Implementation is the fourth step of the nursing process, the step in which the nurse puts the care plan into action. Nursing implementation activities include ongoing assessment, establishment of priorities, allocation of resources, initiation of nursing interventions, documentation of interventions, and documentation of client responses. The implementation phase of the nursing process requires cognitive (intellectual), psychomotor (technical), and interpersonal skills.

Before implementation, the nurse should review the interventions to determine the level of knowledge and the types of skills required to carry them out safely and effectively. Nurses are legally responsible for all nursing care given to their assigned clients, but they may delegate the care to other members of the health care team. Delegation is the process of transferring a selected nursing task in a situation to an individual who is competent to perform that task. The decision to delegate is guided by the needs of the client, safety concerns, the number and type of available personnel, and the nursing management system of the unit or agency.

Nursing management systems are models that determine the number and type of personnel available on a nursing unit. Functional nursing divides care into tasks to be completed and uses various levels of personnel, depending on the complexity of the assignment. The disadvantage of this model is that no one person is responsible for the total care of the client, often leading to fragmented, incomplete, or depersonalized care.

Team nursing uses a registered nurse as the leader, who is responsible for planning and evaluating care. Professional nurses care for the more acutely ill clients, licensed practical nurses care for less acutely ill clients, and nursing assistants assist the nurses and do simple chores. This system is more cost-effective than other systems and provides more individualized care. In primary nursing, the professional nurse assumes full, 24-hour responsibility for total client care for a small number of clients. This form of care is more expensive but provides continuity of care. The total client care model is a variation of primary nursing. However, the responsibility for care changes as the shift changes and is not a 24-hour responsibility.

Modular nursing is another variation of primary nursing, with caregivers assigned to small segments or “modules” of the nursing unit. In case management, the nurse is responsible for planning, implementing, coordinating, and evaluating care for a client, regardless of the client’s location at any given time. This approach is often used for complex clients, along with case management plans or critical pathways. Case management enhances continuity of care and collaboration among health care team members.

A nursing intervention is an action which the nurse performs to help the client achieve the results specified by the expected outcomes of the plan of care. Novice nurses, in particular, should identify the rationales of all interventions, determining the scientific reasons they should be effective. Before an intervention is implemented, five questions should be asked about the intervention: (1) What is to be done? (2) How is it to be done? (3) When should it be done? (4) Who will do it? and (5) How long should it be done?

Some interventions are implemented as standing orders or protocols. Standing orders are standardized interventions written, approved, and signed by a health care practitioner. Protocols are series of standing orders or procedures that should be followed under certain specific conditions.

The Nursing Interventions Classification (NIC) is a taxonomy of nursing developed through the Iowa Intervention Project. The NIC is a method for linking nursing interventions to diagnoses and client outcomes. Nursing interventions in the NIC follow a format: label name, definition, activities that a nurse performs to carry out the intervention, and a list of background readings. Nursing interventions are organized under six “domains:” basic physiological, complex physiological, behavioral, safety, family, and health care delivery system. Nursing intervention activities in the NIC include activities of daily living, therapeutic interventions, monitoring and surveillance, client education, discharge planning, and supervising/coordinating nursing personnel. Nursing interventions should be evaluated after they are implemented by determining whether they result in an improvement of client outcomes.

The nurse is legally responsible for documenting the intervention used and the client’s response to the intervention. Written documentation of intervention is important for effective communication and for reimbursement. Documentation may be in the form of checklists, flow sheets, or narrative summaries. The same information about interventions should be passed along from shift to shift or case to case.