Major careplan = dinosaur???

  1. Our faculty is about to engage in a discussion of the continued value of a "major careplan". One based upon an assigned patient in clinical and inclusive of five Nursing diagnoses, goals/outcomes, interventions (with rationales drawn from literature citations), and evaluation.

    The careplan is graded (but only 10 points out of 400 or so for the semester) and they tend to run 20-30 pages in length. Students spend considerable time, energy and anxiety during the completion of this project (and are required to do one for each of our four principle clinical courses with increasing degrees of acumen). There is little doubt that they learn from them, but there is also a sense that their time (and that of the instructor who must grade them) may be more productively spent engaged in other activities that accomplish the same objectives.

    IS THERE ANY RESEARCH DOCUMENTING A TREND AWAY FROM MAJOR CAREPLAN AS PART OF UNDERGRADUATE NURSING EDUCATION? Is the careplan, as some allege, a dinosaur?
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  2. 13 Comments

  3. by   Enright
    I found the '30 page care plan' to be a complete waste of time in my BSN program (87 grad). I felt it was over emphasized and took away from the clinical lessons we were trying to learn. When I got out into the clinical world, I never worked anywhere that saw care planning as more than a prefunctory gesture at continuity. From 87 though 99, my hospital years, I saw them used less and less in favor of more time saving devices.

    Personally, I think the big care plan is a left over from a time of better staffing and primary nursing. When I began my career, I had 4-5 kids on nights. I had plenty of time to read and digest a big plan of care. When I left hospital work for consulting in 99, I had 20+ kids to care for at night. There was no longer time for anything requiring thoughtful reading.

    I know this is an age old debate and I wish you well with your consideration of what to do with this tool. I actually got a lot more out of those major opus care plans when I was a new grad looking back than I did as a scared to death student.
  4. by   jdomep
    Wow! That's a lot of pages!

    We have to do them before each clinical but ours are short and sweet. We were also told we could go to here

    http://www.us.elsevierhealth.com/Mosby/Gulanick/

    and use this generator...
  5. by   micro
    the principle of doing the careplans in school still is warranted.....
    it is a learning tool......
    but too much emphasis is made of the length and the exactness of it.........
    it does not reflect reality nursing.............
    a balance from a student that needs to deeply ingrain the principle of careplans into their mindset with the reality of the lack of time and patient care.........
    reality nursing 101
    careplans in reality are perfunctory and required.............so there and nic and noc forms that are quickly completed and monitored...........
  6. by   llg
    I have done a little undergraduate teaching -- but have spent most of my career in Clinical Specialist and Nursing Staff Development roles. Thus, I have seen "new graduates" from both sides -- plus, of course, having been a new grad myself many years ago.

    Like many people, I have mixed feelings about care plans. I don't see any need for 30 pages, but feel that the process of assessing, diagnosing, planning an intervention, knowing why you chose that interventions, and evaluating the results of that intervention are CRUCIAL to the intelectual development of a novice nurse. Too many nurses just do things because "that is the routine" without really putting thought into their actions. Sometimes it seems as if they got so turned off of "care planning" by the agony of doing horrible, big projects that they never want to use that process again.

    I think the solution is to come up with a way to document that the appropriate intellectual process was used with EACH PATIENT that the student cares for. Students shouldn't be led to believe that "nursing care planning" has to involve a huge project -- that only has to be done once per course and then never again. It should be a process used automatically with every patient, every time.

    Also, students need the opportunity to practice other forms of communication and documentation. For example, I am always amazed when staff nurses serving on committees or being asked to help with an inservice, etc. say they have no idea how to procede. Some have no idea where to find information, how to organize it for a presentation, or write a simply summary of it to share at a committee meeting.

    I think students should do brief care plans for every patient. Then, you might have them research one topic in-depth per course -- not using the care plan format, but a format more conducive to teaching them how to write up a case study or article for publication, sharing in a staff meeting or inservice, developing a policy or procedure, etc. These are the types of things real nurses should be doing in practice and most nursing students never get practice doing that in school. They just write huge care plans that aren't anything like that used in practice.

    In summary:
    1. Short care plans for each patient to establish the habit of the proper approach to each patient.
    2. The occasional larger, in-depth project in a format more similar to the types of projects that a staff nurse, committee member, or first-line manager or educator might be asked to do in a real-life job situation.

    Just my $.02
    llg
  7. by   canoehead
    llg- I agree completely.

    Care plans are overrated in school, although you need to know how to make one out the 30 pages is overkill. The patients we have in hospital today are in and out in 3-5 days, students perhaps could use some skill building on critical thinking exercises and prioritizing care vrs teaching vrs support and then paperwork on top of it all.
  8. by   boggle
    Ours is a 3-4 page care plan. it demonstrates that you can correctly formulate nursing diagnosis statements that are individualized to your patient, that you can prioritize your nursing diagnoses, that you can come up with NOCs and NICs that specifically apply to your patient's NANDA,, and that you can support your NICs with scientific rationale. I have heard this same style of care plan assignment in other schools in my area.

    I would rather it be short and sweet and learn something well, than a long and frustrating experience.
  9. by   Youda
    I can't speak as an educator; and I'm not aware of any studies. So, take my comments as just another nurse.

    A care plan is a revolving tool. I can't imagine spending 20-30 pages on one, as if when you get your 30-pages written, you're done with it! That's just not how a care plan works, or why anyone does it. It is never finished. Even an admission assessment just hits the major items, and when someone else sees a problem that needs attention, it is added to the care plan. NO ONE spends that much time on a care plan!

    I wonder if the whole process of teaching the 5-steps of care planning would be more effective and 'real to life' if it were a class project instead of an indvidual assignment. The first person do the admit assessment and initial care plan, then pass it on to the next student who's assignment is to add collaborative problems, then the next student gets it and adds some short-term problems, then another to add spiritual-related problems, another to add cultural-related problems, etc. All the while re-evaluating what was written before.

    A 30-page care plan is unworkable in real life. No one has the time to read it, let alone try to implement it!

    I don't think a comprehensive care plan is a dinasaur, but how it is taught! If you just get an assignment to do it, you don't "get" that it's always changing and that no one person is usually responsible for it.
    Last edit by Youda on Oct 5, '02
  10. by   semstr
    a 30 page care-plan!! I can't believe it!! not very realistic and so not very good for teaching nursing students!
    Of course I use care-plans too, but my students work on it together (up to 4 students) and plan the most typical nursing diagnosis on this case.
    The basics are there anyway, in nursingstandards I get from different hospitals, so students can compare them.
    They plan up to 5 or 6 nursing diagnosis and that's it.
    Take care, Renee
  11. by   CraigB-RN
    In some of the CMS rules for Skilled Swing bed and other catagories of hospitals, there is a requirment for a "comprehensive" care plan.

    As to teaching, any tool that gets the students to think beyond the obvious and look for all the problems that a patient may have is a good thing. 30 pages is a bit much though.

    CraigB
    DIrector of Nursing
    Affiliate Facaulty
  12. by   Nanette
    We have started to use concept mapping instead of care plan, different format, the visual aspect of it helps students put things together.
  13. by   Edward,IL
    Nursing is a learned discipline, and the primary reason that patient's come to a nursing situation is to be looked at wholistically, have their health problems identified (nursing diagnosis), interventions planned, and goals (measurable patient-specific outcomes) set.
    The best way to learn how to think like a nurse is through teh development of formal written care plans.
    I have more than twenty years of clinical experience and cannot practice within the requirements of this state's Nursing Practice Act without a nursing care plan.
    I've always used Gordon's Functional Health Patterns Typology to organize health data (history and physical assessment). All significant patient information (regardless of age, medical diagnosis, patient acuity or setting) can be fit into these 11 categories. Nursing diagnoses (current NANDA taxonomy 2002-2003) is the legitimate language to use to identify health problems. Nursing Interventions Classification, Bulecheck and McCloskey, C.V. Mosby, and Nursing Outcomes Classification,
    Meridean Maas, C.V.Mosby are VERY helpful.
    If you make these required texts for the first day of Fundamentals
    and continue them throughout your program, nurses graduate being able to THINK like nurses, organize their thoughts clearly and prioritize.
    Length of care plan does not have to be 20-30 pages, but a care plan should be developed for each patient seen by the student nurse. As for identifying at least three sources, the texts mentioned above have been developed and validated through reasearch already. These will make sense to your students.
    As for what you see going on in hospitals and nursing homes these days, this has nothing to do with the future of nursing.
    Haphazard care with one nurse ot 15-20 patients is on its' way out of style. It is physically impossible and is not lasting.
    Please continue to teach primary nursing and the development of written nursing care plans.
    Thanks, Edward
  14. by   oilinmylamp
    I think care plans as you just described them are definitely a dinosaur.However I do believe simple problem statements with attending goals and interventyions are useful. We ask our students to do thes simple care plans each clinical day. It helps them focus on the goals for the patient that day instead of some long term goal that the student nurse will never see come to fruition or give them a chance to evaluate.If the student has a dehydrated patient and writes a goal to get them to drink 8 oz. of water during their clinical time it is an achievable goal and I think they have a better chance of really learning what goals are important from a nursing point of view.

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