Care Plans - What's their purpose? - What do you think of them?

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I saw a nursing student and her instructor reviewing a care plan today and she was reviewing something about wording of the care plan and it reminded how frustrating nursing education can be and how mixed up it can seem to be sometimes!!!

At my school, anyway, a care plan for something as post-anesthesia nausea would be grilled for the wording of the nursing diagnoses, the specific wording of the nursing interventions and goals.... to make sure that we were using impractical "nurse speak" as opposed to - oh no! - referring to a medical condition directly (eg pt constipated, possibly d/t medication side effect, keep hydrated, adm laxative as ordered, etc). Students should ideally be able to rattle off quickly the what's and why's. I think the nitpicky round-about descriptions required in nursing school make simple concepts more confusing... and end up wasting the valuable time of students.

Specializes in O.R. Nursing - ENT, CTC, Vasc..

The only person around me who complains about care plans is my boyfriend. When I tell him how much time I need to do them (time that is taken away from him and our daughter), he always says, "My mom's a nurse and she never has to do care plans," blah blah blah.

I am the kind of person that has to write things out to understand them, kind of organize them on paper (or on screen, however I'm doing it). So the care plan thing worked for me, as a nursing student. I did them in my first clinical semester. By the 3rd or 4th week of clinicals, if we had written a perfect care plan, we didn't have to write any more (just a shorter summary sheet). Next semester I think we go back to writing them again. With the stupid APA format *sigh*. (Like when I'm an RN on a med/surg floor and I get a handful of patients, I'm going to look it all up in all my books and then write citations for everything - funny.)

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Specializes in Cardiac.

And sorry my post is long- I'm going to try to give you the rationales of why teachers do what they do.

Scribbler-Love your post. I have been thinking of education (CNS in the future- maybe) and of becoming a clinical instructor in the future and I find your post inspiring. Thank you!

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Specializes in Onc/Hem, School/Community.
I am also an instructor, and my thoughts on care plans are as follows.

1) NCLEX doesn't test on NANDA terminology. NCLEX questions are developed by reviewing new graduate practice (what new grads are actually doing in the first 6 months of practice), and since NCLEX finds that new grads are not using this terminology word-per-word in practice, neither do I. My students are to explain the problem in plain english, with a focus on understanding pathophysiology and nursing care.

2) If I am a patient, and not breathing well, I don't care if my nurse knows whether it is ineffective airway clearance or ineffective gas exchange, I just want him or her to recognize an emergency and take the needed steps (O2, positioning, call for help, etc) that I need them to take so I can live. There is a lot of new literature on new grads and failure to rescue. I don't EVER want my students to be unable to recognize an emergency because they spent 8 hrs a day gathering information and not actually caring for the patient.

3) So.....what do I do instead? I have students give brief oral care plans about their patients, and I ask questions. Not just knowledge based questions like "What is vtach?" but "What would you do if you found a patient with this rhythm? What would your first intervention be?" After all, if the nurse recognizes vtach, only to go sit at the nurses' station and drink coffee, that recognition of a fact is useless.

I want any grad coming through my courses to KNOW that they can apply the standards of safe care and make quick decisions. Research tells us that in rescue/emergency situations, the nurse typically makes a decision within 30-60 seconds. I want my students to think like a nurse! They also make rounds. I have them gather assessment data with another student, and they compare notes. What is the most important care for the patient right now? I've found that the old standard care plans only tell me what you COULD do, not what you are actually doing. Most students copy out of a book. I am not interested in how well my students can copy from a book, I want to know how they think. I am also right in there with the students. If the patient vomits, I am there to help clean it up, as well as to ask the student what should we do now to help them out? There are so many other assignments my students do (brief concept maps, acting as lead nurse, conference presentations, etc.) I also have them practice giving and receiving report and "calling the doctor," which I never got a chance to practice while in school.

4) I also care about my students' well-being. I wouldn't feel safe caring for a patient on 2 hours of sleep and I am an experienced nurse. There is no way I would ever ask a new student to assume care for a patient, knowing that he or she had been up most of the night preparing care plans for my class. How can I tell them to lead a balanced life if I don't model one, and make my expectations reasonable? When the do a care plan for me, it is done "on the spot"- right then and there, either a 5 minute care plan that is oral or written. I don't belittle them if they or wrong, or hover over them while they write. I just try to redirect them with questions if they are off-target. Students are the future of nursing. I have made a committment to treat them as such, and not burn them out before they ever begin to practice. So many new grads quit in the first year of nursing. I think it's because they are so unprepared for the realities of nursing as it is. We don't do them any favors by having them complete 5 care plans per rotation with 15-20 pages each.

Throughout nursing school, I have always understood the reasoning behind producing care plans and consider it a good practice; however, your fourth comment is always my primary concern. I never found it helpful to arrive at my clinical rotation on two hours of sleep because I was up all night finishing my care plan. :typing

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Specializes in Onc/Hem, School/Community.
I actually learned a lot by doing care plans - once I figured out what a care plan entailed. A lot of people complain about them, and I agree, it is a lot of work especially with all of the other paperwork that is required of us. But I have learned that *most* of the paper work assigned is very helpful and I learned a lot more in the clinical setting by doing paperwork than by sitting in lecture listening to the instructor talk at us about different disease processes. I would rather do clinicals and paperwork/care plans over lecture.

I agree. I guess you could say that I learned to "connect the dots" by doing care plans. Connecting the pathophysiology, medications, care, and WHY it was being done is a priceless skill that a nurse will always use.

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although i'm not quite to the point of doing care plans i already dislike & fear them from just listening to nursing students who are constantly complaining about them & what or how they can do something right :confused: that the instructor will actually :yeah: them. i agree with what you have said in your thread. i wld like to hear of more instructor's that can remember they to were once where we (the students) are & how discouraging it is to hear constant :argue: negativity! i understand the importance of knowing what & why we are doing for ea. patient but, as you said copying out of a book & working in the real world is two different things. positive feed back & constructive criticism is absorbed & remembered far more than all the neg! students simply feel like they are :banghead: with no pos. movement. one step fwd only to take 3 steps back. again, i :yeah: you as being the instructor we wld all enjoy having & i'm sure learning & remembering far more as we become rn's & give other students encouragement to con't on & the reward at the end is one that only a :nurse: can know.

graciee77

i am also an instructor, and my thoughts on care plans are as follows.

1) nclex doesn't test on nanda terminology. nclex questions are developed by reviewing new graduate practice (what new grads are actually doing in the first 6 months of practice), and since nclex finds that new grads are not using this terminology word-per-word in practice, neither do i. my students are to explain the problem in plain english, with a focus on understanding pathophysiology and nursing care.

2) if i am a patient, and not breathing well, i don't care if my nurse knows whether it is ineffective airway clearance or ineffective gas exchange, i just want him or her to recognize an emergency and take the needed steps (o2, positioning, call for help, etc) that i need them to take so i can live. there is a lot of new literature on new grads and failure to rescue. i don't ever want my students to be unable to recognize an emergency because they spent 8 hrs a day gathering information and not actually caring for the patient.

3) so.....what do i do instead? i have students give brief oral care plans about their patients, and i ask questions. not just knowledge based questions like "what is vtach?" but "what would you do if you found a patient with this rhythm? what would your first intervention be?" after all, if the nurse recognizes vtach, only to go sit at the nurses' station and drink coffee, that recognition of a fact is useless.

i want any grad coming through my courses to know that they can apply the standards of safe care and make quick decisions. research tells us that in rescue/emergency situations, the nurse typically makes a decision within 30-60 seconds. i want my students to think like a nurse! they also make rounds. i have them gather assessment data with another student, and they compare notes. what is the most important care for the patient right now? i've found that the old standard care plans only tell me what you could do, not what you are actually doing. most students copy out of a book. i am not interested in how well my students can copy from a book, i want to know how they think. i am also right in there with the students. if the patient vomits, i am there to help clean it up, as well as to ask the student what should we do now to help them out? there are so many other assignments my students do (brief concept maps, acting as lead nurse, conference presentations, etc.) i also have them practice giving and receiving report and "calling the doctor," which i never got a chance to practice while in school.

4) i also care about my students' well-being. i wouldn't feel safe caring for a patient on 2 hours of sleep and i am an experienced nurse. there is no way i would ever ask a new student to assume care for a patient, knowing that he or she had been up most of the night preparing care plans for my class. how can i tell them to lead a balanced life if i don't model one, and make my expectations reasonable? when the do a care plan for me, it is done "on the spot"- right then and there, either a 5 minute care plan that is oral or written. i don't belittle them if they or wrong, or hover over them while they write. i just try to redirect them with questions if they are off-target. students are the future of nursing. i have made a committment to treat them as such, and not burn them out before they ever begin to practice. so many new grads quit in the first year of nursing. i think it's because they are so unprepared for the realities of nursing as it is. we don't do them any favors by having them complete 5 care plans per rotation with 15-20 pages each.

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Specializes in ER, ICU, Education.

graciee77, I agree. No matter what instructional method you use, it is very important to point out both a student's strengths and their opportunities for improvement. I have yet to interact with a student that had NO positive qualities that could be built on. I don't think there are any like that!

Try not to worry too much about them, you can learn to do this skill successfully also. I think the purpose of a care plan book and references is to show an example of one way to care for a patient. As your confidence grows, you will learn to prioritize based on your own assessments and interactions with your patients. It takes time so don't get discouraged. It never fails to be exciting to watch....students come in "green" and afraid, and I get to watch them grow as a nurse, watch the "light bulb" come on when they start to grasp the difficult concepts and begin to think like a nurse. Just remember, there will always be negative people that will tell you it's too hard and you can't do it. That's why you have to know in your heart that they're wrong :)

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why are they here to stay?:typing

I do agree that care plans in nursing school are a huge pain in the you know what. But, when you get out of school they will still be lurking around We have computer generated ones that can be personalized according to the pt.

If you ever get drug into court or get drilled by JCAHO you will be glad you know something about care plans and why they are here to stay.

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Specializes in med/surg, telemetry, IV therapy, mgmt.
why are they here to stay?:typing

because the federal law interpreted by medicare says they are. who is going to fight medicare and win?

please read post #37 of this thread. your school has an obligation to teach you how to write a care plan since when you graduate many of you are likely to work for a facility where you will be required to do them in some form or another. the "purpose of care plans done by employed licensed nurses in the work place. . .are. . to document the solutions to patient's nursing problems and they become a permanent part of the patient's chart."

the bread and butter of most healthcare facilities today are the medicare and medicaid patients. for any facility to be able to bill and collect payment from medicare for the services they provide to these patients, they must be either medicare certified or jcaho accredited. the law, federal law title 42 of the public health code, section 482.23 (hospital conditions of participation in medicare, nursing services), must be followed above all else and requires that

(b) standard: staffing and delivery of care. the nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. there must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.

(4) the hospital must ensure that the nursing staff develops, and keeps current,
a nursing care plan
for each patient."

42 cfr 482.23(b)(4)

medicare is interpreting this to mean that the care plan be written and done as jcaho has directed:

  • standard pc.4.10 - development of a plan for care, treatment, and services is individualized and appropriate to the patient's needs, strengths, limitations, and goals.

    • rationale for pc.4.10 - planning care, treatment, and services is not limited to developing a written plan. rather, planning is a dynamic process that addresses the execution of care, treatment, and services. the plan for care, treatment, and services must be consistently re-evaluated to ensure that the patient's needs are met. planning for care, treatment, and services includes the following:
      • integrating assessment findings in the care-planning process
      • developing a plan for care, treatment, and services that includes patient care goals that are reasonable and measurable
      • regularly reviewing and revising the plan for care, treatment, and services
      • determining how the planned care, treatment, and services will be provided
      • documenting the plan for care, treatment, and services
      • monitoring the effectiveness of care planning and the provision of care, treatment, and services
      • involving patients and/or families in care planning

this means that a written plan of care is to be included as part of every patient's medical record. trust me on this, students. i was in management on medical record committees. this is not a subject of debate. medicare and jcaho both mandate that written care plans be included in all patient charts and they look for them during their inspections. this also holds true of nursing homes and home health care agencies.

being a nurse is not just about learning to give nursing care. today's nurse must also be educated in the laws pertaining to their practice and here in an example of how one not only impacts our job duties, but has an effect on many other aspects of the work as well.

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Specializes in Cardiac.
This is not a subject of debate. Medicare and JCAHO both mandate that written care plans be included in all patient charts and they look for them during their inspections.

Yes they do. Every inspection that I've been through I've had to pull out the care plan and show it to them.

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Specializes in ICU, Telemetry.

I work on a tele/icu stepdown floor. We start a care plan with each pt admission. We click a radio button on that care plan each shift (assessed, evaluated, closed). But since they actually don't do anything to help us on the floor, we never reference them. It's strictly paperwork for the goverment, and we all think it's a waste of our time.

Did it help me with my "nursing diagnosis" stuff in school? Yes. But a good class in pathophysiology would have been of more use in the real world.

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Specializes in MDS RNAC, LTC, Psych, LTAC.

Excuse me, and with all due respect to original poster, NANDA nursing plan language and APA formatting is not just the domain of a BSN course. I have a ASN from a Midwestern college and we wrote and were graded on care plans one right after another every semester as well as nursing research and we had teaching projects we were graded on and had to do well to pass on to next semester. We had to use patho and pharm information as well as proper formatting and NANDA language in our care plans we had to type.

I used my box of cards until I wore them out and passed them on to a Level I nursing student when I graduated.

I am not trying to turn this into a ASN or BSN thing but I do know our college had a 98% pass rate with NCLEX. I think a "quality nursing education whether ASN or BSN stresses NANDA. However its nice to know because my ASN program was tough when I start back to college to finish my BSN I will be prepared. I do thank GOd now my school was hard. It has helped me alot in being a nurse.

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What does "liberal" have to do with it?

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