The following question was asked of a random group of Journal of Gerontological Nursing readers:
How do you make the care plan a "living, useful document tor all caregivers?
Care planning involves the primary caregiver, the certified nursing assistant. Using the MDS+, we meet with all our staff to develop a user friendly care plan. The care planning is a 24-hour-a-day, 7day-a-week process. Pre- and postconferences and resident care conferences help to make the care plans real and usable.
Computerization, which we are currently in the process of setting up, will assist us in implementing the needed changes in a more timely manner. Our care plans are well used and our primary caregivers are responsible for their development, which gives them ownership and therefore they take pride in making them come "alive."
Colleen Quackenbush, RN, BSN
Director of Nursing
Villa Mary Immaculate Nursing Home
Albany, New York
Communication, comprehension and delivery of the resident's comprehensive plan of care in a nursing facility can become problematic and result in inconsistent, inappropriate delivery of care that does not meet the resident's needs, desires or contribute to problem resolution.
Individualized comprehensive care plans become complicated for staff when they cannot dissect the portions of the resident's plan of care which pertains to their specific discipline. This inability to disseminate interventions results in frustration for both the resident and the staff who are caring for the resident and noncompliance with interventions that lead to goal resolution.
At our facility we tried several ways to communicate the plan of care to residents, families and interdisciplinary staff to assure compliance with interventions and consistent delivery of care; we now have the option of computer-generated, disdpline-specific caregiver reports. The residents' plan of care is now a living instrument that is easily understood by all disciplines involved in the overall process of providing for residents' physical, mental and psychosocial well-being.
The computerized master care plan is established with a problem list which identifies Resident Assessment Protocol Triggers. The following pages list problems, goals individualized to the resident and interventions with responsible parties listed. After entering the master care plan, the caregiver reports are generated for each specific discipline with only the interventions for that discipline listed. Each discipline is given a copy of their specific caregiver report. Nursing department caregiver reports are submitted to nurses and restorative personnel and the certified nursing assistant reports are placed on the Activities of Daily Living chart for each resident. Nursing Assistants read the plan of care when charting for the resident and sign their name once the caregiver report is read.
Residents, family members and staff meet on a quarterly basis to review and revise the individualized plans of care. Any corrections to the plan of care are demonstrated through the caregiver reports which are a current, living care plan.
All residents who enter our nursing facility are assigned two problems: Skin Integrity, Impaired (Actual or Potential); and Injury (Actual or Potential) to prevent skin and injury problems and promote skin integrity and safety. Interdisciplinary staff are inserviced to our expectations of skin care and injury prevention to promote understanding on an annual basis.
The resident plan of care is meaningless unless residents, families and staff understand the expectations. When the plan of care becomes a living instrument that reflects total holistic care (physical, mental and psychosocial), residents, families and staff are empowered.
Computer-specific information is available from: Medical Communications Software, Inc., PO Box 12497, North Kansas City, MO 64116
Jenny Damon, RN, AAS, BSN student
RN Assessment/Care Conference Coordinator
Washington County Hospital, McCreedy Home
This question was submitted by Joan Kramer, RN, MS, Clinical Specialist at Johns Hopkins Geriatrics Center, Baltimore, Maryland. Her comments follow.
OBRA 87 resulted in clear, concise guidelines on the "what" and the "when " of interdisciplinary resident assessment and care planning. What it did not provide was guidance on the "how". The task of implementing a coherent, understandable, and useful care plan process was left to individuals and facilities.
Care planning involves tremendous nursing activity in the postOBRA era. In a review of 29 care plans, Daly, Maas, and Buckwalter (1995) found 214 nursing diagnoses recorded along with 94 nursing interventions. Clearly, developing methods for communicating this complex and highly individualized care plan among many different disciplines, and to caregivers aroundthe-clock is not a simple task.
The respondents to our question have highlighted some basic principles for an effective care planning process:
* involve multiple disciplines
* involve the nursing assistant, family and resident
* make the care plan readily accessible to all users
* educate staff about important (priority) standards of care, e.g., skin integrity, fall prevention
* use computerization as an aid to dissemination, communication and documentation of the care plan.
A number of authors have contributed to our understanding of the "hows" of individualized care. Happ, Williams, Strumpf, and Burger (1996) defined four closely linked critical attributes of individualized care that can guide us in making the care plan a "living" process:
1. Knowing the person involves understanding the individual patterns of response, and details about the person's life including satisfactions, regrets, accomplishments, and diversions. "Knowing" has been described as a reciprocal process in which the patient responds with trust and confidence to the nurse's commitment to "knowing activities" (Jenny & Logan, 1992).
2. Relationship refers to the resident's continuing function as a social being. In long-term care settings, staff become members of the resident's social circle. These relationships help caregivers to know the resident as a person. Important to establishing and mamtaining these relationships are assignment methods that allow for continuous or consistent assignments of staff to residents (Rader, Lavelle, Hoeffer, & McKenzie, 1996; Lustbader, 1996).
3. Choice in issues of daily living and environment embodies respect for individual dignity, personal control and risk-taking (Happ, Williams, Strumpf, & Burger, 1996).
4. Resident participation and direction can only occur if the other three attributes are encouraged and nourished in the care environment. Resident participation can occur even in confused or demented residents by observing behavior(s) and developing an understanding of their meaning (Happ, Williams, Strumpf, & Burger, 1996).
Making the care plan a living document for all caregivers will continue to challenge our creativity and determination in long-term care. Practicing the basic principles offered above, and promoting practices that incorporate the critical attributes of individualized care will go a long way in achieving this goal.
- Daly, J., Maas, M., & Buckwalter, K. (1995). Use of standardized nursing diagnoses and interventions in long-term care, journal of Gerontological Nursing, 21(8), 29-36.
- Happ, M., Williams, C, Strumpf, N., & Burger, S. (1996). Knowing the patient: The route to individualized care. Journal of Gerontological Nursing, 22(3), 15-19.
- Jenny, J. & Logan, J. (1992). Knowing the patient: One aspect of clinical knowledge. image, 24(4), 43-46.
- Lustbader, W. (19%). Tales from individualized care. Journal of Gerontological Nursing, 22(3), 43-46.
- Rader, J. Lavelle, M., Hoeffer, B., & McKenzie, D. (19%). Maintaining cleanliness: An individualized approach. Journal of Gerontological Nursing, 22(3), 32-38.