Before one examines the realm of bedside care plans, one must have a complete knowledge of patient care plans and the necessity for having and using them. Too often the nurse in the acute setting feels that nursing care plans are just "more paperwork" and since the patient's condition changes so rapidly it seems unnecessary to set long or even short-term goals. They fail to see they are constantly assessing situations; however, each individual is doing the assessing and without shared knowledge sometimes it is conceivable that the same problem may be assessed in a 24 hour period by more than 20 people. Think what this does to the patient. It is a constant repetitive effort to teach each of us the easiest way to solve or alleviate the problem. The patient should really only have to give an accurate nursing history once and after that there should evolve a logical and concise approach or plan of action.
In long-term facilities, unfortunately, the situation is sometimes even more of a problem. The staff has the feeling that all the patients and staff are there to stay and, therefore, they begin to feel they each know all of their patients' needs and wants. It becomes inconceivMarion able to think that an individual does not change in a long-term setting. People by their very nature are ever changing. So, too, the chronically ill have to have goals set for them. These goals evolve from patient care conferences, rounds, and the nursing history and become a working tool in the patient care plan.
It is basic then to state that each patient is an individual and as such will have different needs than any other patient. Quality of care can only be determined by the formulation of a patient care plan, evaluation, and revision of the same on a continual basis. It must be paramount in our minds that the only course of action is for all team members to follow a common course of action to benefit the patient.
Patient Care Plans
The reasons for not having or using care plans are briefly reviewed as follows:
1. Lack of knowledge in how to write them.
2. Fear of documenting a "wrong" assessment.
3. Out-dated nurses stations that do not allow them to be used when needed.
4. Some nurses feel only professionals can write care plans and expect most of that information to be delivered to the patient by ancillary personnel.
5. Feelings that the information contained in the plan should be basic to all.
6. Lack of wanting to get involved, e.g., finding out the reason why there are no visitors for a particular patient could make the staff uncomfortable with their own feelings.
7. Lack of support from nursing home or hospital administrators.
8. Head nurse who carry Kardexes around as a symbol of authority.
9. They are basically task oriented which does not allow them to look into the "whys" of what they are doing. It is more a matter of getting the assignments done.
10. Lack of an organized system of charting which does not lead to a problem list that is individual to each patient.
13. Fear that the care plan is not current, thus the chart is used for more up-to-date information.
12. Time consumed just is not worth it.
In a cross sampling of RNs, LPNs, and nursing assistants, the aforementioned reasons were found to be true in many cases. Multiples of these reasons were cited even more frequently.
What then is the answer? Certainly the value of the care plan in any setting can be justified by the accountability of the care being delivered. No scientific process can proceed without a logical planning system.
Let us then address these 12 reasons in a positive vein:
1. Workshops with lecture courses in basic writing techniques can be employed for staff members who feel they lack the knowledge to formulate a care plan. Emphasis on their positive abilities must and should be praised. It is also essential to test the reality of the lack of knowledge as opposed to peer pressure or feelings of insecurity.
2. When the entire team is working for the patient, one begins to realize that it is possible to make a wrong assessment. What is more important to note here is that with a written system of care a wrong assessment will onlv be made once as opposed to several people attempting to assess the same situation incorrectly. Therefore, the team as a whole profits and capitalizes on assessments that do not work and consequently do not waste their time in redundant efforts.
3. I must agree with the nurses who feel that care plans at the bedside are difficult to use. I strongly feel the plan of careshould be with the patientai the bedside so that everyone is aware of the patients' problems and the means we hope to use to resolve the problems. It does seem foolish to leave a patient to walk half a corridor to determine what techniques are being used for comprehensive care. With the information in close proximity to the patient, it is easier for the patient to get the care he needs quicker and safer.
4. If professionals feel they are the only ones who can write the plan of care, then we must certainly question the use of ancillary people in all departments at the bedside. The nursing assistant must feel free to have input into the patient to which she has been assigned. It is an axiomatic fact that people cannot use knowledge they do not possess. Therefore, tools must be made available to ancillary personnel so they can better deliver safer and more protective care.
5. If one keeps in mind that each care plan has to be individualized, it then becomes impossible to think that knowledge is basic to everyone. It is in the application of different approaches that we see the variations of different goals dependent on individual needs.
6. It is very difficult to get involved with the patient we care for because getting involved does cause a certain amount of emotional involvement. In dealing directly with people in the health care setting, I would concede that getting involved occasionally involves the risk of getting hurt; however, not getting involved runs the risk of getting nothing at all.
7. Lack of support from administration has also been given as an excuse for not supporting care planning. I find most administrators eager to support any cause for the patient that will ultimately benefit the over-all patient care. It is an easy way out of things to blame lack of administrative support.
8. The nurse who feels that she needs the Kardex as a means to prove her "vested authority" has problems that should be worked out through either her supervisor, inservice, or peer support. It is of the utmost importance for the nurse to embrace all members of the health care team into the patients' planning.
9. People who are task and time oriented need help in understanding that all people are separate entities and need to have their needs met rather than those of the facility.
10. Since we are now more accountable than ever for what we do with the patients' monies, and with health care costs rising astronomically, we need to definitely increase our awareness for written documentation.
11. If the professional fears that the care plan is not up to date and chooses to use the chart as a source for correct orders, she is basically forgetting the purpose of the nursing process with goal setting as a focal point. Then too, she has to be aware that she has an obligation to update a care plan because an out-of-date plan could cause more potential harm than none at all.
12. Finally, time consumed has to be looked at realistically. In an over-all view, if all members of the health team contributed to the care plan, the final product will evolve to better serve the patient. It will in many cases, stop duplication of effort.
Now that we have explored the value of care plans and their necessity of existence, we can carry it a step further and explore where the care plan should be kept. Through a trial period we found that having the care plans accessible at the bedside was an answer to many of the problems usually purported.
This use of the bedside care plan compared to the one traditionally left at the nurses station has encouraged a higher level of effectiveness in that the patient is more directly involved in their own care.
The patient has input along with each professional helping him or her to set their over-all plan of care. Bedside care planning allows us to use a specific method and tool to assist in delivering optimum health care. It allows for the patient to have more of a voice in their own care and at the same time creates a climate of understanding for themselves.
Health care professionals must now be able to function in a highly complex health care system where tremendous psychological and sociological changes are constantly taking place. While keeping abreast with all the latest changes, the health care professional must also be cognizant of day-to-day patient care. Therefore, health care today, with its multidimensional effects, is more exciting than ever.
In my opinion, the bedside care plan is an effective tool to meet the vital needs of the patient. We find it is more effective in conjunction with the problem-oriented method of charting; however, its use with traditional methods have also been tested and proved of value. Implementation of the care plan requires the acceptance of all staff members, patient orientation by the staff, communication with the families, and finally, initial follow-up by all department heads to ensure the working success of patient care plans.
- Blanchard LB: Will you switch to problem-oriented records? Patient Care, January 1973, ρ 59.
- Bogdonoff MD: The challenge and opportunities of the Weed system. Arch Intern Med 128:832-834, 1971.
- Case records of the Massachusetts Geneial Hospital: New Engl J Med 285:103-113, 1971.
- Hurst JW et al: More reasons why Weed is right. New Engl J Med 288:629-630, 1973.