The faculty members responsible for the basic medical-surgical nursing course at the College of Nursing, University of Hawaii, agreed that a nursing care plan is essential in giving qualified comprehensive care to patients. They agreed on the essential content for a basic patient care plan, but they were unable to agree on the format to be used in formulating the plan. After much deliberation, they decided the problem could be handled best by requiring participation of the sophomore students, since these students would be using the plan as a guide in giving the daily patient care.
The faculty's definition of a care plan was based on Thora Kron's description which states that a care plan is a guide for nursing care which utilizes the abilities of a number of persons to provide continuous care for a patient and is based on the individual needs of the patient. They believed that the general components of the care plan consisted of: (1) identifying a patient's problems and basic needs, (2) selecting appropriate nursing activities and approaches, (3) understanding and applying the scientific rationale underlying the problems, needs, and nursing actions, and (4) evaluating and revising the care plan.
Prior to the initiation of this project, and early in the year, the nursing students were oriented to concepts of group dynamics. The sophomore class was divided into six discussion groups, each consisting of eight students with individual faculty members participating as resource persons. The students were given the opportunity to assume the roles of discussion leader, recorder, and participating members. At the end of the session, discussion was followed with analysis and clarification of the group dynamics process. Team nursing, comprehensive nursing care, and problem solving techniques were other concepts introduced at this time
The philosophy and objectives relating to the student directed project were designed to enable students not only to give comprehensive patient care but also to guide them with their planning, organization, and application of medicalsurgical nursing knowledge and skill. To initiate the project, the students were given a bibliography of articles pertaining to patient care. Subsequently a class discussion was held in order to draw out common concepts gained from these readings. The faculty's definition of a care plan was discussed, and following this a film entitled, "The Patient is a Person," was shown. The film depicted the story of a young man entering a hospital for the first time and the problems he encountered in this new experience. The students were then asked to individually formulate a plan of care based on the impressions they derived from the film. At the next class session, they were asked as a group to compile their interpretations into a single care plan.
At this time, the student understood the care plan to be a concise and completely written outline which serves as a guide for professional and non-professional members of the health team in giving patient care. Nevertheless, they considered die format presented by the faculty difficult to work with. The faculty therefore decided to involve the students in the project to develop a more suitable format for the nursing care plan.
The faculty believed the students would be better able to provide continuity of patient care and to keep a more direct focus on the individual patient and his needs if they were given latitude in the project. They also felt that they could use the nursing care plan as a method of evaluating a student's understanding and ability to apply principles from the physical, behavioral, and social sciences as well as from the science of nursing. The project was not intended to be a formal investigation but was designed to stimulate critical thinking and to encourage independent and group study.
At the College of Nursing, introduction to medical-surgical nursing begins on die sophomore level. Fundamentals in nursing, pharmacology, diet therapy, and health teaching are integrated within the course content. Human relations in nursing (basic psychiatric nursing principles) is taught concurrently. The sixteen-credit medicalsurgical nursing course, which includes four hours of tiieory and sixteen hours of experience in the clinical area weekly, is given over a two-semester period. Clinical experience for the students is provided in two hospital agencies: (1) a small general community hospital and (2) a large military hospital. Students are further divided into two groups in each agency. Hence there was a total of four working groups on the care plan project.
In the initial group meetings the students selected their chairman and a recorder. There was a general consensus among the groups that in order to carry out the project effectively, a division of labor would be necessary. The areas of investigation included the review of periodicals and other literature, interviews with hospital personnel and faculty members, and correspondence with other schools of nursing. In the beginning the students felt hampered because of their limited knowledge and skill in group dynamics and problem solving methods. They soon discovered, however, that the responsibility did not rest with the leader or with students who were more verbal but depended upon the thinking and cohesiveness of the entire group.
During the following two montiis the students met from time to time to discuss their findings and the progress of the project. Faculty members made themselves avadable whenever invitations were extended to them as consultants. Occasionally tiiey overstepped their roles as consultants for it was difficult to refrain from giving unsolicited advice and making decisions. As the project progressed, however, they found themselves becoming deeply interested and enthusiastic about it.
Although the approach and the essential content of the care plan were similar, each group developed an individual form which tiiey used in their daily patient care for a period of two montiis. During mis trial period it was recommended that students meet periodically to evaluate and to revise their plans as seemed necessary. At the end of the two-month trial period, the total class met to give the reports of the groups. At this stage the students expressed some feelings of confusion and dissatisfaction with their progress and the early findings of the group work. Nevertheless, they continued to use their revised care plans for another two montiis. At the end of the last month of the sophomore semester, the group assembled once more to present their final summaries of the project. The class generally agreed that the nursing care plan was a helpful and necessary tool in planning effective individualized patient-centered care They felt, however, that they were not able to determine which one of the four care-plan formats was most desirable because each plan had its own value and merit.
The initial limitation in the care plan project was the concern of the students for the development of a format rather than concern for the essential content needed in formulating the care plan. In addition the groups as a whole felt that they needed a clearer working definition of the terminology used in the care-plan format. For example, Group I included in its evaluation background information on the patient whereas the evaluation made by Group II consisted entirely of the patient's progress during hospitalization. Groups III and IV listed data from the patient's history including such details as the patient's age, race, religion, occupation, allergies, and family background Group IV also included a description of the patient.
Another area of confusion was in the use of the phrases "patient needs" and "patient problems." Students had difficulty in differentiating between a need and a problem. Confusion also arose in the application of scientific principles. Certain groups discussed principles in relation to patient problems and needs and other groups used principles in relation to the nursing intervention. After much discussion, the students agreed that the scientific principles were important and applicable to both areas. They were able to rectify the limitations of their care plans through their individual working groups and in the total group meetings mentioned earlier in this article.
The values derived from the project greatly outnumbered its limitations. In formulating the care plan, students were able to keep their primary focus on the individual patient's needs and problems. They were also better able to differentiate between the needs and problems of patients and nurses. Initially the students had been more concerned with their own needs and problems.
The students also felt they had gained a better understanding of the use and application of the problem solving technique and that they had acquired a greater appreciation of the dynamics of group process. They had developed an increased abdity to organize and execute nursing care in a more effective manner and a greater awareness of the application of scientific principles supporting nursing care.
The faculty also derived and saw innumerable values. While working with the students on their projects, the faculty learned to accept and to assume functioning roles other than that of instructor. They learned the benefits possible from relinquishing greater responsibility to students in assuming more selfdirection for their own learning. The care plan provided opportunities for creative thinking and planning. The different care plans demonstrated the different approaches available in planning patient care. Last but not least, me project was an effective way of integrating the students' learnings from concepts derived from human relations, group dynamics, team nursing, comprehensive patient care, and problem solving.
This student-directed project was successful as a project simply because of the full support and cooperation of the sophomore students. These students unanimously recommended that a similar project be presented to each new sophomore class, and the faculty have since adopted the nursing care plan project as a part of the sophomore medical-surgical nursing course at the College of Nursing, University of Hawaii.