Clinical Care Plan Assignment Discussion Paper
Care plans are part of the core curriculum in most nursing schools. Yet, new hospital nurses often complain that despite all the hype and time spent learning how to make a nursing care plan, they never do it again after graduation. As a nursing leader, you might not have written one for a while, either. Why should you start now?
Care plans help nurses focus on patients in a holistic, big-picture way so they can deliver evidence-based, patient-centered care. Care plans also help hospitals ensure continuity of care across nursing shifts, promote inter-professional collaboration by getting everyone on the same page, and meet documentation requirements for insurers and governing bodies Clinical Care Plan Assignment Discussion Paper.
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Even if your hospital requires care plans, unless it’s a strict requirement, there’s a good chance your nurses aren’t preparing one for every single patient because they’re too busy. Depending on the unit, they might only treat people for a couple of days before they’re overwhelmed with redundant paperwork. Considering that most of the information in a nursing care plan is already required in multiple sections of each patient’s electronic health record (EHR), nurses might not see the point in drafting an official plan of care.
Unless care plans are required, nurses probably won’t make them. And unless care plans are useful, writing them will be perceived as more “busywork” — the bane of every nurse’s existence Clinical Care Plan Assignment Discussion Paper.
What are the benefits of a nursing care plan for hospitals? How can you ensure that care plans are a useful tool that nurses will want to have at their disposal?
Care plans are used to teach nursing students how to individualize patient care, think critically about what’s needed to achieve the desired outcomes, and work towards those outcomes through the nursing process. Experienced nurses already know how to do that, without documenting it and often without even realizing they’re doing it. Still, a formal nursing care plan can be a valuable tool for effective communication in nursing.
Long-term care providers such as nursing homes, mental health facilities, and home health nurses typically use formal care plans, and they are often required to do so by governing bodies like the Joint Commission. Yet, in hospitals, care plans often fall by the wayside.
For hospitals that successfully implement care plans, there are many benefits, including:
- Continuity of care: Nursing care plans ensure that nurses from different shifts or floors have the same patient data, are aware of the patient’s nursing diagnoses, share their observations with one another, and collaborate towards the same goals.
- Inter-professional collaboration: Nurses are the heart of the care team, but they’re not the only members. Physicians, social workers, nursing assistants, physical therapists, and other care providers also need to understand the patient’s health problems, goals, and progress. A nursing care plan puts all this information in one place, providing a clear roadmap to the desired outcomes.
- Patient-centered care: Care plans help to ensure that patients receive evidence-based, holistic care. Nursing diagnoses are standardized to ensure quality care, but nursing interventions are tailored to meet the physical, psychological, and social needs of the individual patient.
- Engaged patients: Setting achievable goals for and with patients helps to guide and measure nursing care. Goals also help motivate patients to become more involved in their recovery, because they can understand exactly what they need to do to achieve the desired outcomes.
- Compliance: The care plan serves as proof of receipt and helps payers determine how much they should reimburse for care Clinical Care Plan Assignment Discussion Paper.
What Is a Nursing Care Plan?
A nursing care plan is the written manifestation of the nursing process, which the American Nurses Association defines as “the common thread uniting different types of nurses who work in varied areas … the essential core of practice for the registered nurse to deliver holistic, patient-focused care.”
The nursing process includes five key steps:
- Assessment: Collecting and analyzing data to gain a holistic understanding of the patient’s needs and risk factors.
- Diagnosis: Using data, patient feedback, and clinical judgment to form the nursing diagnoses.
- Outcomes/Planning: Setting short-term and long-term goals based on the nurse’s assessment and diagnosis, ideally with input from the patient. Determining nursing interventions to meet those goals.
- Implementation: Implementing nursing care according to the care plan, based on the patient’s health conditions and the nursing diagnosis. Documenting care the nurse performs.
- Evaluation: Monitoring (and documenting) the patient’s status and progress towards goals, and modifying the care plan as needed Clinical Care Plan Assignment Discussion Paper.
A nursing care plan is formal documentation of this process, and most care plans are organized into four columns that closely mirror the steps of the nursing process. Care plans include:
- Nursing diagnoses
- Desired outcomes/goals
- Nursing interventions
- Evaluation
NurseLabs notes that some healthcare providers use only three columns, combining “desired outcomes/goals” and “evaluation” into the same column, whereas other providers use five columns, including one for “assessment cues.” Care plans for nursing students typically include another column for “rationale/scientific explanation,” where they are asked to explain the reasoning behind their proposed nursing interventions Clinical Care Plan Assignment Discussion Paper