue, M., Li, S. L., Jing, S. Y., & Qiu, Z. Y. (2019). Positive Coping and Resilience as Mediators between Negative Symptoms and Disability among Patients with Schizophrenia . Frontiers in psychiatry, 10 , 641.

Xie, H. (2013). Strengths-based approach for mental health recovery. Iranian journal of psychiatry and behavioral sciences, 7 (2), 5�10.

Writing the best nursing care plan can sound easy on paper, but the process is demanding and tiresome. If you are a nursing student who wants to delegate writing nursing care plans to someone who can help you do so accurately, affordably, and reliably, you can trust our care plan writers.

We are a nursing writing service website that offers assistance with completing various nursing assignments. The writers are experienced in research and writing nursing papers online. To date, we have supported the dreams of many nursing students, saving them time and money and maintaining their mental health.

Do not miss a deadline because you are busy with a shift; we can take over and make great things happen. Our nursing care plans are original, 100% plagiarism-free, and submitted to your email within your selected deadline. We also allow you to communicate with your writer to make changes together, share perspectives, and exchange ideas.

We can help you write care plans for type 2 diabetes, risk for injury, acute kidney injury, pressure ulcer, pulmonary embolism, chest pain, hypoglycemia, dementia, PTSD, hyperlipidemia, UTI, asthma, CHF, atrial fibrillation, bipolar disorder, risk for fall, ineffective coping, anemia, seizure, constipation, and any other condition or diagnosis.

Do not hesitate to contact us if you need help.

Important NOTICE!

The information in this article and the website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.

Related Readings:

• Topics for nursing essays and research papers.
• Steps and tips for making an abstract poster.
• How to write a complete SOAP Note assignment
• Ideas and potential topics for a nursing capstone paper.
• Approaches, tips, and steps for nursing capstone writing.

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How to Write a Nursing Care Plan

Nursing care plan components, nursing care plan fundamentals.

Knowing how to write a nursing care plan is essential for nursing students and nurses. Why? Because it gives you guidance on what the patient’s main nursing problem is, why the problem exists, and how to make it better or work towards a positive end goal. In this article, we'll dig into each component to show you exactly how to write a nursing care plan. 

A nursing care plan has several key components including, 

• Nursing diagnosis
• Expected outcome
• Nursing interventions and rationales

Each of the five main components is essential to the overall nursing process and care plan. A properly written care plan must include these sections otherwise, it won’t make sense!

• Nursing diagnosis - A clinical judgment that helps nurses determine the plan of care for their patients
• Expected outcome - The measurable action for a patient to be achieved in a specific time frame. 
• Nursing interventions and rationales - Actions to be taken to achieve expected outcomes and reasoning behind them.
• Evaluation - Determines the effectiveness of the nursing interventions and determines if expected outcomes are met within the time set.

>> Related: What is the Nursing Process?

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Before writing a nursing care plan, determine the most significant problems affecting the patient. Think about medical problems but also psychosocial problems. At times, a patient's psychosocial concerns might be more pressing or even holding up discharge instead of the actual medical issues. 

After making a list of problems affecting the patient and corresponding nursing diagnosis, determine which are the most important. Generally, this is done by considering the ABCs (Airway, Breathing, Circulation). However, these will not ALWAYS be the most significant or even relevant for your patient. 

Step 1: Assessment

The first step in writing an organized care plan includes gathering subjective and objective nursing data . Subjective data is what the patient tells us their symptoms are, including feelings, perceptions, and concerns. Objective data is observable and measurable.

This information can come from, 

Verbal statements from the patient and family

Vital signs

Blood pressure

Respirations

Temperature

Oxygen Saturation

Physical complaints

Body conditions

Head-to-toe assessment findings

Medical history

Height and weight

Intake and output

Patient feelings, concerns, perceptions

Laboratory data

Diagnostic testing

Echocardiogram

Step 2: Diagnosis

Using the information and data collected in Step 1, a nursing diagnosis is chosen that best fits the patient, the goals, and the objectives for the patient’s hospitalization. 

According to North American Nursing Diagnosis Association (NANDA), defines a nursing diagnosis as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.”

A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid and helps prioritize treatments. Based on the nursing diagnosis chosen, the goals to resolve the patient’s problems through nursing implementations are determined in the next step. 

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There are 4 types of nursing diagnoses.  

Problem-focused - Patient problem present during a nursing assessment is known as a problem-focused diagnosis

Risk - Risk factors require intervention from the nurse and healthcare team prior to a real problem developing

Health promotion - Improve the overall well-being of an individual, family, or community

Syndrome - A cluster of nursing diagnoses that occur in a pattern or can all be addressed through the same or similar nursing interventions

After determining which type of the four diagnoses you will use, start building out the nursing diagnosis statement. 

The three main components of a nursing diagnosis are:

Problem and its definition - Patient’s current health problem and the nursing interventions needed to care for the patient.

Etiology or risk factors - Possible reasons for the problem or the conditions in which it developed

Defining characteristics or risk factors - Signs and symptoms that allow for applying a specific diagnostic label/used in the place of defining characteristics for risk nursing diagnosis

PROBLEM-FOCUSED DIAGNOSIS

Problem-Focused Diagnosis related to ______________________ (Related Factors) as evidenced by _________________________ (Defining Characteristics).

RISK DIAGNOSIS

The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as evidenced by __________________________ (Risk Factors).

Step 3: Outcomes and Planning

After determining the nursing diagnosis, it is time to create a SMART goal based on evidence-based practices. SMART is an acronym that stands for,

It is important to consider the patient’s medical diagnosis, overall condition, and all of the data collected. A medical diagnosis is made by a physician or advanced healthcare practitioner.  It’s important to remember that a medical diagnosis does not change if the condition is resolved, and it remains part of the patient’s health history forever. 

Examples of medical diagnosis include, 

Chronic Lung Disease (CLD)

Alzheimer’s Disease

Endocarditis

Plagiocephaly 

Congenital Torticollis 

Chronic Kidney Disease (CKD)

It is also during this time you will consider goals for the patient and outcomes for the short and long term. These goals must be realistic and desired by the patient. For example, if a goal is for the patient to seek counseling for alcohol dependency during the hospitalization but the patient is currently detoxing and having mental distress - this might not be a realistic goal. 

Step 4: Implementation

Now that the goals have been set, you must put the actions into effect to help the patient achieve the goals. While some of the actions will show immediate results (ex. giving a patient with constipation a suppository to elicit a bowel movement) others might not be seen until later on in the hospitalization. 

The implementation phase means performing the nursing interventions outlined in the care plan. Interventions are classified into seven categories: 

Physiological

Complex physiological

Health system interventions

Some interventions will be patient or diagnosis-specific, but there are several that are completed each shift for every patient:

Pain assessment

Position changes

Fall prevention

Providing cluster care

Infection control

Step 5: Evaluation 

The fifth and final step of the nursing care plan is the evaluation phase. This is when you evaluate if the desired outcome has been met during the shift. There are three possible outcomes, 

Based on the evaluation, it can determine if the goals and interventions need to be altered. Ideally, by the time of discharge, all nursing care plans, including goals should be met. Unfortunately, this is not always the case - especially if a patient is being discharged to hospice, home care, or a long-term care facility. Initially, you will find that most care plans will have ongoing goals that might be met within a few days or may take weeks. It depends on the status of the patient as well as the desired goals. 

Consider picking goals that are achievable and can be met by the patient. This will help the patient feel like they are making progress but also provide relief to the nurse because they can track the patient’s overall progress. 

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Nursing care plans contain information about a patient’s diagnosis, goals of treatment, specific nursing interventions, and an evaluation plan. The nursing plan is constantly updated with changes and new subjective and objective data. 

Key aspects of the care plan include,

Outcome and Planning

Implementation

Through subjective and objective data, constantly assessing your patient’s physical and mental well-being, and the goals of the patient/family/healthcare team, a nursing care plan can be a helpful and powerful tool.

*This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.

Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

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Nursing Case Studies with Answers

Explore Nursing Case Studies with Answers and examples in Carepatron's free downloadable PDF. Enhance your nursing knowledge and prepare for exams with practical scenarios.

By Wynona Jugueta on Apr 08, 2024.

Fact Checked by Ericka Pingol.

What is a case study?

A case study in medicine is a detailed report of a patient's experience with a disease, treatment, or condition. It typically includes the patient's medical history, symptoms, diagnostic tests, treatment course, and outcome.

Some key things to know about medical case studies template . First, they delve deep into the specifics of a single case, providing a rich understanding of a particular medical situation.

Medical professionals use case studies to learn about rare diseases, unusual presentations of common conditions, and the decision-making process involved in complex cases.

Case studies can identify exciting areas for further investigation through more rigorous clinical trials. While informative, they can't be used to develop general treatment guidelines because they only focus on a single case.

Overall, medical case studies are valuable tools for medical education and research, offering insights into human health and disease complexities.

Printable Nursing Case Studies with Answers

Download this Nursing Case Studies with Answers to analyze complex clinical situations, identify priority needs, and develop effective care plans tailored to individual patients.

What is in a nursing case study?

A nursing case study is a detailed examination of a patient's health condition, treatment plan, and overall care journey, specifically from the perspective of nursing practice. These case studies are essential components of nursing education and professional development, providing valuable insights into clinical scenarios and patient care experiences.

In a case nursing study template , various elements are typically included to comprehensively understand the patient's situation. First and foremost, the case study outlines the patient's demographic information, including age, gender, medical history, and presenting symptoms. This demographic overview sets the stage for understanding the context in which healthcare interventions occur.

Moreover, nursing case studies often delve into the nursing assessment process, highlighting the initial and ongoing assessments nurses conduct to gather relevant patient health status data. These assessments involve physical examinations, vital sign monitoring, and assessment tools to identify potential health issues and risk factors.

Critical thinking skills are essential in nursing case studies, as they enable nurses to analyze complex clinical situations, identify priority needs, and develop effective care plans tailored to individual patients. Nursing students and experienced nurses use case studies as opportunities to enhance their critical thinking abilities and clinical decision-making processes.

Nursing case studies serve several vital purposes within healthcare education and professional practice, whether they are a primary care physician or a group of nursing students. Let's explore each purpose in detail:

Enhancing clinical reasoning skills

One primary purpose of nursing case studies is to enhance nursing students' and practicing nurses' clinical reasoning skills. By presenting realistic patient scenarios, case studies challenge individuals to analyze clinical data, interpret findings, and develop appropriate nursing interventions. This process promotes critical thinking and problem-solving abilities essential for effective nursing practice.

Applying theoretical knowledge to practice

Nursing case studies provide a bridge between theoretical knowledge and practical application. They allow nursing students to apply concepts learned in the classroom to real-world patient care situations. By engaging with case studies, students can integrate theoretical principles with clinical practice, gaining a deeper understanding of nursing concepts and their relevance to patient care.

Facilitating interdisciplinary collaboration

Another purpose of nursing case studies is to facilitate interdisciplinary collaboration among healthcare professionals. Nurses often collaborate with physicians, specialists, therapists, and other team members in complex patient cases to deliver comprehensive care. Case studies offer opportunities for nurses to explore collaborative decision-making processes, communication strategies, and teamwork dynamics essential for providing quality patient care.

Promoting evidence-based practice

Nursing case studies are crucial in promoting evidence-based practice (EBP) within nursing and healthcare settings. Nurses can make informed decisions about patient care interventions by analyzing patient scenarios and considering current research evidence. Case studies encourage nurses to critically evaluate research findings, clinical guidelines, and best practices to ensure the delivery of safe, effective, and patient-centered care.

Fostering professional development

Engaging with nursing case studies contributes to the ongoing professional development of nurses at all stages of their careers. For nursing students, case studies provide valuable learning experiences that help prepare them for clinical practice. For experienced nurses, case studies offer opportunities to refine clinical skills, stay updated on emerging healthcare trends, and reflect on past experiences to improve future practice.

How to write a nursing case study?

Writing a nursing case study involves several essential steps to ensure accuracy, relevance, and clarity. Let's break down the process into actionable steps:

Step 1: Select a patient case

Begin by selecting a patient case that presents a relevant and compelling healthcare scenario. Consider factors such as the patient's demographic information, medical history, presenting symptoms (e.g., joint stiffness, pain), and healthcare needs (e.g., medication administration, vital signs monitoring). Choose a case that aligns with your learning objectives and offers meaningful analysis and discussion opportunities.

Step 2: Gather relevant data

Collect comprehensive data about the selected patient case, including medical records, test results, nursing assessments, and relevant healthcare documentation. Pay close attention to details such as the patient's current health status, past medical history (e.g., diabetes), treatment plans, and any ongoing concerns or challenges. Utilize assessment tools and techniques to evaluate the patient's condition thoroughly and identify areas of clinical significance.

Step 3: Assess the patient's needs

Based on the gathered data, evaluate the patient's needs, considering physical, emotional, social, and environmental factors. Assess the patient's pain levels, mobility, vital signs, and other relevant health indicators. Identify any potential complications, risks, or areas requiring immediate attention. Consider the patient's preferences, cultural background, and individualized care requirements in your assessment.

Step 4: Formulate nursing diagnoses

Formulate nursing diagnoses that accurately reflect the patient's health needs and priorities based on your assessment findings. Identify actual and potential nursing diagnoses related to the patient's condition, considering factors such as impaired mobility, ineffective pain management, medication adherence issues, and self-care deficits. Ensure your nursing diagnoses are specific, measurable, achievable, relevant, and time-bound (SMART).

Step 5: Develop a care plan

Develop a comprehensive care plan outlining the nursing interventions and strategies to address the patient's identified needs and nursing diagnoses. Prioritize interventions based on the patient's condition, preferences, and care goals. Include evidence-based nursing interventions to promote optimal health outcomes, manage symptoms, prevent complications, and enhance the patient's overall well-being. Collaborate with other healthcare professionals as needed to ensure coordinated care delivery.

Step 6: Implement and evaluate interventions

Implement the nursing interventions outlined in the care plan while closely monitoring the patient's response to treatment. Administer medications, provide patient education, perform nursing procedures, and coordinate care activities to effectively meet the patient's needs. Continuously evaluate the effectiveness of interventions, reassessing the patient's condition and adjusting the care plan as necessary. Document all interventions, observations, and outcomes accurately and comprehensively.

Step 7: Reflect and seek assistance

Reflect on the nursing case study process, considering what worked well, areas for improvement, and lessons learned. Seek assistance from nursing instructors, preceptors, or colleagues if you encounter challenges or have concerns about the patient's care. Collaborate with interdisciplinary team members to address complex patient issues and ensure holistic care delivery. Continuously strive to enhance your nursing practice through ongoing learning and professional development.

Nursing Case Studies with Answers example (sample)

Below is an example of a nursing case study sample created by the Carepatron team. This sample illustrates a structured framework for documenting patient cases, outlining nursing interventions, and providing corresponding answers to guide learners through the analysis process. Feel free to download the PDF and use it as a reference when formulating your own nursing case studies.

Download this free Nursing Case Studies with Answers PDF example here 

Why use Carepatron as your nursing software?

Carepatron stands out as a comprehensive and reliable solution for nursing professionals seeking efficient and streamlined workflows in their practice. With a range of features tailored to the needs of nurses and healthcare teams, Carepatron offers unparalleled support and functionality for managing various aspects of patient care.

Nurse scheduling software

One of the key advantages of Carepatron is its nurse scheduling software , which simplifies the process of creating and managing schedules for nursing staff. With intuitive scheduling tools and customizable options, nurses can easily coordinate shifts, manage availability, and ensure adequate staffing levels to meet patient needs effectively.

Telehealth platform

In addition, Carepatron offers a robust telehealth platform that facilitates remote patient monitoring, virtual consultations, and telemedicine services. This feature enables nurses to provide continuity of care beyond traditional healthcare settings, reaching patients in remote areas or those unable to attend in-person appointments.

Clinical documentation software

Furthermore, Carepatron's clinical documentation software streamlines the documentation process, allowing nurses to easily capture patient data, record assessments, and document interventions. The platform supports accurate and efficient documentation practices, ensuring compliance with regulatory standards and promoting continuity of care across healthcare settings.

Commonly asked questions

In clinical terms, a case study is a detailed examination of a patient's medical history, symptoms, diagnosis, treatment, and outcomes, typically used for educational or research purposes.

Case studies are essential in nursing as they provide real-life scenarios for nurses to apply theoretical knowledge, enhance critical thinking skills, and develop practical clinical reasoning and decision-making abilities.

Case studies in nursing education offer benefits such as promoting active learning, encouraging problem-solving skills, facilitating interdisciplinary collaboration, and fostering a deeper understanding of complex healthcare situations.

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• v.35(2); 2020 Feb

Integrating Personalized Care Planning into Primary Care: a Multiple-Case Study of Early Adopting Patient-Centered Medical Homes

Rendelle e. bolton.

1 Center for Evaluating Patient-Centered Care in VA, Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Memorial Veterans Hospital US Department of Veterans Affairs, 200 Springs Road, Bedford, MA 01730 USA

2 Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453 USA

Barbara G. Bokhour

3 Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118 USA

Timothy P. Hogan

4 Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA 01605 USA

Tana M. Luger

5 Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, 650 Charles Young Dr. S. 31-269 CHS, Box 951772, Los Angeles, CA 90095-1772 USA

Mollie Ruben

6 Department of Psychology, University of Maine, 5742 Clarence Cook Little Hall, Orono, ME 04469 USA

7 Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System, US Department of Veterans Affairs, 150 South Huntington Avenue, Boston, MA 02130 USA

Gemmae M. Fix

Personalized care planning is a patient-centered, whole-person approach to treatment planning. Personalized care plans improve patient outcomes and are now mandated for chronic care management reimbursement. Yet guidance on how to best implement personalized care planning in practice is limited.

We examined the adoption of personalized care planning in patient-centered medical home (PCMH) clinics to identify processes and organizational characteristics that facilitated or hindered use in routine practice.

Qualitative multiple-case study design. We conducted site visits at PCMH clinics in four US Veterans Health Administration (VHA) medical centers. Data included 10 general clinic observations, 34 direct observations of patient-provider clinical encounters, 60 key informant interviews, and a document review. Data were analyzed via qualitative content analysis using a priori and emergent coding.

Participants

Employees and patients participating in clinical encounters in PCMH clinics at four VHA medical centers.

Key Results

Each clinic used a distinct approach to personalized care planning: (1) distributed tasks approach; (2) two-tiered approach; (3) health coaching approach; and (4) leveraging a village approach. Each varied in workflow, healthcare team utilization, and degree of integration into clinical care. Across sites, critical components for implementation included expanding planning beyond initial assessment of patient priorities; framing the initiative for patients; using a team-based approach to care plan development and updates; using communication mechanisms beyond the electronic health record; and engaging stakeholders in implementation planning.

Conclusions

Personalized care planning is a novel patient-centered practice, but complicated to implement. We found variation in effective implementation and identified critical components to structuring this practice in a manner that engages patients in treatment aligned with personal priorities. Primary care practices seeking to implement personalized care planning must go beyond simply asking patients a series of questions to establish a plan. They must also engage team members in plan development, communication, and dissemination.

INTRODUCTION

Personalized care planning, a process to collaboratively develop care plans tailored to patient priorities and social contexts, is increasingly important to providing high-quality, patient-centered care. 1 – 3 Despite varying contents and terminologies (e.g., personalized care plans, comprehensive shared care plans), these approaches incorporate common elements including (a) patient-provider discussions to identify goals; (b) development of holistic plans that attend to clinical and non-clinical needs; and (c) mechanisms to share plans across providers to coordinate care. 1 Consonant with goal-directed care, these plans are designed to align healthcare with what matters most to patients, shifting away from a disease-oriented paradigm. 4 – 7 Often used with medically complex patients, personalized care plans have been effective in improving outcomes when integrated into routine care 8 and are now mandated by the Centers for Medicare and Medicaid Services for chronic care management reimbursement. 9

In 2013, the US Veterans Health Administration (VHA) initiated a version of personalized care planning known as personal health planning (PHP). Consistent with approaches described above, PHP is a mechanism to collaboratively develop care plans aligned with patients’ personal goals and social contexts. In its idealized form, PHP is a process involving assessment of patients’ priorities, shared goal identification, and services supporting goal attainment (Fig. ​ (Fig.1). 1 ). Key features include patient-centered communication, incorporation of non-clinical domains like spirituality or relationships, and care coordination across the healthcare system. 10 Adoption is underway across VHA, often in primary care clinics organized according to the patient-centered medical home (PCMH) model. 11 Given PCMH’s emphasis on whole-person care, patient-centered dialogues, and care tailored to patient preferences, these settings align well with the goals of PHP and conceptually are an ideal match for PHP implementation. 12 – 16

Components of personal health planning. Adapted from VHA Office of Patient-Centered Care and Cultural Transformation.

Yet integrating personalized care planning into routine practice is not well understood and may present considerable challenges. 6 Unlike implementing direct-care guidelines such as disease screening or surgical checklists, PHP requires a cultural shift to shape care around patient priorities. 3 , 6 , 10 This shift is similar to the implementation of other complex initiatives including PCMH, requiring buy-in, role negotiation, coordination, and integration with clinical informatics. 17 – 23 Although research on challenges specific to personalized care planning implementation is limited, one feasibility study of PHP identified similar challenges. 10

Therefore, we sought to characterize how personalized care planning was structured and implemented early in VHA’s adoption of this practice. What organizational characteristics facilitated implementation, and which provided challenges? We examine PHP adoption in four VHA PCMH clinics to provide insights into healthcare organizations seeking to incorporate similar patient-centered care practices into routine care.

Study Design

We used a qualitative multiple-case study design 24 – 26 to examine PHP implementation in primary care at four VHA hospitals. Consistent with case study approaches, 24 , 26 we treated each site’s implementation of PHP in one PCMH clinic as a case. We use the terms case, site, and clinic interchangeably. We conducted direct observations of care and key informant interviews, and collected documents relevant to PHP to provide in-depth understanding of the organizational context and adoption approach at each site. As this project was intended to inform VHA operations on PHP implementation, the Bedford VHA Hospital Institutional Review Board designated this study quality improvement, exempting it from further oversight.

Recruitment and Participants

We selected four sites in collaboration with the national office leading PHP implementation based on program robustness, including PHP documentation in the electronic health record (EHR), programs running for at least 1 year, and PHPs conducted with a general patient population. We worked with individuals leading implementation at each site to coordinate a multi-day visit. Clinic employees and patients were invited to participate. We informed individuals that participation was voluntary, was confidential, and would not impact their employment or (for patients) their healthcare. Assent was obtained from all participants.

Data Collection

During 2–3-day site visits between April 2014 and June 2015, investigators conducted (a) general clinic observations; (b) direct observations of clinical encounters; (c) semi-structured interviews with clinic leadership, PCMH team members, other clinic staff, and patients; and (d) review of PHP-related documents. Investigators spent each site visit day in the clinics, conducting observations and inviting clinic employees and a convenience sample of patients present that day to participate in interviews. They also requested copies of PHP-related documents used in the clinic, including EHR templates, and noted posted media about PHP, photographing clinic spaces when possible. Table ​ Table1 1 describes the data collected to support each case. Observations were recorded in field notes to capture key aspects of PHP implementation, communication about PHP, and patient-provider interactions. 27 Interviews focused on experiences with PHP, adoption facilitators/barriers, integration with existing clinical practices, and the clinical team’s role in PHP.

Data Collected to Support Each Case

We conducted a directed content analysis 28 using a priori codes based on principles of patient-centered care. 29 Emergent categories captured additional content relevant to PHP adoption and processes. Six team members coded data in pairs, by site, sorting data into categories to capture relevant content. The entire team discussed coding to ensure consensus. Consistent with case study methodology, 25 , 26 we developed a synthesis for each case by reviewing individual data summaries in coding categories, using constant comparison and summarizing findings for each site. Finally, we compared case-level summaries to understand differences in implementation between sites.

We identified four distinct approaches to implementing PHP at the sites studied: (1) distributed tasks approach; (2) two-tiered approach; (3) health coaching approach; and (4) leveraging a village approach. To characterize each approach, we describe three domains that varied among the sites: clinic context, PHP workflow, and PHP integration (the extent to which PHP was incorporated into clinical care). Findings from general observations ( n = 10), direct observations of clinical encounters ( n = 34), semi-structured interviews ( n = 60), and PHP-related documents ( n = 7) are presented below. Some quotations are included to illustrate specific points. Table ​ Table2 2 provides an overview of the PHP approach at each site.

PHP Approach in Four VHA Primary Care Clinics

All four clinics were selected by site leadership to implement PHP, with discretion in how to locally operationalize the initiative. Each clinic comprised multiple PCMH teams that included a clerk, nursing assistant (NA), nurse (RN), and primary care provider (PCP). Other professionals (e.g., social workers, clinical pharmacists, nutritionists) worked across teams. All clinics retained the components of the PHP model (Fig. ​ (Fig.1) 1 ) including making referrals to known service providers within and outside of the clinic to help patients achieve selected goals. Sites relied on templated progress notes in the EHR to share PHPs. Finally, all sites received support from the national office leading PHP via monthly calls and a centralized website.

Case 1—Distributed Tasks Approach

This Southwestern PCMH clinic received national funding to promote patient-centered care initiatives including PHP. Facility leadership selected this clinic to implement PHP, perceiving this newly opened clinic as an opportunity to test new programs. Staff input on PHP adoption was incorporated through staff-wide meetings.

Patients were chosen in advance for PHP; the nurse reported that she “scrubbed” the appointment list, identifying patients she subjectively thought would be interested in or benefit from a PHP. For selected patients, PHP development was distributed across the PCMH team, engaging all members except the clerk. The nursing assistant would read questions from an EHR template to assess patient priorities and patient self-ratings of current and desired health status. The RN used patient responses documented in the EHR to collaboratively identify goals and develop an action plan. The PCP then briefly reviewed the plan with the patient and approved referrals. Plans were largely based on available VHA and community-based referral options, selected from an existing list.

Integration

PHP was well-incorporated into clinical routines, occurring alongside other tasks. For example, we observed the NA seamlessly move from history-taking and asking prevention questions (e.g., seatbelt use) into asking PHP assessment questions. However, the contrast between routine clinical versus self-reflective questions (e.g., “what brings you joy?”) were unexpected. Several patients were visibly surprised and even tearful as they self-reflected, with one patient later reporting the “personal (questions)…caught me off guard.”

Despite PHP incorporation into clinical routines, we observed care to be minimally organized around patient priorities, including a fixed approach for referrals to address selected goals. For example, all patients observed were referred to a weight loss program, despite only one specifying weight management as his goal. Although PCPs reviewed plans and approved referrals, we observed few conversations with patients about their priorities. Similarly, despite multiple team members engaged in PHP development, we observed minimal communication about PHP among team members. Staff described limited communication with services to which patients had been referred, hindering knowledge of whether patients were receiving adequate support to reach goals. Finally, while posters with PHP-related information were ubiquitous, patients reported unfamiliarity with the initiative.

Case 2—Two-Tiered Approach

This recently redesigned PCMH clinic in a large Northeastern hospital also received national funding to promote patient-centered care. In addition to common PCMH staff, this site employed a health coach to support patients. 30 , 31 Hospital leadership selected this clinic for PHP as part of its cultural transformation to emphasize wellness. Leadership provided organizational supports including policies to ease providers’ administrative responsibilities. Staff received mentoring in patient-centered communication, including PHP, during a weekly half-day in-service.

PHP occurred through a two-tiered approach. First, PCPs would routinely ask all patients three questions to assess patient priorities, gauge patient perceptions of health, and explore interest in health coaching. The health coach would then work with interested patients to develop a PHP. She oriented patients to this process by describing it as “identify(ing) hurdles to help you be your best self.” Once completed, the health coach would provide ongoing support, refer patients for services, and regularly check-in. She characterized her work as the “umbrella” under which patients’ needs were addressed.

We observed that most PCPs incorporated the three questions into clinical encounters but varied in their comfort initiating these conversations. Sometimes the questions were “tacked on” at the end of the encounter, visibly confusing patients who felt they had already expressed their concerns (e.g., pain management). Care was variably tailored to patient priorities: in our observations, some providers and the health coach exemplified patient-centered interactions; others retained provider-driven approaches. Within-team communication about PHP was limited. While problem-solving around general PHP use was explored during weekly in-services, participants reported rarely discussing individual PHPs during smaller team huddles. The health coach shared PHPs with referral services via phone and EHR to coordinate care.

Case 3—Health Coaching Approach

Like site 2, this large Midwestern PCMH clinic employed a health coach. It additionally utilized RN care managers to provide chronic disease management services. The impetus for PHP arose from a regional effort to promote relationship-based care, a model that emphasizes patient-centered communication and patient-provider relationships. 32 A nurse executive led PHP adoption, working closely with the health coach.

PCPs identified patients with chronic conditions whom they felt would benefit from PHP. Receptive patients were referred to the health coach, who developed PHPs. He also provided ongoing support to facilitate goal achievement and linked patients with clinical and non-clinical services. RN care managers from two PCMH teams partnered closely with the health coach to develop PHPs for shared patients.

PHP was fully incorporated into the health coach’s work and PHP posters were hung by his office. While the RN care managers routinely aligned their care with patients’ PHPs, we observed little evidence of integration elsewhere. The health coach was primarily responsible for PHP, with staff members noting that PHP would likely end if he left. Communication was limited, with the health coach reporting rare opportunities to share PHPs with PCMH team members. He felt regularly excluded from huddles due to a lack of recognition of his value as a paraprofessional, describing himself as “gum on the bottom of a shoe” in the eyes of most of PCPs.

We also found varied awareness of PHP among providers to whom patients were referred. For example, a social worker was unfamiliar with PHP. Others with familiarity reported rarely aligning care with PHPs. For example, a clinical pharmacist described looking for PHPs only in “cricket situations” when patients didn’t “volunteer” information. Instead, providers to whom patients were referred developed provider-driven care plans in accordance with their scopes of practice: “[My] plan has more to do with the goals that we actually set for the patients... [We] make sure that they’re onboard…I mean I’m never going to tell a patient, ‘You need to do this,’ without them…acquiescing” (nutritionist).

Case 4—Leveraging a Village Approach

This semi-rural Pacific Northwest PCMH clinic shared space with mental health and nutrition services, facilitating awareness of PHP. Efforts were underway to have clerks who traditionally filled clerical roles be involved in PHP, even training them as paraprofessional health coaches. PHP was blended with other health promotion activities, and adoption was led by a nurse executive and health promotion program manager. Staff described involvement in adoption planning to make the process “patient-friendly.”

PHP was facilitated through a standardized form probing patient priorities and interest in existing referral options. Clerks introduced the concept and patients completed the form independently preceding the visit. Staff then reviewed the form with the patient during the encounter, initiating referrals based on the patient’s responses. Upon check-out, the clerk revisited the plan developed to ensure patient understanding and awareness of referrals. The RN later called patients to discuss their PHP.

Clerks introduced PHP to patients as a new way of practicing healthcare, framing PHP as a shift to patient-driven care, where “if we know what matters most to you, then we can make it what matters most to us too.” While PCPs reported using the form in clinical encounters, our observations revealed inconsistencies: not all providers viewed the form or used it in treatment planning. Further, the list of referral options was not always responsive to patients: we observed some patients decline PHP due to lack of interest in available services.

Communication about established PHPs varied. Clerks and the RN reviewed progress with patients, yet PHP was largely absent from patient-PCP discussions and team huddles. The clinic’s medical director did not view PHPs in the EHR, expressing uncertainty about where to look. Unlike other clinics, referral providers were familiar with PHP and used it to guide care. For example, a mental health practitioner described reviewing PHPs to orient herself to patients’ goals, social context, and interests, allowing her to align treatment.

Themes Across Cases

Although sites differed in their approach to PHP, we identified five overarching areas for facilitating implementation: using an iterative approach; framing the PHP; using a team-based approach; communicating beyond the EHR; and team engagement in implementation planning.

Using an Iterative Approach

When sites used PHP as an iterative process, they achieved better incorporation of patient goals in care planning. We found that sites 2 and 3 achieved richer PHP integration through their respective approaches, where plans were developed and revised as patients’ lives evolved. An embedded health coach followed patients and provided ongoing support to achieve goals. Alternatively, sites 1 and 4 treated PHP development like other clinical tasks, lacked follow-up on patient goals, and based plans on pre-identified referral options.

Framing the PHP

Sites that framed PHP better oriented patients to its purpose and engaged them at the start. At site 4, clerks described PHP to patients upon giving them the PHP form in advance of their appointment, while health coaches at sites 2 and 3 spent time introducing patients to the concept of PHP and health coaching services. In contrast, when framing was absent, patients struggled to respond to PHP questions or identify personal priorities and goals. At site 2, in the absence of the health coach, we observed a provider asked the “what really matters” question at the end of the clinical encounter. This resulted in confusion for the patient who replied that his previously discussed pain was what mattered. A similar pattern was found at site 1, where patient confusion and distress were observed when PHP questions were asked without adequate framing.

Using a Team-Based Approach

We identified two disparate styles to PHP development in the context of team-based care: spreading responsibility across team members (sites 1 and 4) versus reliance on health coaches (sites 2 and 3). When PHP was not addressed by all team members (sites 2 and 3), we found that clinical conversations by uninvolved healthcare workers failed to acknowledge and align treatment with patient priorities. Alternatively, at site 3, where RN care managers were included in PHP conversations, we observed strong alignment between care and patient priorities. Simultaneously, at this same site, the failure of the nutritionist and clinical pharmacist to utilize PHPs to guide care planning resulted in unaligned, provider-driven treatment.

Communicating Beyond the EHR

We found important communication gaps at all sites despite consistent EHR documentation. Across all sites, the EHR was the primary communication mechanism, yet alone was insufficient. Discussions about patients’ PHPs were excluded from huddles, team meetings, and other routine team communications at all sites, unless informally initiated by the person charged with leading PHP. Subsequently, not all team members were familiar with patient goals or developed plans. At site 3, PCPs were unfamiliar with the process, which they perceived as the responsibility of the health coach; at site 4, not all PCPs were aware they could view the PHP in the EHR.

Team Engagement for Implementation

Most sites engaged clinic staff in PHP design, facilitating its awareness and use. This was accomplished through half-day planning retreats, periodic staff meetings to review adoption challenges, and incorporation of ideas across all staff members (e.g., patient-friendly edits to the form used at site 4). Notably, however, PCPs across most sites were minimally engaged with implementation planning, resulting in less PHP familiarity and use.

We found substantial variation in PHP implementation in four VHA PCMH clinics, including variation in workflow, ownership and delegation, staff engagement, and utilization. Like PCMH reorganization, 13 PHP was envisioned as a way to transform treatment planning. The approaches taken by the sites studied achieved varying degrees of success incorporating PHP into clinical routines, organizing care around patient priorities, and communicating about PHP. Even the early adopting sites with robust PHP practices profiled in our study faced challenges. Our findings provide several important insights into future adoption of personalized care planning programs like PHP.

Personalized care planning is more than a set of questions for patients to answer. It is a process to orient care around patient priorities, with follow-up conversations enabling plan revisions responsive to patients’ evolving lives. 1 , 2 , 10 Sites in our study variably achieved this spirit, with two sites accomplishing this goal via ongoing health coaching. The remaining sites approached PHP as a box to be checked, which did not always align with patient priorities. As we have described elsewhere, 6 , 33 in the absence of broader efforts to transform culture, care planning initiatives like PHP are at risk of being implemented in a manner similar to other quality improvement tools such as clinical reminders or checklists. Our case study findings substantiate this argument. As primary care clinics adopt personalized care planning initiatives, conceptualizing planning as an iterative process that routinely engages patients in conversations about what really matters better aligns care with patients’ needs. Some sites in our study subjectively selected patients perceived to be good candidates for PHP, perhaps due to limited time and resources. In an ideal world, all patients would have the opportunity to explore and share their health goals with providers, ensuring care that considers patients’ life contexts. 7 , 34 However, in contexts with limited resources, focusing PHP on patients with complex chronic conditions may be warranted.

Patient-centered care initiatives, like PHP, are distinctly different from other disease-centric programs. They necessitate different patient-provider interactions, recognizing patients as experts in their own lives and collaboratively engaging stakeholders, including patients and care team members alike, as partners. 5 This may be very different for patients who are used to traditional, prescriptive care. Indeed, in our study, we found that patients were unaccustomed to this approach; lack of framing resulted in confusion and distress. Future PHP adoption efforts should attend to framing as a key component. Using clerks to introduce PHP, as one site in our study did, may help orient patients and unburden busy providers while achieving a key PCMH goal of optimizing staffs’ responsibilities. 35

We found that PHP adoption required an integrated, team-based approach consistent with the PCMH model 36 , 37 for its successful incorporation into clinical care. Sites in our study took two overarching approaches to incorporating PHP in teams: one spread responsibility; the other centralized responsibility among health coaches. While spreading responsibility better engages all team members, it requires role shifts and communication to become fully integrated into care. This was difficult for the clinics in our study to achieve in practice. Alternatively, while placing responsibility on a single team member (e.g., health coach) created deeper collaboration with patients and facilitated patient goal–directed care, it failed to adequately engage the full team, particularly PCPs. With core principles of team-based care comprising mutual goals, role clarity, trust, and communication, 22 , 37 future implementation should carefully consider team-based approaches to develop and disseminate plans that engage but not overburden already busy members by identifying a PHP lead or point person within the team.

Communication is critical for coordination across healthcare systems, and informatics applications increasingly play a role in such efforts. 38 The EHR is necessary to enable asynchronous coordination around personalized care plans. 1 , 2 However, in our study, clinics’ reliance on the EHR was insufficient to share PHPs across the team and coordinate care around patient priorities. Developing EHR mechanisms that better represent complex evolving patient goals and readily display this information is needed for successful PHP implementation. Moreover, if PHP is to truly become a living document that originates in primary care and is brought forward through all aspects of care, then healthcare systems must incorporate additional communication mechanisms to ensure shared awareness of patient goals. Incorporating discussions of PHP into team huddles may be one strategy to facilitate better communication. 19 , 39

Successful implementation of new practices requires buy-in among those tasked with delivery. When stakeholders are engaged in the design of new practice innovations, they may be more likely to adopt them. 40 , 41 In our study, engaging clinic staff was critical to PHP implementation. Yet sites struggled to adequately engage PCPs in the PHP process, mirroring research on how demands faced by PCPs may limit engagement in transformational initiatives. 13 , 22 , 39 , 42 This raises important questions for future research regarding the role of PCPs as team leaders in PCMH and related distribution of work when implementing PHP. Further, when providers both in and outside of the clinic have limited knowledge of PHP, patients may receive mixed messages about treatment priorities. Clinics seeking to implement initiatives like PHP should engage stakeholders early and continue to promote PHP once implemented.

LIMITATIONS

This study examined PHP adoption in only four VHA PCMH clinics, all utilizing different approaches to PHP. There are likely additional approaches to PHP implementation not captured in our study. Transferability of our findings to other sites will depend in part on similarities with the sites we describe here. Future research should examine personalized care planning adoption in other healthcare organizations, expand studies to include additional aspects of implementation such as cost, and test how variation in implementation relates to patient and organizational outcomes.

Personalized care planning has the potential to transform how healthcare is delivered, intimately engaging patients in their treatment and aligning care with their priorities. Yet providers are unlikely to be successful implementing personalized care planning on their own without broader infrastructure and cultural transformation initiatives to support its integration into care. As healthcare organizations continue to adopt these practices, attention must be given to planning as an ongoing process and framing this new approach for patients and providers alike. Implementation should include the healthcare team in program design, and thoughtfully engage them in the development, communication, and dissemination of personalized care plans. While embedding plans in the EHR is necessary, it is not enough to promote shared understanding and system-level coordination aligned with patient goals. Establishing patient and team-centered communication mechanisms will be critical to truly implementing personalized care plans as a patient-centered innovation in practice.

Acknowledgments

Thank you to Jeffrey Solomon, PhD, for his assistance with data collection; Therasia Roland, MSW, for her assistance with data coding; and Juliet Wu, BS, for her assistance with manuscript preparation.

Funding Information

This study was funded by the US Department of Veterans Affairs, Office of Patient-Centered Care and Cultural Transformation, and the Quality Enhancement Research Initiative (grant no. PCE13-001). Dr. Fix is a VA HSR&D Career Development awardee at the Bedford VA (CDA no. 14-156).

Compliance with Ethical Standards

As this project was intended to inform VHA operations on PHP implementation, the Bedford VHA Hospital Institutional Review Board designated this study quality improvement, exempting it from further oversight. Verbal assent was obtained from all participants.

The authors declare that they do not have a conflict of interest.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US Government.

Prior Presentations

This paper has not previously been presented.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Prostate Cancer: Survivorship Care Case Study, Care Plan, and Commentaries

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• 1 Saint Joseph Hospital.
• 2 Saint Louis University.
• PMID: 34800113
• DOI: 10.1188/21.CJON.S2.50-56

This case study highlights the patient's status in care plan format and is followed by commentaries from expert nurse clinicians about their approach to manage the patient's long-term or chronic cancer care symptoms. Finally, an additional expert nurse clinician summarizes the care plan and commentaries, emphasizing takeaways about the patient, the commentaries, and additional recommendations to manage the patient. As can happen in clinical practice, the patient's care plan is intentionally incomplete and does not include all pertinent information. Responding to an incomplete care plan, the nurse clinicians offer comprehensive strategies to manage the patient's status and symptoms. For all commentaries, each clinician reviewed the care plan and did not review each other's commentary. The summary commentary speaks to the patient's status, care plan, and nurse commentaries.

Keywords: cancer; care plan; nursing; prostate cancer; survivorship care.

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• Survivorship*

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Case study: a patient with uncontrolled type 2 diabetes and complex comorbidities whose diabetes care is managed by an advanced practice nurse.

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Geralyn Spollett; Case Study: A Patient With Uncontrolled Type 2 Diabetes and Complex Comorbidities Whose Diabetes Care Is Managed by an Advanced Practice Nurse. Diabetes Spectr 1 January 2003; 16 (1): 32–36. https://doi.org/10.2337/diaspect.16.1.32

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The specialized role of nursing in the care and education of people with diabetes has been in existence for more than 30 years. Diabetes education carried out by nurses has moved beyond the hospital bedside into a variety of health care settings. Among the disciplines involved in diabetes education, nursing has played a pivotal role in the diabetes team management concept. This was well illustrated in the Diabetes Control and Complications Trial (DCCT) by the effectiveness of nurse managers in coordinating and delivering diabetes self-management education. These nurse managers not only performed administrative tasks crucial to the outcomes of the DCCT, but also participated directly in patient care. 1  

The emergence and subsequent growth of advanced practice in nursing during the past 20 years has expanded the direct care component, incorporating aspects of both nursing and medical care while maintaining the teaching and counseling roles. Both the clinical nurse specialist (CNS) and nurse practitioner (NP) models, when applied to chronic disease management, create enhanced patient-provider relationships in which self-care education and counseling is provided within the context of disease state management. Clement 2 commented in a review of diabetes self-management education issues that unless ongoing management is part of an education program, knowledge may increase but most clinical outcomes only minimally improve. Advanced practice nurses by the very nature of their scope of practice effectively combine both education and management into their delivery of care.

Operating beyond the role of educator, advanced practice nurses holistically assess patients’ needs with the understanding of patients’ primary role in the improvement and maintenance of their own health and wellness. In conducting assessments, advanced practice nurses carefully explore patients’ medical history and perform focused physical exams. At the completion of assessments, advanced practice nurses, in conjunction with patients, identify management goals and determine appropriate plans of care. A review of patients’ self-care management skills and application/adaptation to lifestyle is incorporated in initial histories, physical exams, and plans of care.

Many advanced practice nurses (NPs, CNSs, nurse midwives, and nurse anesthetists) may prescribe and adjust medication through prescriptive authority granted to them by their state nursing regulatory body. Currently, all 50 states have some form of prescriptive authority for advanced practice nurses. 3 The ability to prescribe and adjust medication is a valuable asset in caring for individuals with diabetes. It is a crucial component in the care of people with type 1 diabetes, and it becomes increasingly important in the care of patients with type 2 diabetes who have a constellation of comorbidities, all of which must be managed for successful disease outcomes.

Many studies have documented the effectiveness of advanced practice nurses in managing common primary care issues. 4 NP care has been associated with a high level of satisfaction among health services consumers. In diabetes, the role of advanced practice nurses has significantly contributed to improved outcomes in the management of type 2 diabetes, 5 in specialized diabetes foot care programs, 6 in the management of diabetes in pregnancy, 7 and in the care of pediatric type 1 diabetic patients and their parents. 8 , 9 Furthermore, NPs have also been effective providers of diabetes care among disadvantaged urban African-American patients. 10 Primary management of these patients by NPs led to improved metabolic control regardless of whether weight loss was achieved.

The following case study illustrates the clinical role of advanced practice nurses in the management of a patient with type 2 diabetes.

A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 1997, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 118–127 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lb.”), but no further action was taken.

Referred by his family physician to the diabetes specialty clinic, A.B. presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon.

A.B. also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken chromium picolinate, gymnema sylvestre, and a “pancreas elixir” in an attempt to improve his diabetes control. He stopped these supplements when he did not see any positive results.

He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control. “What would knowing the numbers do for me?,” he asks. “The doctor already knows the sugars are high.”

A.B. states that he has “never been sick a day in my life.” He recently sold his business and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, A.B. has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies.

During the past year, A.B. has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG).

A.B.’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports, “when the cost of cigarettes topped a buck-fifty.”

The medical documents that A.B. brings to this appointment indicate that his hemoglobin A 1c (A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ≤130/80 mmHg for both cardiovascular and renal health. 11  

A.B. has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years.

Physical Exam

A physical examination reveals the following:

Weight: 178 lb; height: 5′2″; body mass index (BMI): 32.6 kg/m 2

Fasting capillary glucose: 166 mg/dl

Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg

Pulse: 88 bpm; respirations 20 per minute

Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriolovenous nicking, no retinopathy

Thyroid: nonpalpable

Lungs: clear to auscultation

Heart: Rate and rhythm regular, no murmurs or gallops

Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally

Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle

Lab Results

Results of laboratory tests (drawn 5 days before the office visit) are as follows:

Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)

Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)

Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)

Sodium: 141 mg/dl (normal range: 135–146 mg/dl)

Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)

Lipid panel

    • Total cholesterol: 162 mg/dl (normal: <200 mg/dl)

    • HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl)

    • LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl)

    • Triglycerides: 177 mg/dl (normal: <150 mg/dl)

    • Cholesterol-to-HDL ratio: 3.8 (normal: <5.0)

AST: 14 IU/l (normal: 0–40 IU/l)

ALT: 19 IU/l (normal: 5–40 IU/l)

Alkaline phosphotase: 56 IU/l (normal: 35–125 IU/l)

A1C: 8.1% (normal: 4–6%)

Urine microalbumin: 45 mg (normal: <30 mg)

Based on A.B.’s medical history, records, physical exam, and lab results, he is assessed as follows:

Uncontrolled type 2 diabetes (A1C >7%)

Obesity (BMI 32.4 kg/m 2 )

Hyperlipidemia (controlled with atorvastatin)

Peripheral neuropathy (distal and symmetrical by exam)

Hypertension (by previous chart data and exam)

Elevated urine microalbumin level

Self-care management/lifestyle deficits

    • Limited exercise

    • High carbohydrate intake

    • No SMBG program

Poor understanding of diabetes

A.B. presented with uncontrolled type 2 diabetes and a complex set of comorbidities, all of which needed treatment. The first task of the NP who provided his care was to select the most pressing health care issues and prioritize his medical care to address them. Although A.B. stated that his need to lose weight was his chief reason for seeking diabetes specialty care, his elevated glucose levels and his hypertension also needed to be addressed at the initial visit.

The patient and his wife agreed that a referral to a dietitian was their first priority. A.B. acknowledged that he had little dietary information to help him achieve weight loss and that his current weight was unhealthy and “embarrassing.” He recognized that his glucose control was affected by large portions of bread and pasta and agreed to start improving dietary control by reducing his portion size by one-third during the week before his dietary consultation. Weight loss would also be an important first step in reducing his blood pressure.

The NP contacted the registered dietitian (RD) by telephone and referred the patient for a medical nutrition therapy assessment with a focus on weight loss and improved diabetes control. A.B.’s appointment was scheduled for the following week. The RD requested that during the intervening week, the patient keep a food journal recording his food intake at meals and snacks. She asked that the patient also try to estimate portion sizes.

Although his physical activity had increased since his retirement, it was fairly sporadic and weather-dependent. After further discussion, he realized that a week or more would often pass without any significant form of exercise and that most of his exercise was seasonal. Whatever weight he had lost during the summer was regained in the winter, when he was again quite sedentary.

A.B.’s wife suggested that the two of them could walk each morning after breakfast. She also felt that a treadmill at home would be the best solution for getting sufficient exercise in inclement weather. After a short discussion about the positive effect exercise can have on glucose control, the patient and his wife agreed to walk 15–20 minutes each day between 9:00 and 10:00 a.m.

A first-line medication for this patient had to be targeted to improving glucose control without contributing to weight gain. Thiazolidinediones (i.e., rosiglitizone [Avandia] or pioglitizone [Actos]) effectively address insulin resistance but have been associated with weight gain. 12 A sulfonylurea or meglitinide (i.e., repaglinide [Prandin]) can reduce postprandial elevations caused by increased carbohydrate intake, but they are also associated with some weight gain. 12 When glyburide was previously prescribed, the patient exhibited signs and symptoms of hypoglycemia (unconfirmed by SMBG). α-Glucosidase inhibitors (i.e., acarbose [Precose]) can help with postprandial hyperglycemia rise by blunting the effect of the entry of carbohydrate-related glucose into the system. However, acarbose requires slow titration, has multiple gastrointestinal (GI) side effects, and reduces A1C by only 0.5–0.9%. 13 Acarbose may be considered as a second-line therapy for A.B. but would not fully address his elevated A1C results. Metformin (Glucophage), which reduces hepatic glucose production and improves insulin resistance, is not associated with hypoglycemia and can lower A1C results by 1%. Although GI side effects can occur, they are usually self-limiting and can be further reduced by slow titration to dose efficacy. 14  

After reviewing these options and discussing the need for improved glycemic control, the NP prescribed metformin, 500 mg twice a day. Possible GI side effects and the need to avoid alcohol were of concern to A.B., but he agreed that medication was necessary and that metformin was his best option. The NP advised him to take the medication with food to reduce GI side effects.

The NP also discussed with the patient a titration schedule that increased the dosage to 1,000 mg twice a day over a 4-week period. She wrote out this plan, including a date and time for telephone contact and medication evaluation, and gave it to the patient.

During the visit, A.B. and his wife learned to use a glucose meter that features a simple two-step procedure. The patient agreed to use the meter twice a day, at breakfast and dinner, while the metformin dose was being titrated. He understood the need for glucose readings to guide the choice of medication and to evaluate the effects of his dietary changes, but he felt that it would not be “a forever thing.”

The NP reviewed glycemic goals with the patient and his wife and assisted them in deciding on initial short-term goals for weight loss, exercise, and medication. Glucose monitoring would serve as a guide and assist the patient in modifying his lifestyle.

A.B. drew the line at starting an antihypertensive medication—the angiotensin-converting enzyme (ACE) inhibitor enalapril (Vasotec), 5 mg daily. He stated that one new medication at a time was enough and that “too many medications would make a sick man out of me.” His perception of the state of his health as being represented by the number of medications prescribed for him gave the advanced practice nurse an important insight into the patient’s health belief system. The patient’s wife also believed that a “natural solution” was better than medication for treating blood pressure.

Although the use of an ACE inhibitor was indicated both by the level of hypertension and by the presence of microalbuminuria, the decision to wait until the next office visit to further evaluate the need for antihypertensive medication afforded the patient and his wife time to consider the importance of adding this pharmacotherapy. They were quite willing to read any materials that addressed the prevention of diabetes complications. However, both the patient and his wife voiced a strong desire to focus their energies on changes in food and physical activity. The NP expressed support for their decision. Because A.B. was obese, weight loss would be beneficial for many of his health issues.

Because he has a sedentary lifestyle, is >35 years old, has hypertension and peripheral neuropathy, and is being treated for hypercholestrolemia, the NP performed an electrocardiogram in the office and referred the patient for an exercise tolerance test. 11 In doing this, the NP acknowledged and respected the mutually set goals, but also provided appropriate pre-exercise screening for the patient’s protection and safety.

In her role as diabetes educator, the NP taught A.B. and his wife the importance of foot care, demonstrating to the patient his inability to feel the light touch of the monofilament. She explained that the loss of protective sensation from peripheral neuropathy means that he will need to be more vigilant in checking his feet for any skin lesions caused by poorly fitting footwear worn during exercise.

At the conclusion of the visit, the NP assured A.B. that she would share the plan of care they had developed with his primary care physician, collaborating with him and discussing the findings of any diagnostic tests and procedures. She would also work in partnership with the RD to reinforce medical nutrition therapies and improve his glucose control. In this way, the NP would facilitate the continuity of care and keep vital pathways of communication open.

Advanced practice nurses are ideally suited to play an integral role in the education and medical management of people with diabetes. 15 The combination of clinical skills and expertise in teaching and counseling enhances the delivery of care in a manner that is both cost-reducing and effective. Inherent in the role of advanced practice nurses is the understanding of shared responsibility for health care outcomes. This partnering of nurse with patient not only improves care but strengthens the patient’s role as self-manager.

Geralyn Spollett, MSN, C-ANP, CDE, is associate director and an adult nurse practitioner at the Yale Diabetes Center, Department of Endocrinology and Metabolism, at Yale University in New Haven, Conn. She is an associate editor of Diabetes Spectrum.

Note of disclosure: Ms. Spollett has received honoraria for speaking engagements from Novo Nordisk Pharmaceuticals, Inc., and Aventis and has been a paid consultant for Aventis. Both companies produce products and devices for the treatment of diabetes.

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eMethods 1. Semi-Structured Interview Guide for Primary Care Team Members

eMethods 2. Discussion Questions for Patient Engagement Studio (PES) With Patient Stakeholders

eTable 1. Descriptive Statistics for Social Determinants of Health (SDOH) Screening Responses

eTable 2. Descriptive Statistics for Practices, Providers and Patients With Unrestricted Sample (N = 147 096)

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Rudisill AC , Eicken MG , Gupta D, et al. Patient and Care Team Perspectives on Social Determinants of Health Screening in Primary Care : A Qualitative Study . JAMA Netw Open. 2023;6(11):e2345444. doi:10.1001/jamanetworkopen.2023.45444

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Patient and Care Team Perspectives on Social Determinants of Health Screening in Primary Care : A Qualitative Study

• 1 Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Greenville
• 2 Department of Medicine, Prisma Health, Upstate, University of South Carolina School of Medicine Greenville, Greenville
• 3 Department of Epidemiology/Biostatistics, Arnold School of Public Health, University of South Carolina, Greenville
• 4 Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville
• 5 Addiction Medicine Center, Prisma Health, Greenville, South Carolina

Question   Are patient and clinician factors associated with early implementation of social determinants of health (SDOH) screening in primary care, and what strategies can improve these efforts?

Findings   In this qualitative study of 78 928 primary care visits from the inception of primary care–based SDOH screening, visits with a physician assistant, belonging to a racial minority group, and having noncommercial/nonprivate health insurance were associated with greater screening likelihood. Stakeholders suggest that patient-clinician rapport, practice champions, streamlined questions, and referral follow-up ability may improve screening implementation.

Meaning   Results of this study suggest that primary care SDOH screening is feasible but limited by barriers that can be overcome with consideration of stakeholder feedback.

Importance   Health systems in the US are increasingly screening for social determinants of health (SDOH). However, guidance incorporating stakeholder feedback is limited.

Objective   To examine patient and care team experiences in early implementation of SDOH screening in primary care.

Design, Setting, and Participants   This qualitative study included cross-sectional analysis of SDOH screenings during primary care visits from February 22 to May 10, 2022, primary care team member interviews from July 6, 2022, to March 8, 2023, and patient stakeholder engagement on June 30, 2022. The setting was a large southeastern US health care system. Eligible patients were aged 18 years or older with completed visits in primary care.

Exposure   Screening for SDOH in primary care.

Main outcomes and Measures   Multivariable logistic regression evaluated patient (eg, age, race and ethnicity) and care team characteristics (eg, practice type), and screening completeness. Interviews contextualized the quantitative analysis.

Results   There were 78 928 visits in practices conducting any SDOH screening. The population with visits had a mean (SD) age of 57.6 (18.1) years; 48 086 (60.9%) were female, 12 569 (15.9%) Black, 60 578 (76.8%) White, and 3088 (3.9%) Hispanic. A total of 54 611 visits (69.2%) were with a doctor of medicine and 13 035 (16.5%) with a nurse practitioner. Most had no SDOH questions answered (75 298 [95.4%]) followed by all questions (2976 [3.77%]). Logistic regression analysis found that clinician type, patient race, and primary payer were associated with screening likelihood: for clinician type, nurse practitioner (odds ratio [OR], 0.13; 95% CI, 0.03-0.62; P  = .01) and physician assistant (OR, 3.11; 95% CI, 1.19-8.10; P  = .02); for patient race, Asian (OR, 1.69; 95% CI, 1.25-2.28; P  = .001); Black (OR, 1.49; 95% CI, 1.10-2.01; P  = .009); or 2 or more races (OR, 1.48; 95% CI, 1.12-1.94; P  = .006); and for primary payer, Medicaid (OR, 0.62; 95% CI, 0.48-0.80; P  < .001); managed care (OR, 1.17; 95% CI, 1.07-1.29; P  = .001); uninsured or with Access Health (OR, 0.26; 95% CI, 0.10-0.67; P  = .005), and Tricare (OR, 0.71; 95% CI, 0.55-0.92; P  = .01). Interview themes included barriers (patient hesitancy, time and resources for screening and referrals, and number of questions/content overlap) and facilitators (communication, practice champions, and support for patient needs).

Conclusions and Relevance   This qualitative study presents potential guidance regarding factors that could improve SDOH screening within busy clinical workflows.

Health systems in the US recognize the importance of social determinants of health (SDOH) in patient outcomes and care. The SDOH are economic and social conditions affecting health outcomes, 1 health care use, 2 and health inequities. 3 Health systems are increasingly engaging in SDOH screening. 4 Although such screening can potentially improve health outcomes and reduce health care use, 5 , 6 there is limited peer-reviewed evidence incorporating patient and clinician or care team characteristics and perspectives when describing early screening initiatives.

Given the personal nature and limited evidence guiding SDOH screening adoption, 7 - 9 it is critical to understand stakeholder perspectives. Prior research indicates that health care professionals recognize the importance of addressing patient SDOH needs and strive to adopt patient-centered approaches 10 but face ethical and time-related challenges. 8 , 11 , 12 Existing work reports greater SDOH screening uptake in primary care vs specialist visits and lower completion among patients requiring interpreters and patients with racial and ethnic minority status. 7 Studies on patient and caregiver perspectives have documented SDOH screening acceptability and preferences. 13 The role of practice and care team characteristics in screening uptake has not been assessed within a multistakeholder analysis.

To address this research gap, we conducted a qualitative study of a large southeastern US health care system's experiences during the early stages of SDOH screening in primary care. Quantitative analysis examined practice, care team, and patient characteristics and SDOH screening uptake. Qualitative analysis engaged team member feedback. Patient experts informed interview protocols and finding interpretation. Our goal was to identify barriers and facilitators to SDOH screening within primary care to inform future screening.

This qualitative study was classified as exempt by the Prisma Health institutional review board in accordance with 45 CFR §46. In February 2022, Prisma Health, South Carolina’s largest nonprofit health system with approximately 1.5 million unique patients annually, began screening adults for SDOH needs in primary care practices with the goal of annual screening. Practices had implementation flexibility and determined how and when to screen during the clinical workflow. Patients were screened using a 16-question electronic health record (EHR)–embedded survey (eTable 1 in Supplement 1 ). Questions were chosen using validated questionnaires and clinical input on system priorities and resource availability. Answers triggered automated input of community-based service information curated to patient SDOH needs and location into patient after-visit summaries using an EHR-compatible platform connecting patients to community-based organizations (NowPow; Unite Us). Practices provided the after-visit summaries to patients at visit end. Reporting follows the 21-item Standards for Reporting Qualitative Research ( SRQR ) reporting guideline.

The study population included patients aged 18 years or older with a visit in a family or internal medicine practice in the northwestern region of South Carolina from February 22 to May 10, 2022. Visits classified as future, cancelled, no show, or left without being seen were excluded. The last screen on a day was the patient final value, and the same patient could have multiple visits over the study period. In 2021, the northwestern region (4 counties) had 813 069 inhabitants, with 14.2% in poverty (11.4% nationally) and 13.9% uninsured (10.2% nationally). The population is 75.8% White, 14.6% Black, 6.5% Hispanic, 0.4% American Indian or Alaska Native, 1.6% Asian, and 0.1% Native Hawaiian or Other Pacific Islander. 14

The primary outcome was SDOH screening completion status. Visits with a response to at least 1 question were deemed partial screening while complete screening included responses to all questions. Our primary outcome compared visits with complete or partial screening (any screening) with no screening. Secondary outcomes compared visits with complete vs partial or no screening and visits with complete screening vs partial screening.

Potential explanatory variables included practice type (family or internal medicine), clinician qualification (medical doctor, doctor of osteopathic medicine, nurse practitioner, and physician assistant), patient demographic characteristics (age, sex, race and ethnicity [treated as classified in the electronic medical records as separate fields], preferred language, primary payer), and SDOH risk (calculated as the ratio of screener questions with positive responses to the total number of questions answered by patients). Race and ethnicity came from the EHR and thus were primarily patient self-reported. Race is reported as Asian, Black, White, 2 or more races, other race, patient refused, or unknown. Other race comprises American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and other as reported in the EHR. Ethnicity is reported as in the EHR. We included SDOH risk to test whether patients with a need might be more likely to be screened (ie, care team members suspect a need or patients are more likely to answer questions).

Binary logistic regression was used to determine the odds of screening completion. Standard errors were clustered by practice to account for practice-specific differences. A 95% CI not including 1 indicated statistical significance. We tested for multicollinearity using variance inflation factors and omitted variable bias using the Ramsey Regression Equation Specification Error Test (RESET). Analysis was conducted using Stata/MP, version 11 (StataCorp LLC).

Six practices were categorized as higher-adopting facilities as they performed SDOH screening during at least 4.0% of visits over the study period. Two of these practices were excluded because of involvement in other SDOH-related studies. Lower-adopting practices performed at least 10 screenings but in less than 2.0% of visits. Four practices met this criterion, but 1 practice was excluded because of involvement in SDOH pilot efforts. Higher- and lower-adopting was defined by quantitative analysis. We excluded practices performing no or minimal screening because we wanted to learn from those practices with some screening familiarity and those screening at both higher and lower levels. These 7 practices were approached for interviews of primary care team members (ie, physicians, administrative staff, nursing staff, and allied health professionals). Six practices participated in a total of 9 interviews (at least 1 interviewee from each of these 6 practices). Interview findings contextualized the quantitative analysis.

Two trained medical students (E.K. and M.J.) conducted and recorded 9 semistructured interviews online between July 6, 2022, and March 8, 2023. The students had not met the interviewees or worked in these clinics prior to the interviews. Interview questions focused on potential barriers and facilitators to screening (eMethods 1 in Supplement 1 ). Oral consent was obtained prior to interviews. Interviews were transcribed verbatim by a speech-to-text service (rev.com). Interview recordings were accessible only to interviewers and the team member uploading for transcription. Interviewers asked questions aimed to not yield identifying information. Additionally, transcripts were kept either on secure file-sharing systems or on password-protected computers. Using a web application (Dedoose), transcripts were coded by 2 research team members (D.G. and M.M.) and analyzed using an inductive grounded theory approach, in which important concepts and themes are derived from close reading of the text, and similar concepts are grouped into conceptual categories (codes). No further interviews were necessary as theme saturation was achieved.

To ensure the research was relevant and ethical for patients and the broader community, we included a meeting with patient experts from the University of South Carolina Patient Engagement Studio (PES) in our research strategy. 15 - 17 The PES is built on guidance from the Patient-Centered Outcomes Research Institute and provides structured opportunities for research teams to engage with community-recruited patient experts. Patient expert refers to individuals or caregivers with substantial health system interaction due to their health conditions who are trained in communication, research methods, and team building.

The research team met with patient experts on June 30, 2022, prior to interviews with primary care practices. In accordance with standard PES processes, 18 patient experts were provided the health system SDOH screening tool as presession reading material. Discussion topics at that meeting included screening and referral processes (eMethods 2 in Supplement 1 ). Patient expert feedback was incorporated into the research process through practice interview topics and by incorporating what we heard from patient experts when discussing study results.

Over the study period, there were 147 096 practice visits, with 3630 (2.5%) involving complete (2976 [3.8%]) or partial (654 [0.8%]) SDOH screening. In the restricted sample, 22 of 58 practices (37.9%) performed any screening during the study period ( Table 1 ). Of the 78 928 visits (mean [SD] age of 57.6 [18.1] years; 48 086 [60.9%] were female, 12 569 [15.9%] Black, 60 578 [76.8%] White and 3088 [3.9%] Hispanic) in the restricted sample, 41 574 (52.7%) were in family medicine and 37 354 (47.3%) in internal medicine practices. Most visits were with medical doctors (54 611[69.2%]), followed by nurse practitioners (13 035 [16.5%]), doctors of osteopathic medicine (5877 [7.4%]), and physician assistants (2958 [3.8%]). On average, patients had a mean (SD) of 0.08 (0.13) (95% CI, 0.08-0.09) positive responses per SDOH question answered.

The SDOH screener responses in order of question appearance are given in eTable 1 in Supplement 1 . Earlier questions were more likely to be asked and answered. Overall, patient response refusal was low (≤3.3%). Descriptive statistics for the unrestricted sample (visits to all practices) are given in eTable 2 in Supplement 1 .

Table 2 displays regression results examining factors associated with any SDOH screening (complete or partial screening vs no screening) in the restricted (model 1) and unrestricted (model 2) practice samples. In model 1 (restricted), compared with visits with a medical doctor, visits with a physician assistant had 3.11 (95% CI, 1.19-8.10; P  = .02) greater odds of any screening done, while visits with nurse practitioners had significantly lower odds (odds ratio [OR], 0.13; 95% 0.03-0.62; P  = .01) of any screening done. Visits with patients identifying as Asian (OR, 1.69; 95% CI, 1.25-2.28; P  = .001), Black (OR, 1.49; 95% CI, 1.10-2.01; P  = .009), or 2 or more races (OR, 1.48; 95% CI, 1.12-1.94; P  = .006) were more likely to have any screening compared with visits with patients identifying as White. With regard to primary payer, visits where patients had managed care had 1.17 (95% CI, 1.07-1.29; P  = .001) greater odds of any screening compared to visits where patients had private or commercial payers. Visits where patients had Medicaid (OR, 0.62; 95% CI, 0.48-0.80; P  < .001), were uninsured or had Access Health (OR, 0.26; 95% CI, 0.10-0.67; P  = .005) or had Tricare (OR, 0.71; 95% CI, 0.55-0.92; P  = .01) had lower odds of any screening. Practice type, patient age, sex, language, and ethnicity had no significant associations with screening likelihood. Results were consistent in model 2 (unrestricted) except for visits with physician assistants and uninsured patients, where the finding was not significant.

We also compared visits completing the entire screening questionnaire vs partial or no screening ( Table 3 ) for the restricted practice sample. In model 3, compared with visits with a medical doctor, visits with a physician assistant had 3.78 times (95% CI; 1.43-10.0; P  = .007) greater odds of screening completion while visits with a nurse practitioner had lower screening completion odds (OR, 0.15; 95% CI, 0.03-0.75; P  = .02). Visits where patients identified as Black had greater odds of screening completion (OR, 1.33; 95% CI, 1.01-1.74; P  = .04) than visits where patients identified as White. Visits where patients had managed care had 1.15 (95% CI, 1.05-1.26; P  = .002) times greater screening completion odds than visits where patients had private or commercial payers. However, screenings were less likely to be complete if patients had Medicaid (OR, 0.53; 95% CI, 0.40-0.72; P  < .001), Tricare (OR, 0.76; 95% CI, 0.58-0.98; P  = .04), or were uninsured or had Access Health (OR, 0.14; 95% CI, 0.05-0.40; P  < .001). Results were consistent in model 4 comparing the odds of complete vs partial screening.

Model 5 extended model 4 to include patient SDOH risk from screening responses. Patient SDOH risk was not associated with screening completion (OR, 1.03; 95% CI, 0.56-1.88; P  = .93). Results in model 5 are consistent with model 4.

All models had variance inflation factors of less than 10 indicating absence of multicollinearity. Models 4 and 5 had omitted variable bias.

We identified 7 themes regarding barriers and facilitators from health care team member interviews for implementing SDOH screening ( Table 4 ). Care team members reported patient reluctance in responding to screener questions. Hesitancy was attributed to perceptions about questions being intrusive or offensive. Interviewees reported patients reacting unfavorably to sensitive questions (eg, violence/abuse, financial strain). Time to administer the screener, interpret results, and address identified needs posed challenges with existing workloads.

Clinicians expressed concerns about potential patient response burden and overlap with routine care questions (eg, stress and Patient Health Questionnaire 2). Clinicians suggested streamlining the screener by combining multiple related questions and then tailoring subsequent questions based on patient initial responses.

Some clinicians felt inadequately trained in navigating the screening tool and expressed uncertainty about effective use of screening results. Many practices lacked social workers or resource navigators to connect patients with resources and follow up on referrals. Clinicians felt their attention diverted from the primary goal of medical care provision.

Care team members reported that screening facilitated patient care by uncovering socioeconomic issues not identified in routine care. Practices that informed patients about the screening purpose, assured them it would not affect care, and obtained verbal consent prior to screener administration perceived more successful uptake.

Some practices identified practice champions as being responsible for screening implementation and supporting patient needs. Some practices had a referral coordinator or social worker who connected patients to community-based resources and provided follow-up support. Clinicians reported they would benefit from training on how to best use screening.

Table 5 presents feedback from patient experts. Patient experts preferred that screening be done at annual appointments to allow for discussion time and in the examination room to ensure privacy. Patient experts emphasized rapport building between patients and care teams and providing information about the screening purpose. They expressed the importance of empathetic clinicians performing screening. Recommendations for rephrasing questions included expanding the partner violence or abuse questions (eTable 2 in Supplement 1 ) to include safety concerns related to family members, neighborhoods, and caretakers. Patient experts expressed concern about timely referral follow-up.

This qualitative study assessed factors associated with SDOH screening completion in primary care and explored patient and care team member perspectives on screening. We found that clinician type, patient race, and primary payer were linked to any screening but that practice type, patient age, sex, language, ethnicity and SDOH risk were not.

Completion rates differed in this study (3.8%) from previous research (58.7%) 7 also examining systemwide SDOH screening implementation. This may be related to study duration, timing (intra–COVID-19 pandemic vs pre–COVID-19 pandemic), or implementation (recommendation for all primary care patients vs preassigned screening). 7 Based on qualitative interviews, our study completion rates may be affected by the desire to receive more resources to support patient referrals.

Our findings suggest that primary care visits with nonphysician clinicians, such as physician assistants, may be favorable for SDOH screening. However, this result did not hold for nurse practitioners and deserves further research, as previous studies demonstrated nonphysician clinician confidence in addressing SDOH needs and greater community-based resource awareness. 19 Clinician type could be serving as a proxy for visit type as our data set did not include visit reason. Consistent with previous studies, 20 our interview-based findings suggest that clinicians faced an additional time burden from incorporating SDOH screening, which they perceived to affect care provision.

We found patients with managed care to be more likely to be screened, while those with Medicaid and those who were uninsured or had Access Health and Tricare were less likely. Medicare and Medicare Advantage had no effect relative to private or commercial payer status. Patients with Medicaid and uninsured or had Access Health may benefit most from screening; therefore this finding is critical for further implementation. Of note, these patients may have been screened via other programs at the health system thus, lack of screening in primary care is not necessarily reflective of screening otherwise.

A lack of association between screening and other patient characteristics (age, gender, language, ethnicity, SDOH risk) suggests that perhaps these characteristics are not associated with SDOH needs in the perceptions of those performing screening. These results differed from previous research that found members of racial and ethnic minority groups less likely to be screened, 7 thereby providing support for universal implementation across primary care practices as a potential mitigation against screening disparities. 7

In our quantitative analysis, questions appearing later in the screener were less likely to be completed. Interviews further explained this finding as questionnaire length and repetitive questions led to a greater perceived patient response burden by health care clinicians. Although there is no consensus on screener length, existing tools range from 6 to 23 questions. 21 Generally, short-form surveys are more acceptable to patients. 22 Notably, patients did not express the same concerns as clinicians about survey length or repetitiveness.

Interviews and patient expert feedback found that patient–care team communication is crucial for screener uptake. Sensitive questions about patient needs may lead to incomplete or untruthful responses if patients have privacy concerns, 10 , 23 feel embarrassed, or fear stigmatization. 24 Patient experts and health care team members emphasized rapport building and communicating the screening purpose to mitigate patient concerns and build trust. Future investigation should include assessment of standard phrasing to introduce the screener rationale and consideration of the best location and visit type for screening. Last, patient experts and care team members expressed concerns about referral follow-up, perceiving that care would benefit from an enhanced ability to follow up on referral outcomes.

Our study has a few limitations to be considered. First, findings are restricted to primary care practices within 1 health system in 1 region, limiting generalizability. However, this study is comprehensive by including all primary care practices in 1 region covered by a large health system that statewide serves approximately 25% of residents. 14 Second, we used a convenience sample of practice staff for our qualitative assessment. This restricted our examination of how qualitative themes differed based on practice characteristics. However, practice choice for interviews was based on screening implementation to intentionally capture those screening at higher and lower adoption rates. Third, our data set included whether a survey was taken on MyChart (Epic). No surveys were done on MyChart. Accordingly, we were unable to test screening modality association with screening completion. We also had no information on screening completion via telemedicine vs office visits and did not include this topic in our interview guide. In addition, we do not know at what rate patients refused to verbally consent to screener administration if a practice asked for such consent.

Although health systems face different challenges in implementing SDOH screening, identifying and addressing common barriers are critical for improved patient activation and care collaboration. Future research should focus on robust assessment of strategies to improve screening uptake.

Accepted for Publication: October 19, 2023.

Published: November 28, 2023. doi:10.1001/jamanetworkopen.2023.45444

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Rudisill AC et al. JAMA Network Open .

Corresponding Author: A. Caroline Rudisill, PhD, MSc, Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 300 E McBee Ave, Ste 401, Greenville, SC 29601 ( [email protected] ).

Author Contributions: Dr Rudisill and Ms Gupta had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Rudisill, Eicken, Macauda, Self, Thomas, Hartley.

Acquisition, analysis, or interpretation of data: Rudisill, Eicken, Gupta, Macauda, Self, Kennedy, Kao, Jeanty.

Drafting of the manuscript: Gupta, Kao, Hartley.

Critical review of the manuscript for important intellectual content: Rudisill, Eicken, Macauda, Self, Kennedy, Thomas, Jeanty.

Statistical analysis: Rudisill, Gupta, Self.

Obtained funding: Rudisill, Eicken.

Administrative, technical, or material support: Rudisill, Kennedy, Thomas, Kao, Jeanty.

Supervision: Rudisill, Eicken, Macauda.

Conflict of Interest Disclosures: Dr Rudisill reported grants from the Prisma Health Transformative Seed Grant Program during the conduct of the study and The Duke Endowment, Centers for Disease Control and Prevention, Viiv Healthcare, University of Michigan/National Institute on Aging/National Institutes of Health, South Carolina(SC)/NIA/NIH, SC Research Foundation (SCRF)/BlueCross/BlueShield Foundation of SC and National Heart, Lung, and Blood Institute/NIH. Dr Eicken reported grants from Prisma Health Transformative Seed Grant Program during the conduct of the study; grants from the Duke Endowment and grants from the Prisma Health Transformative Seed Grant Program outside the submitted work; Dr Eicken sits on the board of the Piedmont Health Foundation. Ms Gupta reported grants from Prisma Health during the conduct of the study; and support from the Duke Endowment. Dr Self reported grants from Prisma Health during the conduct of the study; personal fees from Companion Animal Parasite Council and personal fees from Merck outside the submitted work. Dr Kennedy reported grants from Prisma Health The Patient Engagement Studio received a portion of the grant to provide feedback during the conduct of the study; and has received 2 Eugene Washington Engagement Awards for capacity building with patients from the Patient-Centered Outcomes Research Institute in 2020 and in 2021. Ms Kao reported grants from Prisma Health Seed Grant during the conduct of the study. Ms Jeanty reported grants from Prisma Health Seed Grant Program during the conduct of the study. Mr Hartley reported grants from Prisma Health Seed Grant Program during the conduct of the study. No other disclosures were reported.

Funding/Support: This research was funded by the Prisma Health Research Seed Grant program.

Role of the Funder/Sponsor: The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

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Optimizing evidence-based practice implementation: a case study on simulated patient protocols in long-term opioid therapy

• Ellen Green   ORCID: orcid.org/0000-0003-2643-984X 1 ,
• Megan Hamm 2 ,
• Catherine Gowl 2 ,
• Reed Van Deusen 2 ,
• Jane M. Liebschutz 2 ,
• J. Deanna Wilson 3 &
• Jessica Merlin 2  

Implementation Science Communications volume  5 , Article number:  44 ( 2024 ) Cite this article

35 Accesses

Metrics details

Substantial work has been done to update or create evidence-based practices (EBPs) in the changing health care landscape. However, the success of these EBPs is limited by low levels of clinician implementation.

The goal of this study is to describe the use of standardized/simulated patient/person (SP) methodology as a framework to develop implementation bundles to increase the effectiveness, sustainability, and reproducibility of EBPs across health care clinicians.

We observed 12 clinicians’ first-time experiences with six unique decision-making algorithms, developed previously using rigorous Delphi methods, for use with patients exhibiting concerning behaviors associated with long-term opioid therapy (LTOT) for chronic pain. Clinicians were paired with two SPs trained to portray individuals with one of the concerning behaviors addressed by the algorithms in a telehealth environment. The SP evaluations were followed by individual interviews, guided by the Consolidated Framework for Implementation Research (CFIR), with each of the clinician participants.

Participants

Twelve primary care clinicians and 24 SPs in Western Pennsylvania.

Main measurement

The primary outcome was identifying likely facilitators for the successful implementation of the EBP using the SP methodology. Our secondary outcome was to assess the feasibility of using SPs to illuminate likely implementation barriers and facilitators.

The SP portrayal illuminated factors that were pertinent to address in the implementation bundle. SPs were realistic in their portrayal of patients with concerning behaviors associated with LTOT for chronic pain, but clinicians also noted that their patients in practice may have been more aggressive about their treatment plan.

Conclusions

SP simulation provides unique opportunities for obtaining crucial feedback to identify best practices in the adoption of new EBPs for high-risk patients.

Zoom simulated patient evaluations.

Peer Review reports

Contributions to the literature

This study uses simulated patients (SPs) in implementation science planning, offering insights into identifying gaps and tailoring implementation strategies effectively.

Focusing on long-term opioid therapy, our research exemplifies SPs’ practical role in implementing evidence-based practices, addressing a critical gap in substance use therapy.

Beyond training, our findings provide insights into SPs as facilitators for professionals dealing with high-risk patients, acknowledging both the potential benefits and limitations of the SP methodology.

Introduction

Timely adoption of current evidence-based practices (EBPs) is key to ensuring high-quality care in our changing health care environment. Creating EBPs alone is insufficient to ensure their implementation. Without well-designed implementation strategies, the adoption of these practices can take decades [ 1 ]. This is because clinicians often face barriers to implementing EBPs, including limited awareness, resistance to change, and resource constraints. Organizational culture, patient factors, and the complexity of implementation further contribute to the challenges. Evaluation of implementation strategies outside of an active practice setting can address these barriers and increase the likelihood of dissemination, long-term adoption, and appropriate use of EBPs by providing a controlled environment for assessment, feedback, and identification of facilitators for a successful implementation [ 2 , 3 , 4 ]. We argue that the standardized/simulated patient/person (SP) methodology serves as a valuable tool for formulating implementation strategies for EBPs before their application in practice.

SPs are people trained to portray complex behaviors and react as an actual patient would to a clinician in real time creating a fully interactive patient-clinician experience outside of a real-world practice [ 5 ]. SPs can be trained to consistently exhibit specific emotions (e.g., anger [ 6 ]), desires (e.g., prescriptions), and/or patient needs (e.g., language barriers [ 7 ]) across clinicians. The flexible nature of simulation can be leveraged to reflect either a single patient encounter or multiple patient visits portraying the passage of time depending on the application (e.g., teach providers how to perform a physical exam or re-evaluate patients after a new prescription). While SP methodology is commonly used to train and test clinicians on new techniques [ 5 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ], its application to the planning phases of implementation science remains limited. Our work specifically leverages SP methodology within the planning phases of an implementation bundle for an EBP - a novel approach that has been underutilized in existing literature.

There are several advantages to using SP methodology as a part of implementation strategy. First, the consistent portrayal of a patient case can help identify gaps in EBP implementation and facilitate targeted solutions for future implementation. Second, recruiting clinicians from multiple and diverse practices to use the EBPs with SPs can provide insight into how the EBP would be best implemented in their unique practice setting after the provider has first-hand experience with the EBP. This can provide richer and more diverse insight for implementation scientists relative to feedback from directly implementing an EBP into a singular practice that may not generalize to other clinics.

Likewise, evaluating an EBP outside of the daily activities of a typical clinical practice provides clinicians with immediate and protected time for debriefing. Without dedicated time for good feedback, it is difficult to identify areas of improvement for implementation. Also, developing implementation strategies for EBPs in practice can be high risk for patients. The use of SPs provides a safe environment to develop implementation strategies and gain active experience with EBPs without putting patients at risk [ 16 ]. Lastly, SPs can provide insight into events that may be uncommon or take a long time to occur in practice, which can expedite necessary adaptation of implementation strategies for EBPs. Overall, SPs may provide a critical step in increasing the likelihood of a successful adoption of an EBP by identifying the barriers and facilitators prior to implementation in the field.

For these reasons, we adopted the SP methodology for a research project implementing an evidence-based approach to addressing concerning behaviors in patients on long-term opioid therapy (LTOT), such as diversion, use of other substances, or non-adherence to pain therapy. Although the evidence for the effectiveness of LTOT is limited [ 17 , 18 , 19 ], there are millions of Americans prescribed opioid analgesics yearly, with more than 17% of Americans receiving an opioid prescription in 2017, with an average of 3.4 opioid prescriptions dispensed per patient [ 20 ]. Multiple efforts to improve opioid prescribing have occurred on the broader policy level (e.g., prescription drug monitoring programs), the insurance level (limits on doses or length of time), and through education (the RDA risk evaluation and mitigation strategy program [ 21 ] and most recently, the drug enforcement agency requirement for training on addiction and opioids) [ 22 ]. While opioid prescribing has decreased overall [ 23 ], none of these broader measures address concerning behaviors among patients taking LTOT. To augment non-specific recommendations in the CDC guide to prescribing opioids (“weigh the risks and benefits” [ 24 ]) and other broader prescribing policy, our team previously developed a set of evidence-based clinical decision-making algorithms using Delphi process to address concerning behaviors among patients prescribed opioids. The lack of uptake of most clinical guidelines [ 25 , 26 ] led the team to look for effective ways to implement these EBP. Because the concerning behaviors of patients on LTOT may occur sporadically among primary care physicians (PCPs), using the SP methodology would allow for rapid feedback, making it attractive for developing and testing potential implementation methods of the EBP.

In this article, we describe the SP methodology for developing an implementation bundle for a new EBP to address concerning behaviors among patients on LTOT. In conjunction with the SP methodology, we used observation and discussion from one-on-one structured interviews to develop an implementation bundle to increase the likelihood of effective, sustainable, and reproducible adoption in practice. Our approach was guided by the Consolidated Framework for Implementation Research (CFIR), a commonly used tool to guide qualitative inquiry about how clinicians would implement EBPs in practice [ 27 ].

We demonstrate the important and practical use of the SP methodology for developing implementation strategies for a new EBP: 6 treatment algorithms designed to address common and challenging behaviors associated with long-term opioid therapy (LTOT) developed by Merlin and colleagues and published in 2016 [ 28 ]. As previously described, these algorithms were developed using a modified Delphi process [ 29 , 30 ], a rigorous methodology that uses several rounds of questionnaires sent to a panel of experts to find consensus on how to respond to behaviors such as missing appointments with clinicians prescribing the opioid, taking more opioid than prescribed, and substance use. One of the algorithms is included as an example of the new EBP in Fig. 1 . In the present study, we conducted SP sessions with providers using 6 SP cases, one for each algorithm. These SP sessions were followed by one-on-one structured interviews with questions mapping onto domains from the CFIR to assist in the development of an implementation bundle for the new EBP.

SEQ figure \* ARABIC 1: “Other Substance Use” Algorithm

Case development

We developed 6 SP cases. Each case simulated a patient exhibiting a unique concerning behavior addressed by the algorithms (see Table 1 outlining the behaviors portrayed). The SP cases were written with unfolding steps to represent three visits with a provider, because the algorithms guide decision points that would normally occur in subsequent follow-up visits in real-life practice (Fig. 1 ). The unfolding nature of the scenarios was piloted early in the SP case development process to ensure feasibility.

SP cases were next reviewed by a Patient-Provider Advisory Board (PPAB) consisting of 3 patients with lived experience with opioids, 4 researchers (among whom are PCPs familiar with caring for patients with opioid misuse disorder), and a primary care provider with familiarity with providing care for patients with opioid misuse. SP cases were edited based on feedback from the PPAB. In concert with the review of the 6 cases, the PPAB reviewed the instructions which provided context, expectations for SP-clinician interactions, and training on the algorithms (see Appendix ). Finally, cases and instructions were piloted with an SP and a provider outside of the panel. During this pilot, a physician with topical expertise was recruited to interact with SPs portraying two SP cases over three subsequent visits on a remote/telehealth platform (Zoom). This pilot helped to further develop the other five SP cases in structuring how clinicians would be oriented, updated, and guided through the simulations.

Training and description of organization for SPs

Four experienced SPs were recruited from the University of Pittsburgh SP program to portray the patients exhibiting misuse behaviors. The SPs in the University of Pittsburgh School of Medicine SP Program received foundational training in case portrayal, providing feedback, supported physical exam training, and checklist scoring. This 16-h onboarding combines both active training and also guided observation of SP activities. It prepares SPs to identify, recognize, and reward learner skill in portrayal, and to record it faithfully in assessments.

To allow rotation, redundancy and information sharing, the SPs worked in pairs for each case, alternating the role of moderator and patient. When not portraying the patient, the SP acted as a moderator by providing clinicians with inter-visit updates in accordance with what the clinicians ordered in the first session and noted the passage of time between visits. A fifth experienced SP was recruited to proctor the event—orienting the clinicians as they arrived, running the Zoom sessions, and serving as a backup should one of the other SPs not be able to participate. They also were given an overview of case content, portrayal, and event structure. SPs were provided with case materials a week in advance of the portrayal date, were able to ask questions over email, and completed a case-specific training to align portrayal with parameters provided in the inter-visit updates with SP staff in the 45 min preceding the simulation. The SP program follows the Association for Standardized Patient Educators (ASPE) Standards of Best Practice, which “were written to ensure the growth, integrity, and safe application of SP-based education practices.” [ 9 ]

Description of session for clinicians

Clinicians were emailed information and instructions about the event prior to participating in the session (see Appendix ). All sessions were held virtually via the Zoom interface due to the COVID pandemic. During the sessions, there was a brief orientation for participants. The orientation included (1) a brief training in how to use the algorithms; (2) an overview of how to approach the simulated interaction (i.e., as close to real practice as possible); and (3) an overview of the one-on-one interview that would follow to discuss the approaches to implement the management algorithms.

Clinicians then moved into Zoom breakout rooms to begin their patient encounters. Clinicians were given up to 60 min to have their 3 distinct visits per patient. There was a 15-min break, and then another 60 min for the second patient scenario.

For each of the 60-min SP scenarios, clinicians were told that they were about to see a patient who was being seen by one of their partners (Dr. Williams) who recently left the practice. Dr. Williams had started the patient on opioid therapy and had an opioid agreement with the patient. Participants were given a copy of Dr. Williams’ last progress note and the opioid agreement prior to meeting the patient. After reviewing this information, the clinicians joined a Zoom breakout room with the SP portraying their patient. Once the provider ended the first encounter, the portraying SP turned off their camera, and, to reflect the passage of time between visits, the moderator gave the clinicians the results of any testing they ordered and any information about the patient that had changed between the last and next visit. The provider indicated when they were ready to start the next encounter. This process was repeated between the second and third encounter.

Data collection: semi-structured interviews

Immediately after they interacted with the SPs, each participant completed a one-on-one interview to reflect on and assess the experience, as well as to provide feedback on how the algorithms should ultimately be integrated into practices like theirs. Interviews were conducted by three experienced qualitative data specialists who work at Qualitative, Evaluation and Stakeholder Engagement Research Services (Qual EASE) at the University of Pittsburgh. Multiple interviewers conducted the interviews, because multiple interviews needed to be conducted at the same time following each SP session. Interviewers used a semi-structured interview guide developed by the research team that covered the following domains: (1) Assessment of their orientation to the algorithms, including training; (2) Assessment of their interaction with the SPs; (3) Assessment of and opinions on the algorithms; and (4) Description of how they thought the algorithms would operate in their practices, and how they could best be implemented there. Interviews were conducted on Zoom and recorded.

Questions and further probing were used to best assess how the algorithms could be implemented in their practices, which map onto several CFIR domains and constructs as shown in Table 2 .

Within one week of their completion, the qualitative methodologist associated with the project wrote a summary of each interview, which was forwarded to the study team so that they could begin to plan for implementation. Following that initial summary, interviews were transcribed verbatim with identifying details redacted. Under the supervision of the qualitative methodologist, experienced analysts at Qual EASE inductively developed a codebook reflecting the content of the interviews, with coding categories reflecting the four areas of the interview guide mentioned above. Use of the codebook was practiced on two transcripts by 2 Qual EASE coders, following which they both applied the codebook to the remaining 10 transcripts. Cohen’s Kappa statistics were used to assess intercoder reliability; the average kappa score was 0.8565, indicating “near perfect” agreement. The primary coder for the project then conducted a conventional content [ 31 ] and thematic analysis [ 32 , 33 ], which was reviewed by the qualitative methodologist, and shared with the study team to better facilitate implementation planning.

Data collection: development of implementation bundle

The final step to developing the implementation bundle—which included materials for initial training, an online algorithm interface, e-consultation support, and electronic health record (EHR) integration for the 6 algorithms—was to review notes from the structured interviews. The bundle was then drafted and reviewed by the PPABs and co-Is.

Recruitment and study sample

Recruitment emails were sent to Community Medical Inc. (CMI). CMI is a network of 400 primary care and specialty physicians who practice throughout western and central Pennsylvania and provide care for over 495,000 patients. The practices cover a large geographic area; however, the network is predominantly in Allegheny County. Participants were required to be primary care clinicians at CMI practices and at least 18 years of age. Each of the clinicians were recruited to participate in two virtual patient evaluations followed by one-on-one interviews. The experience lasted approximately 4 h and clinicians were paid $1000 for their participation. We ultimately recruited 12 PCPs to participate in the virtual experience, which provided two perspectives for each of the 6 SP cases.

Table 3 summarizes the demographic characteristics of the clinicians participating in our study. All of our participants (100%) were trained as physicians with 33% specializing in Internal Medicine, while 66% specialized in Family Medicine during their residency. There was a prevalence of urban practitioners (58%), followed by those in suburban areas (42%), with an absence of participants from rural locales. We had 42% male and 58% female participants. The racial and ethnic composition of our study cohort is diverse, with White participants comprising the majority at 50%, followed by 33% of participants identifying as Asian. Additional categories encompass Hispanic, Latino, or Spanish origin of any race (17%), and two or more races (17%), with a nuanced representation of other racial and ethnic identities.

Implementation support strategies

When asked about how algorithms should be implemented in practices like theirs, clinicians indicated that the orientation they had received to the algorithms would be a useful implementation support strategy. Other themes illustrating helpful implementation support strategies included (1) the importance of having the algorithm use endorsed by practice leadership, and of having a local “champion” who promoted their use; (2) integration of the algorithm workflow into practice EHRs; (3) practice and location-specific inputs into the algorithms, such that a suggestion to refer to a specialist come with a list of who, specifically, to refer to, or a suggestion to call security provide the practice-specific number for security; (4) access to specialists who could help interpret unclear or difficult-to read drug screens or suggest a particular course of action with a tricky patient.

Representative quotes supporting these themes, as well as the CFIR domains that they map to, are provided in Table 4 . These findings were integrated into an implementation toolkit that included an initial training session followed by a suite of supports, including EHR integration, algorithm guidance hosted on a separate website with links to useful tools, and support for clinician participants via e-consultation.

Simulation feedback from clinicians

We identified two themes related to the physicians’ encounters with the SPs: (1) clinicians found it useful to practice the algorithms with the SPs; (2) while clinicians applauded the skill of the SPs, they noted that not all actual patient counters go so smoothly. Each is presented in more detail below.

Clinicians found it useful to practice the algorithms with the SPs

Clinicians interviewed found it useful to practice the algorithms with the SPs. As will be discussed below, not all clinicians found the scenarios or SP reactions to be fully realistic. However, they did find practicing the algorithms in this way to be a useful way of learning the algorithms. As one provider put it:

It was a good chance to sort of get to look through the algorithm while I’m talking to them and sort of follow along. So, that was good to get familiar with the algorithm itself in a situation where you don’t feel like you’re with a real patient who you’re, like, ignoring to read through the algorithm.

Another provider similarly reflected:

So, that was really helpful, because this is sort of cut and dry of the way it’s written. And not until you’re in an actual patient scenario do you see some of the gray nuances. For example, one of the cases, the patient was having trouble sleeping secondary to pain. So, she was using her oxycodone in the evening to help with sleep, but it was related to pain. So, it wasn’t this clear-cut ‘I’m just using this to fall asleep at night.’ It was ‘I’m using this because at night my pain is worse which is affecting my sleep, so that’s why I’m using it.’ Which is a gray space. So, having the algorithm to sort of follow through and use as a guide let me make sure I’m asking all the right questions, let me make sure I’m offering all the other alternative things, was definitely beneficial.

While clinicians applauded the skill of the SPs, they noted that not all actual patient counters go so smoothly

Many clinicians described the practice session with SPs as being realistic or very similar to encounters with real patients. One provider described themselves as “shocked” at how realistic the SPs were, adding that “I felt very engaged in each of the scenarios. Like, they knew their background, they kind of were living the patient. I was really impressed... the scenarios were spot-on.” Other clinicians described the scenarios as “realistic situations that you can see in the office every day,” and “totally realistic.”

However, some clinicians described pointed differences with real life patient visits. For example, the following provider described that some of their actual patients would simply never agree to the treatment plans presented in the algorithms:

In the back of my mind I’m thinking of my actual patients who I’ve run into these instances and how this would go, and I don’t think it would’ve – it won’t go the way that it went with the SPs. Because it sometimes doesn’t matter how good your rapport is, they just aren’t gonna do what’s suggested... I think I run into much harder stops with some of my real non-SP patients.

Another clinician echoed this description, noting that:

My experience is that patients don’t normally accept what you say so easily. […] The interactions that I have with my patients are not anything like these, ‘cause these were very calm, very reasonable, willing to listen to you; they seemed to have a health literacy level that is well beyond a lot of the patients I deal with.

While these concerns were not voiced by every clinician, they were voiced by clinicians who experienced different scenarios with the SPs, indicating that patients may not always be agreeable to the actions suggested in the algorithm—and that that lack of agreement would be something that would need to be managed in an ongoing patient relationship, rather than disappearing at the end of the role play with the SP.

In this study, we used the SP methodology in combination with one-on-one interviews guided by CFIR to develop an implementation bundle for 6 algorithms designed to address common and challenging behaviors associated with LTOT. We found the use of the SP methodology to be a valuable tool for highlighting important components of an implementation bundle. Specifically, we found that an implementation bundle addressing (1) the importance of having the algorithm use endorsed by practice leadership, and of having a local “champion” who promoted their use; (2) integration of the algorithm workflow into practice EHRs; and (3) practice and location-specific inputs into the algorithms would be most effective in promoting the successful adoption and implementation of the EPBs for the LTOT algorithms. We also found that the SPs were realistic in their portray of patients with LTOT; however, it was noted that patients of the clinicians that participated in the simulations were likely to be more resistant to the adoption of the recommendations outlined by the algorithms than the SP portrayal. SPs are trained to recognize and reward participant skill, which may account for this observation.

Of methodological note in the realm of qualitative research: completing the interviews just after the SP interactions set an excellent stage for collecting qualitative data, likely because clinicians had just had a novel experience that was fresh in their minds. They could also talk about the details of the SP cases without concern for inappropriately describing actual patient cases in too much detail and contrast the SPs with their patients in general. This made for highly engaging interviews in which rapport building between interviewer and interviewee was more easily built. Additionally, interviews were conducted by qualitative research specialists who were not personally invested in the development of the algorithms or orientation to the algorithms, setting the stage for open and honest feedback.

In this study, we used the SP methodology in combination with one-on-one interviews guided by CFIR to develop an implementation bundle for 6 algorithms designed to address common and challenging behaviors associated with LTOT. Our findings underscore the value of the SP methodology in elucidating essential components of the implementation bundle. Specifically, we found that an implementation bundle addressing (1) the importance of having the algorithm use endorsed by practice leadership, and of having a local “champion” who promoted their use; (2) integration of the algorithm workflow into practice EHRs; and (3) practice and location-specific inputs into the algorithms would be most effective in promoting the successful adoption and implementation of the EPBs for the LTOT algorithms. We also found that the SPs were realistic in their portrayal of patients with LTOT; however, it was noted that patients of the clinicians that participated in the simulations were likely to be more resistant to the adoption of the recommendations outlined by the algorithms than the SP portrayal.

Of methodological note in the realm of qualitative research: completing the interviews just after the SP interactions set an excellent stage for collecting qualitative data, likely because the experience was fresh in their minds. They could also talk about the details of the SP cases without concern for inappropriately describing actual patient cases in too much detail and contrast the SPs with their patients in general. This made for highly engaging interviews in which rapport building between interviewer and interviewee was more easily built. Additionally, interviews were conducted by qualitative research specialists who were not personally invested in the development of the algorithms or orientation to the algorithms, setting the stage for open and honest feedback.

Despite the merits of the SP approach in examining EBP implementation, several limitations warrant consideration. The applicability of SP methodology to diverse practices and various points in care management raises questions about its universal relevance. The effectiveness or practicality of SPs for EBP training and adoption may vary across different clinical settings, requiring careful consideration when extrapolating findings to practices with distinct characteristics or specific care management points.

The selection of long-term opioid therapy (LTOT)-related care as a case study introduces a contextual limitation. While SP methodology effectively addresses concerns within LTOT-related care, the transferability of findings to other healthcare scenarios might be constrained. The unique nature of LTOT-related care may not fully capture challenges present in different medical specialties or care contexts.

Additionally, while the goal of this manuscript is to illuminate the SP methodology, our study's findings may not be universally generalizable, considering factors such as regional variations in healthcare practices and differing levels of familiarity with EBP implementation. The dynamic nature of clinical practice introduces a limitation in capturing all potential scenarios through SP methodology. Clinician encounters with patients can vary widely, and SPs may not fully replicate the complexity of real-world situations.

Overall, this study demonstrates the potential of using the SP methodology guided by the CFIR framework to develop effective implementation strategies for improving care in real-world healthcare settings. The use of SPs allowed the research team to observe the EBP in practice with feedback from end-users with experience from different health care clinics. The CFIR framework provided a comprehensive approach to guiding the development of an implementation bundle that addressed the multiple factors that influence EBP implementation. The study’s success prompts further exploration of whether the developed implementation bundle correlates with increased EBP adoption levels to further validate the use of SPs for this purpose.

Availability of data and materials

The dataset supporting the conclusions of this article is available from the corresponding author on reasonable request.

Abbreviations

Consolidated framework for implementation research

Community Medical Inc.

Co-investigator

Evidence-based practice

Electronic health record

Long-term opioid therapy

Primary care physician

Patient-provider advisory board

Simulated patient

Luciano M, Aloia T, Brett J. 4 Ways to make evidence-based practice the norm in Health Care. Harv Bus Rev. 2019;4.

Rapport F, Clay-Williams R, Churruca K, et al. The struggle of translating science into action: Foundational concepts of implementation science. J Eval Clin Pract. 2018;24(1):117–26. https://doi.org/10.1111/jep.12741 .

Article   PubMed   Google Scholar  

Brownson RC, Jacobs JA, Tabak RG, et al. Designing for dissemination among public health researchers: findings from a national survey in the United States. Am J Public Health. 2013;103(9):1693–9. https://doi.org/10.2105/AJPH.2012.301165 .

Article   PubMed   PubMed Central   Google Scholar  

Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10(1):1–14.

Article   Google Scholar  

Barrows HS. An overview of the uses of standardized patients for teaching and evaluating clinical skills. AAMC Acad Med. 1993;68(6):443–51.

Article   CAS   PubMed   Google Scholar  

Liao C-S, Hsieh M-C. Standardized Patient Training: Using ANGER to quickly evoke anger in standardized patients. Med Teach. 2015;37(9):883–883.

Zabar S, Hanley K, Kachur E, et al. “Oh! She doesn’t speak English!” Assessing resident competence in managing linguistic and cultural barriers. J Gen Intern Med. 2006;21:510–3.

Taylor LJ, Adkins S, Hoel AW, et al. Using Implementation Science to Adapt a Training Program to Assist Surgeons with High-Stakes Communication. J Surg Educ. 2019;76(1):165–73. https://doi.org/10.1016/j.jsurg.2018.05.015 .

Bryant KA, Wesley GC, Wood JA, Hines C, Marshall GS. Use of standardized patients to examine physicians’ communication strategies when addressing vaccine refusal: a pilot study. Vaccine. 2009;27(27):3616–9. https://doi.org/10.1016/j.vaccine.2009.03.048 .

Lewis KL, Bohnert CA, Gammon WL, et al. The association of standardized patient educators (ASPE) standards of best practice (SOBP). Adv Simul. 2017;2(1):1–8.

Wilson L, CHSE C-A, Wittmann-Price RA. Review manual for the certified healthcare simulation educator exam. Springer Publishing Company; 2018.

Book   Google Scholar  

Jeffries P. Clinical simulations in nursing education: Advanced concepts, trends, and opportunities. Lippincott Williams & Wilkins; 2022.

Google Scholar  

Ross JG, Burrell SA. Standardized patient simulation to facilitate learning in evidence-based oncology symptom management. J Nurs Educ. 2018;57(4):250–3.

Rethans JJ. Needs assessment in continuing medical education through standardized patients. J Contin Educ Health Prof. 1998;18(3):172–8.

Ainsworth MA, Rogers LP, Markus JF, Dorsey NK, Blackwell TA, Petrusa ER. Standardized patient encounters: a method for teaching and evaluation. JAMA. 1991;266(10):1390–6.

Oxman AD, Flottorp SIGNE. An overview of strategies to promote implementation of evidence-based health care. Evid-Based Pract Prim Care. 2001;2:101–19.

Busse JW, Wang L, Kamaleldin M, et al. Opiods for Chronic Noncancer Pain: A Systematic Review and Meta-analysis. JAMA. 2018;320(23):2448–60.

Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the space randomized clinical trial. JAMA. 2018;319(9):872–82.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;162(4):276–86.

Prescribing Practices. Centers for Disease Control and Prevention. Updated August 13, 2019. Accessed December 6, 2023. https://www.cdc.gov/drugoverdose/deaths/prescription/practices.html .

Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS). U.S. Food and Drug Administration. Updated November 14, 2023. Accessed January 31, 2024. https://www.fda.gov/drugs/information-drug-class/opioid-analgesic-risk-evaluation-and-mitigation-strategy-rems .

U.S. Department of Justice, Drug Enforcement Administration. Letter to DEA Registered Practitioners. https://deadiversion.usdoj.gov/pubs/docs/MATE_Training_Letter_Final.pdf . Accessed January 31, 2024.

United States Dispensing Rate Maps. Centers for Disease Control and Prevention. Updated December 11, 2023. Accessed January 31, 2024. https://www.cdc.gov/drugoverdose/rxrate-maps/index.html .

Dowell D, Ragan KR, Jones CM, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep. 2022;71:1–95 No. RR-3.

Fischer F, Lange K, Klose K, et al. Barriers and Strategies in Guideline Implementation – A Scoping Review. Healthcare (Basel). 2016;4(3):36.

Jiang V, Brooks EM, Tong ST, et al. Factors Influencing Uptake of Changes to Clinical Preventitive Guidelines. J Am Board Fam Med. 2020;33(2):271–8.

Breimaier HE, Heckemann B, Halfens RJ, Lohrmann C. The Consolidated Framework for Implementation Research (CFIR): a useful theoretical framework for guiding and evaluating a guideline implementation process in a hospital-based nursing practice. BMC Nursing. 2015;14:1.

Merlin JS, Young SR, Azari S, et al. Management of problematic behaviours among individuals on long-term opioid therapy: protocol for a Delphi study. BMJ Open. 2016;6(5):e011619.

Dalkey N, Helmer O. An experimental application of the Delphi method to the use of experts. Manag Sci. 1963;9(3):458–67.

Keeney S, McKenna HA, Hasson F. The Delphi technique in nursing and health research. John Wiley & Sons; 2011.

Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15:1277–88.

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.

Braun V, Clarke V. Thematic Analysis: A Practical Guide. Thousand Oaks, CA: Sage Publications; 2021.

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Acknowledgements

Not applicable.

A completed SRQR checklist has been completed for this paper.

We gratefully acknowledge funding from NIDA Agency for our publication through an R34 grant mechanism entitled “Consensus-based algorithms to address opioid misuse behaviors among individuals prescribed long-term opioid therapy: developing implementation strategies and pilot testing.” Project Number: 5R34DA050004-03. Jessica Merlin is supported by the following grant from the NIH: K24DA05683701A1.

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Ellen Green

School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA

Megan Hamm, Catherine Gowl, Reed Van Deusen, Jane M. Liebschutz & Jessica Merlin

Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA

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Contributions

EG contributed to the development of the standardized patient protocol and was a major contributor to writing the manuscript. MH conducted the interviews as well as analyzed and interpreted the data. CG and RVD developed the standardized patient protocol and conducted the simulations. JDW and JML contributed to the development of the standardized patient cases and interpretation of the data to ensure it aligned with primary care practice. JM provided oversight to the entire study.

Corresponding author

Correspondence to Ellen Green .

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This study was conducted at School of Medicine, University of Pittsburgh, Pittsburgh PA between June and July of 2021. The University of Pittsburgh IRB determined that the study was considered an exempt-level research project (STUDY20030189).

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Appendix: Instructions for participants

Dear Participant,

Thank you for participating in our study of opioid misuse in primary care.

In this exercise, you will encounter 2 different simulated patients played by standardized patients (SPs) of the SP Program of the University of Pittsburgh School of Medicine. The purpose of these visits is to help us study clinical algorithms for managing opioids.

Therefore, please be aware of the following expectations:

For this simulated scenario, each of these patients were started on opioid treatment by one of your partners who recently left your practice (Dr. Kia Williams). You may not have started opioids if it were up to you, but they have already been started and have an opioid agreement with this practice. Therefore, please focus your time on the algorithms and not on whether the patient should/should not have been started on opioids.

You will see each patient in 3 separate “telemedicine” visits via Zoom. Therefore, you do NOT need to perform a physical examination for these visits.

The “visits” will occur in break out rooms on the Zoom platform. The 1 st visit will be to establish care with you after Dr. Williams has left the practice. The next 2 visits will be follow-up visits.

For each scenario, there will be a “moderator” in the breakout room with you and the SP. The moderator’s camera will be off. This person will be helping with timing of the visits, and they will post updates about the patient’s case before each visit in the chat section.

Therefore, please enable the chat on your screen.

Also, please “hide nonvideo participants”, so the presence of the moderator is not a distraction for you as you conduct the visits. (If you need help in how to do this, please ask, so a team member can walk you through the steps)

In the interest of transparency, the moderators are also SPs. They are not clinicians.

After you are done with the visits, you will meet with researchers from the study to debrief your experience.

Timing of the whole activity:

Orientation: 30 min

Encounter with 1 st patient: 60 min

Break (including time to prepare for 2 nd patient): 15 min

Encounter with 2 nd patient: 60 min

Debrief with researchers: 75 min

Timing of your patient visits: You have 1 h for each session, which includes 3 distinct visits with the same patient. You will see timing banners at 15-min increments, and a 5-min warning. How you divide the time between the three visits is up to you.

If it would help you communicate with the patients in the simulation, here is some information about Dr. Kia Williams:

Dr. Williams recently left your practice to be closer to her family in South Carolina. Her father’s dementia has been worsening, and she wanted to be closer to her family in this time. As your partner, she was well liked by your colleagues, the staff, and her patients. She was an excellent doctor and a friend.

Prior to meeting each patient, we will share Dr. Williams’ last progress note with you. You will have time to review that information before starting the first visit. This note will have information about what work up has been done and what pain treatments have been tried.

The patients are aware of what has been tried, and they can answer these questions, but for the sake of this study, you do not need to explore this in great detail given the limited timeframe of each visit.

Dr. Williams had an opioid agreement with each of the patients you will meet today. This will also be shared with you in case you need to reference it during the sessions.

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Green, E., Hamm, M., Gowl, C. et al. Optimizing evidence-based practice implementation: a case study on simulated patient protocols in long-term opioid therapy. Implement Sci Commun 5 , 44 (2024). https://doi.org/10.1186/s43058-024-00575-y

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Received : 28 September 2023

Accepted : 21 March 2024

Published : 22 April 2024

DOI : https://doi.org/10.1186/s43058-024-00575-y

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