What is a Nursing Care Plan and Will I Have to Write One?
A nursing care plan (NCP) is a document that outlines in detail what a patient's needs are, how you will treat them, and what reasonable goals are for their progress. It can be considered a live document as amendments and progress will be documented throughout the period of time the patient is receiving care.
What's the Importance of a Nursing Care Plan?
An NCP is important for many reasons; here are just a few:
- Helps nurses focus on individualized care, each patient has unique needs, and the treatments and goals should reflect that.
- Prompts critical thinking for clinicians to apply understanding of sometimes complex issues into concrete steps in reaching the established outcomes.
- Promotes communication among clinicians from different disciplines (physicians, nurses, assistants, therapists, dietitians, and other allied health professionals) who are all working with the patient.
- Ensures continuity of care throughout shift and staffing changes.
For our readers with experience in NCPs, what's missing from our list?
What are the Main Parts of a Nursing Care Plan?
There are five main parts to an NCP. They require a thorough patient assessment at the onset in order to determine the diagnosis. With the information gathered, achievable goals (outcomes) are identified, and the interventions necessary to reach said goals (this component is also referred to as implementation) are explicitly defined and evaluated. Some NCP formats condense those necessary steps into three columns; others, four.
These five components of the NCP are extracted directly from the American Nurses Association's (ANA) description of the nursing process:
1. Assessment
"An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data but also psychological, sociocultural, spiritual, economic, and lifestyle factors as well. For example, a nurse's assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain but the patient's response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.
2. Diagnosis
The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse's care plan.
3. Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient's care plan so that nurses, as well as other health professionals caring for the patient, have access to it.
4. Implementation
Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient's record.
5. Evaluation
Both the patient's status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed."
Will I Have to Write a Nursing Plan of Care?
If you're wondering, 'Will I have to make a nursing care plan?', the odds are high that yes, you will have to make one, although it depends on your work setting. However, if you're wondering if you specifically have to write one, as in writing one out on a paper chart, then the answer is maybe. Healthcare technology advancements are wide-ranging and aren't only focused on procedures and specialized diagnostics. These advancements include computerized care plans (also referred to as digital care plans) as well which are believed to help to further improve patient care. Not all facilities have transitioned to computerized NCPs, but you can expect the transition to continue.
How Computerized Nurse Care Plans Improve Patient Care
General perceptions of technological advancements often find that taking a task or process from the standard paper form and streamlining it into the digital realm helps that task or process to be more efficient and perhaps quicker. However, nursing operates in the scientific world, and a general perception or feeling isn't a data-driven conclusion; so, we take this statement and look at what medical journals are saying.
Adams and Duchene, authors of the journal, Computerization of patient acuity and nursing care planning. New approach to improved patient care and cost-effective staffing, that there is a need for nursing administrators to rationalize staffing and defend their budgets and this can be done through digital classification, "a computerized patient classification system that integrates patient acuity with patient care plans and nursing diagnoses. Direct cost accounting of nursing care according to patient needs and outcomes can be justified by correlating this management and practice data."
An Electronic Nursing Patient Care Plan Helps in Clinical Decision Support authors Wong CM, Wu SY, Ting WH, Ho KH, Tong LH, and Cheung NT take a definitive stance in their journal writing, "To enhance the quality of care and patient safety in both hospitals and community care setting, it is essential that an integrated electronic decision support system for nurses is designed to track documentation and support care or service including observations, decisions, actions and outcomes throughout the care process at each point-of-care. The Patient Care Plan project was set up to achieve these objectives...Preliminary results showed very promising improvement in clinical care."
Walters S., author of the journal, Computerized care plans help nurses achieve quality patient care, posits, "Computerization can significantly enhance the speed, quality, comprehensiveness, and effectiveness of creating patient-specific care plans. The benefits to nursing administrators include more efficient use of nursing resources, more effective use of nursing skills and expertise, and improved patient management."
Authors Daly JM, Buckwalter K, and Maas M. published their research which compared the written nursing care plans to computerized nursing care plans, Written and computerized care plans. Organizational processes and effect on patient outcomes had less conclusive results saying, "There were significantly more nursing interventions and activities on the computerized care plan, although this care plan took longer to develop at each of the three time periods. Results from this study suggest that use of a computerized plan of care increases the number of documented nursing activities and interventions, but further research is warranted to determine if this potential advantage can be translated into improved patient and organizational outcomes in the long-term care setting."
In What Settings Can I Expect to Do a Nursing Plan of Care?
Ultimately, if your work setting requires NCPs, then you must, whether written or computerized. Often healthcare facilities with government oversight require care plans, including mental health facilities, long-term care facilities, nursing homes, and skilled nursing facilities. Home health agencies and hospitals may require NCPs as well.
