Developing Nursing Care Plans - Health And Social Care
CPDCONTINUINGPROFESSIONALDEVELOPMENTDeveloping nursing care plansNS832 Ballantyne H (2016) Developing nursing care plans. Nursing Standard. 30, 26, 51-57.Date of submission: August 31 2015; date of acceptance: October 16 2015.AbstractAims and intended learning outcomesThis article aims to enhance nurses’ understanding of nursing care plans,reflecting on the past, present and future use of care planning. Thisinvolves consideration of the central theories of nursing and discussionof nursing models and the nursing process. An explanation is provided ofhow theories of nursing may be applied to care planning, in combinationwith clinical assessment tools, to ensure that care plans are contextspecific and patient centred.This article aims to enable you to developa comprehensive understanding of nursingcare plans so that you may begin tocritique, adjust, develop and adapt themto suit the requirements of different contextsof care. After reading this article andcompleting the time out activities you shouldbe able to: Outline the concepts and processes ofplanning care that enable you to use nursingcare plans effectively. Discuss how nursing models and the nursingprocess relate to nursing care plans. Describe how nursing care plans can benefitpatients and nurses. Identify potential problems with nursingcare plans in practice. Outline the advantages anddisadvantages of using nursing care plansin practice.AuthorHelen Ballantyne Staff nurse, Transplant Continuing Care Unit,Papworth Hospital NHS Foundation Trust, Cambridge, England.Correspondence to: hballantyne@nhs.netKeywordscare bundles, care pathways, care plan, care planning, critical thinking,models of care, nursing process, nursing theory, patient-centred careReviewAll articles are subject to external double-blind peer review and checkedfor plagiarism using automated software.RevalidationPrepare for revalidation: read this CPD article, answer the questionnaireand write a reflective account. www.rcni.com/revalidationOnlineFor related articles visit the archive and search using the keywords above.To write a CPD article: please email gwen.clarke@rcni.comGuidelines on writing for publication are available ionNursing care plans are based on nursingtheory, which is taught throughout nurseeducation, but is seldom revisited thereafter.Nursing care plans are complex, involvingmany aspects of nursing theory and practice.Therefore, nurses may find it difficult tounderstand how these aspects relate to careplanning in practice.The terms ‘care planning’ and ‘care plan’are often used interchangeably. Thiscontributes to misunderstanding of the theoryof care plans, encouraging some nursing staffto dismiss them as irrelevant to practice.‘Care planning allows a nurse to identify apatient’s problems and select interventions thatwill help solve or minimize these problems’(Matthews 2010), and ‘Care plans are thewritten records of this care planning process’(Barrett et al 2012). Essentially, care planningis the action, while a care plan is a record ofthat action.NURSING24 other:: vol uses30 no26 :: permission.2016 51DownloadedSTANDARDfrom RCNi.com by {individualUser.displayName} on May 18, 2017. For personalfebruaryuse only. NowithoutCopyright 2017 RCN Publishing Company Ltd
CPD care planningEvolution of planning nursing careIn 1978, the planning of nursing care wasbecoming a common topic for discussion in thenursing profession (Clarke 1978). In contrast,a nurse job analysis in 1953 did not recogniseor include care planning as a nursing task(Goddard 1953). Reflecting on past ways ofworking, Lelean (1973) observed that nursingcare was often dictated by ward routine.It was a functional, activity-based method ofnursing where patients became names on a listaccording to the procedures they required.There are anecdotal stories of care beingprovided by word of mouth, via bath books,TPR (temperature, pulse, respiration) books,dressing books and work lists. This reflecteda task-based system of nursing, where theemphasis was on the activity rather than thepatient. However, by implication, there wasplanning of care using these lists, since carewas provided and patients’ needs were met.The aim now is to provide individualised care,with emphasis on the patient’s unique needs.This evaluation of care planning in nursinghistory does not make the assumption thatnursing in the 1960s and 1970s was poorand nursing in the present day is better, nordoes it reflect the level of care given or theoutcomes experienced. Nurses have alwaysplanned, carried out and documented thatcare, albeit in varying levels of detail. It is themethod of planning care that has changed overtime (Walsh 1998). For example, consider adressing change. In the 1970s, the care wasplanned in the dressing book, the task tickedoff once completed and plans made to repeatthe care if required, with a further entry inthe dressing book. One can speculate thatcare plans may be required now more thanever, given the increased complexity of care,access to information and changing healthcareenvironments.The nursing process1 Make a note of allthe nursing models youcan think of. Considerthem individually andtry to remember thebasic principles of each.Is there any particularmodel which you believeapplies best to yourplace of work? Discussthis with a colleague tofind out if you agree.The development of the nursing process(Yura and Walsh 1967) may be considered themost influential change in approaches to thinkingabout nursing care. The nursing process is a clearand straightforward cyclical model, consisting offour concepts of nursing: assessment, planning,implementation and evaluation. The centralconsideration of the nursing process is that itlooks first at the patient and then thinks about thecare that is required, rather than deciding whatcare the patient needs and then looking at thepatient and how this might be implemented. Theemphasis is on patient assessment, encouragingnurses to identify with the patient’s potential andactual health problems (Aggleton and Chalmers2000). Assessment may be considered the firststage in the planning of nursing care, since it startsthe process of gathering information to makedecisions about suitable interventions.In general, planning nursing care isthe process of setting goals that providebenchmarks for evaluating care. These goalsmay be adapted after the nursing interventionhas been implemented. Modifications to thisprocess may be used, depending on factorssuch as the culture of nursing, the context orthe patient. A nursing diagnosis stage may beinserted between the assessment and planningstages. Carpenito-Moyet (2009) stated: ‘anursing diagnosis is a clinical judgment aboutindividual, family or community responsesto actual or potential health problems/lifeprocesses.’ Therefore, a nursing diagnosisacknowledges the actual or potential healthproblem and labels it. ‘A nursing diagnosis iscommonly referred to as a diagnostic statementor identification of problem or need’ (Matthews2010). This stage is not often used explicitlyin the UK. However, it may be argued thatit is used implicitly throughout the nursingprocess since patient needs are identified andaddressed. For example, consider a patienthandover, where nursing diagnoses are oftenmade after a formal assessment, and severalnursing diagnoses, for example, anxiety, riskof impaired skin integrity and disturbed sleeppattern, may be used routinely.If one applies the nursing process to afamiliar life activity, such as buying a house,it is possible to understand its usefulness. Afamily plans to move house; the assessmentconsists of a list of needs, for example a garden,a primary school nearby and three bedrooms.The process is planned; visiting estate agentsor using online tools. The intervention is whenthe family moves in. Evaluation of the situationis continuous, as the family assesses the house,lives in it, adapts it, reassesses and possiblymoves out once their needs change.Complete time out activity 1Other nursing modelsThe next aspect of nursing theory to consider,while keeping the nursing process in mind, isnursing models. These models offer a range ofbeliefs and values to guide nurses through thestages of problem-solving and provide directionregarding that which is relevant and important(Barrett et al 2012). Walsh (1998) described thenursing process as a tool to provide structure to52 february24 from:: volRCNi.com30 no 26by:: 2016STANDARDDownloaded {individualUser.displayName} on May 18, 2017. For personal use only. NoNURSINGother uses withoutpermission.Copyright 2017 RCN Publishing Company Ltd
care delivery and models of nursing as tools toinstruct us on how care should be given.Several definitions of nursing models referto their use in the nursing process. They oftenprovide detail to be used in conjunction withthe nursing process to facilitate care. Manynursing models fit into one or more of thefour stages of the nursing process. However,several nursing models were published beforethe nursing process was formalised. This lendsvalidity to the nursing process, since it indicatesthat the process was in use informally before itwas formally documented.Models of nursing can be abstract anddifficult to measure, yet are practised daily,usually without a formal label. Differentmodels prioritise different aspects of care andreflect the care priorities of the nurse. Nursesin different environments provide care in astructured and detailed way, but their prioritiesand action points differ. For example, thepriority in a critical care unit is to managethe needs that patients are unable to managethemselves, while the emphasis in an outpatientclinic may be on assisting patients with self-careand self-medication.Certain models of nursing prompt nurses toensure they are assessing the whole patient andnursing holistically. The Roper-Logan-Tierneymodel of nursing based on activities of dailyliving is frequently used in assessment andadmission documentation (Roper et al 2000).King (1981) developed a model that emphasisedthe importance of therapeutic relationships, theability of all humans to interact meaningfullywith one another in pursuit of a common goal.This led to a shift from the four-stage nursingprocess towards developing a goal-orientednursing record. King (1981) identified theimportance of communication and informationsharing when setting goals, since withoutcommunication, goals are unlikely to be met.Therefore, King’s (1981) model emphasises theimportance of excellent communication skillsto establish a beneficial interaction to achievethe goals of care, rather than a checklist ofaspects to cover in the patient assessment.The Neuman systems model focused on theperson as consisting of a core of resource, withseveral lines of resistance or defence (Neumanand Fawcett 2010). The model suggests thatthese lines of resistance fluctuate according tophysiological, sociocultural, psychological,spiritual and developmental variables. A personexperiencing an extreme level of any of thesevariables may find it difficult to resist their effectsand may experience symptoms of ill health. Forexample, a patient with a supportive family,no comorbidities and an effective relationshipwith their GP may recover more quickly froma myocardial infarction than a patient whois recently divorced and has type 2 diabetesand a history of missed GP appointments. Inthis model, nursing is required when the lineof resistance has been diminished and can nolonger protect a person. The emphasis is onpreventive health to ensure that the patient iswell-equipped to resist any stressors that mayarise as a result of their diagnosis.Each of these models of nursing has differentpriorities. By including selective aspects ofeach of the models, it is possible for the nurse todevelop patient centred, context-specific careplans that enable high quality care planningand comprehensive documentation. Forexample, a care plan encompassing aspects ofthe Roper-Logan-Tierney, King and Neumanmodels might adopt a holistic approach to thepatient to ensure physical symptoms are assessedand self-care goals are set, and to initiate atherapeutic relationship to facilitate interventionsand further assessment as required.Despite their long history, models of nursingare still debated. Bakker and Mau (2012) statedthat it is essential to incorporate the opinionsof the main partners in care to develop amodel of nursing that best reflects professionalnursing practice. This approach encouragesthe development of models of nursing, wherepatients and the multidisciplinary team areconsulted. Care pathways are one applicationof this theory.Care pathwaysCare pathways were first used in the 1990s inthe United States and have been employed in theNHS in a range of clinical settings since 1992.They were introduced as a means of assistinghealthcare professionals to deliver high quality,evidence-based and cost effective care (Kozieret al 2008). Walsh (1998) explained that indeveloping a care pathway, all professionalsinvolved in patient care are bought togetherand come to a consensus about the standards ofcare and expected outcomes for selected patientgroups within an agreed time frame.Care pathways stimulate debate anddiscussion. Some patients meeting certaincriteria will require the same general treatment.These treatments may be pharmaceutical, forexample pain relief or they may be clinical, suchas the placement of an intravenous cannula. Thecare pathway provides a stimulus to deliver andrecord such interventions. The idea of all patientsNURSING:: vol uses30 no26 :: permission.2016 53DownloadedSTANDARDfrom RCNi.com by {individualUser.displayName} on May 18, 2017. For personalfebruaryuse only. 24No otherwithoutCopyright 2017 RCN Publishing Company Ltd
CPD care planningreceiving the same treatments contradicts theconcept of holistic patient-centred care thatnurses are encouraged to deliver. However,if patients meet relevant criteria, standardinterventions can be performed, freeing up timefor individual care in other areas.Clinical assessment toolsClinical assessment tools are often usedas a part of the nursing process and carepathways. They may be considered as amodern addition to nursing models thatenable the nursing process. Clinical tools,for example the Glasgow Coma Scale (www.glasgowcomascale.org), aim to ensure thatcare is consistent, considered and appropriateto each patient. Using clinical assessmenttools also provides a baseline from whichto measure variation, improvement ordeterioration in the patient’s health status ascare progresses.Assessment skills may vary widely betweenstaff and clinical tools provide guidance andobjectivity to counter instinctual assessment.A patient with a normal blood pressure, heartrate and respiratory rate may still feel unwell,and the nurse should be able to reassure thepatient and perform an assessment based ondifferent priorities. The nurse may perhapsquestion the feelings of the patient; are theyscared, confused or anxious?Care bundles2 Refer to theInstitute for HealthcareImprovement (2016b)document on usingcare bundles toimprove health care.In particular, sourcestatistics on how carebundles have improvedpatient outcomes foraspects of acute care.Discuss with a colleaguehow you could improvepatient outcomes inyour clinical area.The use of care pathways is a departure from apatient-specific nursing care plan. This may beredressed in part by including definite clinicalinstructions for specific problems. Care bundleswere created by the Institute for HealthcareImprovement (2016a) to meet this requirement.A care bundle is a group of evidence-basedbest practices related to a disease or set ofsymptoms that result in improved outcomeswhen they are implemented together thanwhen they are implemented individually(Norman 2010). For example, the Institute forHealthcare Improvement (2012) developed anevidence-based list of interventions that werelinked to reductions in ventilator-associatedpneumonia in patients in intensive care units.These interventions included positioning ofthe patient’s head, regular assessment forextubation, oral care and daily sedation breaks.Care bundles promote efficiency and patientsafety, establish high quality care, and are costeffective and reason based, thus contributingto improved patient outcomes (Norman 2010).They are usually used in conjunction withthe nursing process. Nurses plan their care,gathering equipment and thinking it through;intervene, performing the care; and continuallyevaluate, ensuring the patient remains stable.In this way, the care bundle is applied to theintervention aspect of the nursing process,linking specialist clinical knowledge withfundamental nursing theory.National Service Frameworks are extensionsof the care bundle. They have been developedat government level to address high priority,high mortality diseases. They directly affect thecare provided since they set clear requirementsfor care based on the best available evidence(Kozier et al 2008). Moreover, they provideguidance and support for organisations toenable them to achieve these requirements.Complete time out activity 2Critical thinkingThere are many useful tools and models thatassist in the planning of nursing care andconsequently the production of useful, patientcentred, contextual care plans. To date, thedevelopment of standardised care plans forindividual nursing diagnoses or conditionshas been the next step in the process of careplanning. Not every model or clinical tool willbe used in each care plan. Equally, every patientis different. Critical thinking skills should alwaysbe applied to practice to ensure that nurses donot make assumptions or work unquestioningly.Price and Harrington (2016) describedcritical thinking as a process in whichinformation is gathered, sifted, synthesisedand evaluated, to understand a subject or issue.They applied this in practice, explaining thatcritical thinking enables the nurse to functionas ‘a knowledgeable doer, someone whoselects, combines, judges and uses informationto proceed in a professional manner’. Nursescannot apply standard care plans to all patientsand, therefore, critical thinking ensures thatcare is patient centred and adaptedas necessary.Complete time out activities 3 and 4Role of nursing care plansWhen applying critical thinking to nursing careplans, it should not be assumed that care plansare always beneficial because they have beenaround for years. Kaufman (2012) describednursing care plans as the common language ofnurses, indicating a clear familiarity with themand potential reliance on them. However, thisshould not prevent nurses questioning the use54 february24from:: volRCNi.com30 no 26by:: 2016STANDARDDownloaded {individualUser.displayName} on May 18, 2017. For personal use only. NoNURSINGother uses withoutpermission.Copyright 2017 RCN Publishing Company Ltd
of nursing care plans and their role in clinicalpractice. When asking: ‘What is the role of thenursing care plan in practice?’ there are threemain answers:1. To facilitate standardised, evidence-based,holistic care.2. To record care.3. To measure care.A nursing care plan can facilitate holistic carefor patients, when used by nurses throughouttheir career. A nursing care plan can be usedas a learning tool (Kaufman 2012), whereby anovice nurse may rely on such a plan to guidetheir practice. Experienced staff may relymore on their experience. However, providingnursing care is challenging and there are severalpotential barriers to care.Shorter lengths of patient stay, higher patientacuity and technological advances are factorsthat may restrict the amount of time availableto care for patients (Norman 2010). Otherissues that may affect patient care includestaffing levels and an increasing number ofcomplex patients with multiple comorbidities.A useful and relevant nursing care planmay help a member of the nursing team toacknowledge these barriers and work aroundthem. Moreover, such barriers mean that thestandard of care cannot always be relied on;omissions may be made and human error ismore likely. A documented care plan can offerguidance and clarity and may also providejustification for using nursing time to ensure athorough patient assessment.Nursing care plans can also be used torecord the care that has been given. Thisallows nursing staff to acknowledge thecare provided, share it to ensure continuityand reassess its effects and patient needsas required. This documentation enablesnurses to demonstrate that they are workingwithin the professional standards of practiceoutlined by the NMC (2015). The Code:Professional Standards of Practice andBehaviour for Nurses and Midwives (NMC2015) states: ‘nurses must keep colleaguesinformed when sharing the care of individualswith other healthcare professionals and staff’.It requires registered staff to keep ‘clear andaccurate records relevant to their practice’and states that this documentation should becontemporary, kept secure and attributed tothe professional in question. A comprehensivenursing care plan that has documented caremeets these requirements, and may protectthe nurse in the case of a complaint ordisciplinary action.Lastly, and perhaps most controversially, anursing care plan allows care to be measured.The requirement to measure care andensure that it meets essential standards andbenchmarks may be seen by some nursingstaff as time-wasting. Historically, nursinghas been seen as a vocational act, noble andself-sacrificing. The requirement to assessthe care given may sometimes be seen asan affront to the experience, expertise,disposition and personality of a nurse.However, measurement of care is essentialto ensure that patients are receiving thesame level of care, despite being cared forby different nurses with different levels ofeducation and experience, and with differentpriorities and models of working.One important criticism of nursing careplans is the difficulty in maintaining theirrelevance as patient needs change. LaDuke(2008) remarked: ‘Today’s nurse continuallyreceives and analyzes new data, rapidlytransforming them into action amid crushingworkloads. Any care planning document thatrequires constant manual revision to reflectthis changing information is a problem, nota solution.’ LaDuke (2008) concluded thatnursing care plans belong in nurse educationand should not be used in clinical practiceunless they can be guaranteed to providereal-time information with test results andspecific instructions for implementation.Care Planning in the Treatment of Long TermConditions: Final Report of the CAPITOLProject (Department of Health (DH) 2012a)provided interesting insights. The reportacknowledged that: ‘Care plans are designed toprovide a record of agreements between patientand professional about goals and preferences,and to help to organise services around the needsof individual patients and ensure that needs areregularly reviewed’ (DH 2012a). The reportwas designed with the aim of assessing theimplementation and outcomes of nursing careplans within the NHS. The DH (2012a) reportfound that there were so few care plans in placethat part of the CAPITOL project was shiftedto focus on identifying the perceived and actualbarriers that prevented care plans being put inplace, rather than evaluating their usefulness.The DH (2012a) report identifiedambivalence concerning the effectiveness andrelevance of care plans and a lack of clarityon how the care plan should be structured,especially in relation to comorbidities andthe contributions of multidisciplinary staffat separate locations. Where limited time3 Nursing andMidwifery Council(NMC) revalidation,which comes intoeffect on April 1 2016,encourages nurses toconsult their code ofconduct and reflecton how it links totheir professionalpractice. Read TheCode: ProfessionalStandards for Practiceand Behaviour forNurses and Midwives(NMC 2015). Whichparts of The Code maybe directly related tothe use of nursing careplans? Reflect on howyour practice adheres tothese parts of The Code.Compare your answersto the points mentionedlater in this article.4 Nurses are requiredto keep a portfolio ofevidence for revalidation.Planning activities andidentifying developmentaims is an essentialpart of preparing forrevalidation. Using anursing care plan ornursing process format,write a plan for theupcoming year. Assessyour development needs,plan goals, and includecourses you might liketo participate in, and thepeople you might need tospeak to, to realise yourplans. Use the documentthroughout the year tomonitor your progressand re-evaluate the skillsand knowledge you needto acquire.NURSING:: vol uses30 no26 :: permission.2016 55DownloadedSTANDARDfrom RCNi.com by {individualUser.displayName} on May 18, 2017. For personalfebruaryuse only. 24No otherwithoutCopyright 2017 RCN Publishing Company Ltd
CPD care planning5 Design a nursingcare plan using the 6Csof nursing as a basicframework for a group ofpatients you are familiarwith. Try to ensurethat all their needs areaccounted for.6 Critique a nursingcare plan that you usein practice. Attempt toidentify its strengthsand limitations. Does itprovide patient-centredcare? Is there anythingmissing? Is the formateasy to use? How wouldyou change it?7 Now that you havecompleted the article,you might like to writea reflective account aspart of your revalidation.Guidelines to help youare on page 62.was available, the report established thatcare plans were given lower priority whencompared with other markers of care. Forexample, there was increased understandingof the Quality and Outcomes Framework(QOF) programme (Health and Social CareInformation Centre 2016) – a voluntaryprogramme that awards achievement pointsto GPs when managing long-term conditionssuch as asthma or diabetes. When combinedwith incentives, the QOF was used morereadily. The DH (2012a) report demonstratedthat the effects of effective care plans andcare planning were unclear and that furtherwork was required to improve levels of careplanning which may result in patient benefits.Complete time out activity 5It is difficult to reach a conclusion on thebenefits of nursing care plans. The evidence iscontradictory and differences in the informationand structure between healthcare organisationsmake direct comparisons difficult. Perhaps weare attempting to standardise aspects of nursingcare that cannot be standardised. Consideringthe 6Cs of nursing: care, compassion,competence, communication, courage andcommitment (DH 2012b) as a set of goals fornursing, is it possible to equate a clear, accuratenursing care plan with a compassionate andcaring nurse? Comprehensive nursing care plansmay not compensate for the absence of beneficialpersonality traits that patients would like to seein nursing staff.Complete time out activity 6DiscussionConclusionKeogh (2015) stated that the essence ofprofessionalism is being able to describe theservices you provide and define how well youdo it. A clear, accurate and contemporarynursing care plan should enable nursesto achieve this, maintaining professionalintegrity while providing excellentevidence-based care.There are many unanswered questionsregarding care plans. Further investigationis required to determine if wards that arefailing to deliver basic care use care plansroutinely. Radcliffe (1999) observed thatcare plans for children under five years havebeen held in their home with their parents formany years. This ‘red book’ has documentednursing care, providing healthcare goals,guidelines and care notes. Therefore, wouldoptimum care planning be achieved whenpatients are able to write their own care planwith the help of the nurse, read it at the end oftheir care and evaluate it for themselves?Nursing care plans may be used as a toolto promote holistic care. The careplanning process is central to patient-centredcare, enabling nursing staff to plan theinterventions and, where possible, discussthem with the patient. However, health careis complex. Different groups of patientsrequire different interventions and differentcare goals. A care plan for one patient maynot suit another, even if they have the sameneeds. Therefore, care plans should be usedwith consideration.Nurses should continually question the carethey provide and evaluate their plan of care.Selective use of tools by nurses, for example careplans, care bundles, care pathways, and clinicalassessment tools, can result in a patient-centredcare plan that facilitates the delivery of care,ensures that nothing is forgotten, and recordsand measures the quality of care, to the benefitof the patient and the nurse NSComplete time out activity 7ReferencesAggleton P, Chambers H (2000)Nursing Models and NursingPractice. Second edition. PalgraveMacmillan, Basingstoke.Bakker D, Mau J (2012) Thenursing model of care: don’tforget the patient perspective.Nursing Management. 43, 10,8-11.Barrett D, Wilson B, Woollands A(2012) Care Planning: A Guidefor Nurses. Second edition.Routledge, Abingdon.Carpenito-Moyet LJ (2009)Nursing Care Plans andDocumentation: Nursing Diagnosisand Collaborative Problems.Fifth edition. Lippincott Williamsand Wilkins, Philadelphia PA.Department of Health (2012a)Care Planning in the Treatmentof Long Term Conditions: FinalReport of the CAPITOL ing finalBower%20et%20al 7%20Mar%2013.pdf (Last accessed:January 19 2016.)Clarke M (1978) Planning nursingcare: recent past, present andfuture. Nursing Times. 74, 5, 17-20.Department of Health (2012b)Compassion in Practice: Nursing,Midwifery and Care Staff. OurVision and Strategy. The StationeryOffice, London.Goddard H (1953) The Workof Nurses in Hospital Wards:Report of a Job Analysis.Nuffield Provincial HospitalsTrust, London.Health and Social Care InformationCentre (2016) Quality and OutcomesFramework. www.hscic.gov.uk/qof(Last accessed: January 19 2016.)56 february24 from:: volRCNi.com30 no 26by:: 2016ST
care bundles, care pathways, care plan, care planning, critical thinking, models of care, nursing process, nursing theory, patient-centred care Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software. Revalidation Prepare for revalidation: read this CPD article, answer the .
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