How Keep/Stop/Start Analysis Can Improve Nursing Practice

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Patient education and communication with others on the healthcare team is essential for enabling quality care.
Patient education and communication with others on the healthcare team is essential for enabling quality care.

It's interesting when we learn something new from an unexpected source. That is exactly what happened to me recently. My niece is working on her MBA and doing a fellowship at a marketing company. She was describing a project she is working on and told me, “We are using the Change Management Model and are doing a Keep, Stop, Start analysis.” I had never heard of that concept before, yet it made perfect sense to me. Keep what works, stop what doesn't, start new approaches. It is not a complicated system for assessing the efficacy of a program — it is a simple, easy-to-remember way of analyzing a program. And it has so many applications! I was excited about thinking of how it could apply to nursing.

All nursing is teamwork. We go into a patient's room on our own and function with autonomy during the work day, but at some point we give our report to another nurse and go home. Continuity is always a challenge. Even when we take care of a patient over the course of several days or through their disease trajectory, managing their care over time can be a challenge. Shift-to-shift RN reports are essential, yet patient “hand-off” has the potential for creating misinformation. Patient education and communication with others on the healthcare team is also essential. I wondered whether we could add Keep/Stop/Start to our daily routines — not as a substitute for other assessment tools but as one more instrument that could be useful under certain circumstances.

How might Keep/Stop/Start be incorporated into practice?

CASE

Maria went through 8 of 10 rounds of chemotherapy before she said, “No more.” Her initial response to the therapy was good — her carcinoembryonic antigen (CEA) was drastically reduced — but in short order her scans revealed tumor growth in her liver. She was offered a new treatment course and was mulling over whether or not she wanted to put herself through it. She had significant pain with her liver metastases, but said, “I'm the kind of person who never even takes an aspirin. I don't want to take anything.”

I went through my usual talk about pain medications and strategies for managing pain. I included specifics about her liver capsule pain and why I thought pain medication would help her be more functional. Her response was a thin smile and her body language clearly stated that she wasn't buying it. I did what we all do sometimes: I assessed the situation and quickly reviewed how I was approaching her. I realized I needed to keep going with the objective information about pain management and make it understandable. I needed to stop using language that, based on her cool response, sounded more like I was trying to force her to do what she didn't want to do rather than giving her the information so that she could make an informed decision. And I needed to start listening. Earlier in the conversation she had said that she liked information given to her straight up. As I adjusted my conversation with her I harkened back to that. “You told me you want me to be a straight shooter. Clearly, I've taken a wrong turn in my explanation. Can you tell me more about your hesitation about taking pain medications?” In this instance, the communication challenge was between me and a patient, and I was able to use Keep/Stop/Start to help me get back on track.  

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