Are care plans valuable?

[Nurse Beth]

We just had a mock survey, and the surveyor pointed out our (electronic) care plans were not always pertinent to the diagnosis, had not been updated, or closed out when no longer a "problem".

But I think there's a reason that the nurses don't place a high value on care plans, and why they're seen as "busy work" Nurses sometimes feel they don't really add value to their patient care.

What do you think? Thanks!

[VANurse2010]

Care plans are not appropriate for acute or critical care. They are a time glutton that detract from actual patient care of acutely ill patients. If CMS etc. want them for long-term goals for long-term patients - I get that, but that's not what I think most of us are talking about.

[KeepItRealRN, BSN, RN]

Care plans are not appropriate for acute or critical care. They are a time glutton that detract from actual patient care of acutely ill patients. If CMS etc. want them for long-term goals for long-term patients - I get that, but that's not what I think most of us are talking about.

^^^This, Yes^^^

[KeepItRealRN, BSN, RN]

Care plans are not appropriate for acute or critical care. They are a time glutton that detract from actual patient care of acutely ill patients. If CMS etc. want them for long-term goals for long-term patients - I get that, but that's not what I think most of us are talking about.

Exactly. The perspective I come from is an ICU setting. It is in this setting that I find the "care plan" useless and a waste of time. In the acute ICU setting the plan changes from one hour to the next, and is as I've said before, communicated via a nurse to nurse text box at my facility. For the long term rehab type patient, then it may have value. In the ICU setting it is a waste of time that can be devoted to actual care or charting.

[MSrn2015]

I feel like this type of information should have also been given in report--this patient is a high fall risk, has a hx of falls and has specific safety protocols in place during ambulation to prevent a fall. This may have been a case of a caregiver simply not following what should have been done. Would reading the ambulation instructions in a care plan have made a difference in this case? Can't say for sure, but I don't personally think so.

As a disclaimer, I'm a new grad and have yet to start working on the floor. In my experience during my rotations the nurses simply breezed through the care plans to get them charted and done; it was considered another hoop to jump through.

Example: Patient documented as fall risk (yeah, yeah, everybody's a fall risk, but this one had fallen backwards on her butt several times at home before being admitted). She was supposed to use a walker and NEVER be allowed to walk without somebody next to her with contact guard at all times, duly noted in her admitting RN's plan of care. Guess what? You bet. Somebody got floated to her floor and was walking with her, but was walking in front of her WITH HIS BACK TO HER, and she fell backwards, pulling the walker over with her. Died, too, as so many old birds do when they fall, hit their heads and break their pelves. Big settlement, not because an old lady was going to live a long time or miss a lot of work, but to send a message to the facility about following a written plan of care based on an RN assessment, per the state nurse practice act and the ANA Scope and Standards of Nursing Practice.

Her plan of care clearly indicated that someone should be next to her and keeping a hand on her because she tended to fall backwards, but hey ... care plans are a waste of time and we don't read them. Besides, we know how to walk people, we do it all the time. The walker is all she needs for support and balance, everybody knows that.

Uh, huh.

[nurseprnRN, BSN, RN]

Precisely. It was in the plan of care, but in spite of it being there, the person ambulating her didn't pay attention to it, and the patient fell. All that time spent on that care plan was for naught.

Just because some disagree with you doesn't call for snark. You feel one way, others feel another.

My point was not that the RN's plan of care was for naught because the culture was not to pay attention to them. It was that people should pay attention to them, must pay attention to them, and the institutional culture should do a much better job of seeing that their employees value nursing enough to do it completely.

But hey. As I said, I see the records from lots of institutions. Not snark, fact. YMMV.

[MunoRN, RN]

Whether or not care plans are valuable is completely dependent on how we are defining "care plan".

If we're talking about the old-style care plan that gets written as a stand-alone component and put in folder somewhere then no, that's of little use in actually helping to manage patient care. This type of care plan used to be common primarily because it was easier for in-house compliance staff to see that it's complete, and also easier for surveyors to review, but the problem was that it was only for the benefit of them, and was of little benefit to staff caring for the patient or the patient themselves.

What you'll more often find these days, and for good reason, are much more fragmented care plans that exist where they need to, rather than in a folder somewhere. The sign above the patient's bed that has their swallowing precautions is part of the plan of care, the "turn due at" clock on the patient's door is part of the plan of care, the note on the whiteboard that says how the patient is to ambulate is part of the plan of care. All of these things combined make up the full plan of care, which makes it harder to review but does make it useful.

[Karou]

I don't think they add any value to nursing care where I work, but they do help with charting. Adding specific problems to the care plan auto populates certain rows to our flow sheets. So when a nurse may not automatically think to add something, when charting, it might be there if it was auto populated with a care plan problem.

Skin integrity impairment or pressure ulcers auto populates skin intervention and assessment rows, for example.

Since we staff by acuity, which is determined mysteriously and magically by a program that pulls information from our charting, I see it helping that way.

But no one ever updates the care plans or sometimes doesn't even add the "basic care plan". I make it a part of my routine when I chart to update them, for managements sake more than my own.

Edited to add that at my hospital, the care plans are really generic click and add problems. "Skin integrity impairment", "diabetes", "anxiety", "fall risk", ect... You are supposed to select what applies to your patient from the list on each problem. Specific things like "must take pills whole in applesauce for swallowing safety" or "ambulate with assistance and walker only" are under the order summary, which people are more likely to read and pay attention to (they should!).

[emmy27]

While the theory behind nursing care plans is good, the actual implementation in every acute care setting I've ever worked or done clinicals has been terrible to the point of uselessness. Should a consistent expectation of meeting a patient's specific goals be communicated from caregiver to caregiver and kept in an accessible record for review? Yep. Do care plans in either the nursing school sense or the real-world sense as I've encountered them meet that goal in a functional way? Nope.

Bloated NANDA language doesn't help where used, neither does generic tickybox auto-generation. If 90% of your acute care patients automatically qualify as "fall risk," noting a "fall risk" care plan has been established does very little to trigger extra caution for any individual patient beyond the expected level of caution (and no amount of insisting that it SHOULD do is going to change that aspect of human nature- it's like highlighting an entire textbook), and digging through care plan documentation to get to freetext notes of actual useful information specific to that patient (when it's been bothered to be put in at all) has been awkward and time-consuming in all the documentation systems I've used. If your patient is very unstable, updating a care plan multiple times a shift *is* a drain on time that should be spent caring for an unstable patient.

Generally speaking, I've gotten far more critical information for keeping patients safe from shift report and reading nursing notes than from formal care plans, ever, because formal care plans have always been awkward, generic, and imprecise, and the time and effort needed to make them useful and specific is often both not available and would essentially be double-charting, since so many of these concerns are already documented elsewhere.

If the only thing standing between staff and legal trouble is a tool generally found to be useless or actively detrimental to their workflow, the problem might be with the implementation of the tool and/or the existence of the legal expectation, not the staff.

[dudette10, MSN, RN]

In acute care, they are just another documentation requirement, which takes us away from actual patient care. In LTC--from what LTC nurses have said--they are the bread and butter of nursing care.

In school, they are an important learning tool, but too much emphasis is put on the structure of the diagnosis statement than the actual plan of care. Take a look at the student forums where they struggle with where their assessment data goes (is it a r/t or an aeb?) rather than actually identifying the pertinent problems and interventions.

I also have have an issue with Epic's care planning tool. Many of the care plans are based on medical diagnoses, and then they are redundant with actual nursing diagnoses. You can chooses pancreatitis, but you can also choose acute pain, which is included in the pancreatitis care plan. You can choose heart failure, and you can also choose decreased cardiac output, which is included in the heart failure care plan. The tools themselves are substandard.

[dudette10, MSN, RN]

Edited to add that at my hospital, the care plans are really generic click and add problems. "Skin integrity impairment", "diabetes", "anxiety", "fall risk", ect... You are supposed to select what applies to your patient from the list on each problem. Specific things like "must take pills whole in applesauce for swallowing safety" or "ambulate with assistance and walker only" are under the order summary, which people are more likely to read and pay attention to (they should!).

You must work with Epic, from your description. There is a dysphasia care plan and an impaired physical mobility care plan. We don't get orders like that in my hospital...that's a nursing assessment and care planning function that the docs rarely, if ever, put in orders for. I do the click thing, but I also free form under each problem so that other HCWs can see what the patient needs. I like to spend more time on my notes than the flowsheets, which no one looks at. I know the residents look at our notes, the MAR report, the I/O summaries, and the VS summaries. Outside of those things...nope.

[dudette10, MSN, RN]

For myself, days when I don't update the written care plan (EMR section specifically labeled "cate plan") are days when I didn't have time to chart anything during my shift except drip titration which I do in real time, barely had time to scarf down a meal, and am looking at staying over to finish charting. Those days I do the minimum necessary charting because my time is valuable. I want to go home--not pour over Epic w/ a fine tooth comb.

Now of course I critically think and plan care appropriate to the situation. Take the issue of risk for impaired skin integrity. The LAL mattress, cervical collar care, and repositioning of ETT is already documented in the PCS. The q 2 hr repositioning, pillow under heels, changed electrode/sat probe site, etc. is already documented in the VS/infusions flow sheet. So now I'm working past 2330; do I want to spend time double charting--it's not a matter of "if it wasn't documented, it wasn't done," because I did chart what I did for the skin; or do I want to go home? Not a difficult choice.

I am still struggling with double-charting because of what people actually look at. They look at the notes, not the flowsheets. Also, it seems that surveyors want to see care plan documentation in the notes, and don't give a whit that I've ticked off interventions related to the care plan in the flowsheets. The surveyors, therefore, aren't seeing the forest for the trees.

[dudette10, MSN, RN]

Example: Patient documented as fall risk (yeah, yeah, everybody's a fall risk, but this one had fallen backwards on her butt several times at home before being admitted). She was supposed to use a walker and NEVER be allowed to walk without somebody next to her with contact guard at all times, duly noted in her admitting RN's plan of care. Guess what? You bet. Somebody got floated to her floor and was walking with her, but was walking in front of her WITH HIS BACK TO HER, and she fell backwards, pulling the walker over with her. Died, too, as so many old birds do when they fall, hit their heads and break their pelves. Big settlement, not because an old lady was going to live a long time or miss a lot of work, but to send a message to the facility about following a written plan of care based on an RN assessment, per the state nurse practice act and the ANA Scope and Standards of Nursing Practice.

Her plan of care clearly indicated that someone should be next to her and keeping a hand on her because she tended to fall backwards, but hey ... care plans are a waste of time and we don't read them. Besides, we know how to walk people, we do it all the time. The walker is all she needs for support and balance, everybody knows that.

Uh, huh.

Was this an incident in acute care or sub-acute or LTC?