The central role of nurses in assessing patient needs and planning care is one of the core areas emphasised in Future Nurse, the Nursing and Midwifery Council's (NMC) (2018a) nursing proficiency standards. The document categorises ‘assessing needs and planning care’ as the third of seven areas of proficiency, which are grouped into ‘platforms’. Future Nurse emphasises that the delivery of person-centred care and evidence-based nursing interventions are vital components for effective patient assessment and care planning. The standards further highlight that the nurse should understand the need to assess each patient's capacity to make their own decisions and to allow them the opportunity to give and withdraw consent.
An assessment is a form of a dialogue between client and practitioner, in which they discuss the needs of the former to promote their wellbeing and what they expect to happen in their daily life (National Institute for Health and Care Excellence (NICE), 2021). Nursing assessment involves collecting data from the patient and analysing the information to identify the patient's needs, which are sometimes described as problems.
The process of planning care employs different strategies to resolve the needs identified as part of an assessment. Ideally, this will include the selection of appropriate evidence-based nursing interventions. When planning care, the patient's needs and wishes should be prioritised, and the individual must be involved in the decision-making process to ensure a person-centred approach. The planned care must take into account the patient's conditions, personal attributes and choices. It is worth noting that the principles of care planning are transferable between hospital, home and care home settings.
Section 2 of the NMC Code highlights the importance of partnership working with patients to ensure the delivery of effective high-quality care and of involving them in their care, which includes empowering patients by enabling them to make their own decisions (NMC, 2018b). The patient should be viewed holistically, with importance placed on the physical, psychological, social and spiritual aspects of the person's life, which are inextricable.
The intrinsic factors of a patient's condition will often affect their concordance with the advice and treatment offered. Consequently, it is important to understand the reasons for non-concordance and to tailor treatments/recommendations to each individual, which will improve the quality of care delivered.
Brooker (2007) developed the acronym VIPS to address some of the confusion surrounding what should or should not be perceived as person-centred care. VIPS stresses the following:
- V is a value base that affirms the value of each human being, irrespective of age and cognitive ability. This is the foundation for individualised care
- I is individualised care that considers the individual's distinctiveness and holistic needs
- P is about seeing the world from the patient's perspective, to ensure that the health professional takes the patient's point of view into account when providing care
- S is about maintaining a social environment that supports the patient's psychological needs, including their mental, emotional and spiritual needs.
Health professionals should endeavour to involve the patient in decision-making and enable them to make choices as much as possible, using a range of approaches to achieve this (Lloyd, 2010). Unless proven otherwise, a nurse must assume that a patient has the capacity to make their own decisions, in line with the Mental Capacity Act 2005.
The following draws on the author's experience in mental health nursing but can be applied to other areas of nursing care.
Care planning
Planning care is essential in the delivery of appropriate nursing care. Following assessment of a patient's needs, the next stage is to ‘plan care’ to address the actual and potential problems that have been identified. This helps to prioritise the client's needs and assists in setting person-centred goals. Planned care will change as a patient's needs change and as the nurse and/or other health professionals identify new needs. Care planning assists professionals to communicate information about the patient's care to others (Department of Health (DH), 2013a; NICE, 2021), to facilitate continuity of care. Communication may be predominantly verbal, but it will also always involve documentation in a variety of formats, including computer-based, handwritten or preprinted care plans.
It is essential for nurses to consider their consultation style when developing a care plan in order to reduce the risk of paternalism when communicating with the patient and discussing their needs. Collaborative consultation encourages patients to participate in their care and improves rapport, while a paternalistic approach will generally minimise an individual's part in, and responsibility for, their own care needs and may compromise care outcomes and concordance (Leach, 2010). A collaborative/partnership consultation style facilitates a person-centred approach by the practitioners and involves the patient in their care. Such an approach can include asking questions such as: ‘We have different types of treatment approaches that could be considered, what are your preferences?’ This is in contrast to a paternalistic consultation style with the health professional announcing any decisions with a statement such as: ‘I am going to prescribe a certain treatment for you.’
When drawing up a care plan with a patient the nurse should take into account a number of considerations (Box 1).
Box 1.Nursing considerations
- The patient should know the reason for the assessment
- The assessment should be flexible and adaptable to the needs of the individual
- The patient must be fully involved and their dignity, independence, and interests should be paramount
- The patient can have someone with them, if preferred
- Appropriate language and terminologies should be used throughout the consultation
- The diversity of the individual client, their beliefs, values, culture and their circumstances must be considered
- It is essential to consider the patient's gender, sexuality, ethnicity, disability and religion as part of the assessment
- Be open to listening to the patient's personal history and life story
- The entire family's needs should be considered, inclusive of the patient and their carers: remember the importance of providing holistic care
- Cost-effectiveness should also be taken into account
Sources: Department of Health, 2011; National Institute for Health and Care Excellence, 2021
Stages of care planning
Care planning has been described as the third stage of the nursing process (NMC, 2018a; Toney-Butler and Thayer, 2021). It includes assessing the patient's needs, identifying the problem(s), setting goals, developing evidence-based interventions and evaluating outcomes (Matthews, 2010). This will require the health professional to apply high-level critical thinking, decision-making and problem-solving skills. It is important to note that a care plan can be prescriptive: it is devised after a patient has been assessed through the prescription of nursing actions (Hogston and Simpson, 2002) or through collaborative working involving the multidisciplinary team.
In some situations there will be differences between what the nurse sees as a priority in terms of the patient's needs and what the patient wants. An example of this would be a patient with mental health problems who may be at high risk of self-harm, who may need to be put on intermittent 15-minute observation. In such cases, a patient would be deemed as not having capacity to make decisions and the nurse will need to use their clinical judgement to prescribe the best treatment option. The care plan can still be agreed in conjunction with the patient once the nurse has explained the reasons for the interventions and acknowledged in the care plan that this is not the patient's preferred choice.
In situations where the patient has capacity to make decisions, the care plan should be agreed in collaboration with the service user (NHS England, 2016a).
Identifying needs
As part of the care planning process, the nurse will identify a patient's needs/problems and propose a set of interventions to address them in order of priority, ensuring that everything is in agreement with the patient. To ensure that appropriate goals are set, a patient's needs will be classified as high, intermediate and low.
Goals
Each goal provides an indication as to the expected outcome, along with the proposed interventions required to meet the patient's problems/needs, all of which must be patient centred. It is important, in collaboration with the patient, to set both short-term, achievable goals and longer-term goals that may take days, weeks or months to accomplish. One way nurses can ensure this is to apply the SMART goal-setting approach to ensure that the goals are (Revello and Fields, 2015; NurseChoice, 2018):
- Specific
- Measurable
- Achievable
- Realistic
- Timely (within a defined time frame).
Interventions
Interventions are nursing actions/procedures or treatments built on clinical judgement and knowledge, performed to meet the needs of patients. The actions should be evidence based and indicate who will carry them out, when and how often (Hogston and Simpson, 2002). The scheduled interventions will have been agreed with the patient with the aim of improving their health condition, and each subsequent action should strive to meet the goals set at the previous stage. Brooks (2019) outlined three types of intervention:
- Those independently initiated by nurses
- Those that are dependent on a physician or other health professionals
- Those that are interdependent, that is, those rely on the experience, skills and knowledge of multiple professionals.
Independent nursing interventions are planned and actioned by nurses autonomously (NMC, 2018a), and these actions do not require the nurse to have direction from another health professional. When actioning interventions dependent on other health professionals, the nurses must determine the appropriateness of any directions from other health professionals before carrying them out because the nurse remains accountable for the actions, for example, the administration of prescribed medication (NMC, 2018a). Due to developments in the nursing profession, some advanced nurse practitioners can now prescribe interventions, eg prescription of medication can be done by nurse independent prescribers or nurse supplementary prescribers (Royal College of Nursing, 2014). Interdependent interventions are usually recorded in collaborative care plans reviewed in multidisciplinary (MDT) meetings and must be agreed by all parties involved. Both the goals and interventions must be communicated in a timely manner to all those involved in the patient's care.
Evaluation
This is the stage when a planned intervention is evaluated to assess whether or not it has been achieved. This can be an ongoing process, and the care plan should document the frequency and time frame for evaluating the intervention. If the initial goal becomes unachievable, the nurse will be required to reassess the patient's needs, and review and revise the interventions.
Benefits of care planning
The DH (2011) highlighted that the aim of care planning is to improve the quality of care and outcomes by respecting individual wishes and enabling patients to acknowledge the ownership of their condition and ensuring they have the ability to influence the outcomes. Health professionals should engage individuals in decision-making and facilitate them to take control of their health by agreeing common goals to improve outcomes. This will have additional benefits for both the patient and health services as it should reduce the number of GP appointments and emergency admissions the patient may require. Promoting self-management of long-term conditions can also help slow progression of illness.
Care planning empowers patients to care for themselves when they are self-managing their health and when they may have difficulty accessing a health professional. This became evident during the pandemic, with patients often having to go for extended periods between appointments with their health professionals. Care planning has really come into its own in community care in the past few years, which became evident during the pandemic—particularly in the field of mental health—because it leads to better patient concordance with treatment and other care needs without the need for constant input by health professionals. This benefits both health professionals and the NHS: it increases job satisfaction, brings efficiency savings and improves the quality of patient care (DH, 2011).
Model of care
Models of care are used to deliver best practice in health care. An integrated services care model is multifaceted and enables the co-ordination of care by different health and social care professionals to meet individual patient needs. It encompasses patient-centred care and enables care staff across different providers to reduce duplication, confusion, delay and gaps in services (Monitor, 2015). In the modern NHS, this is the preferred model of care.
The care plan is an integral part of this model because it enables the creation of shared care plans that map different care processes. It becomes a point of reference for various providers involved in the care of the patients, ensuring the co-ordination of care across services (Curry and Ham, 2010; World Health Organization, 2016).
Care pathways
Care pathways, which are also known as critical pathways, clinical pathways, integrated care pathways, care paths and care maps, are used to describe a specific patient journey that dictates the care to be provided or process to be followed for a patient's particular condition or needs. An evidence-based care process is established for specific conditions by considering expert opinion that takes into account the evidence to recommend interventions that have been shown to achieve better health outcomes cost-effectively (Centre for Policy on Ageing, 2014).
Care pathways are often developed at local level and have been shown to be efficacious at meeting local needs. They are also known to improve cross-setting collaborations. Clinical pathways are aimed at providing effective health care appropriate for the patient group of conditions, thereby reducing hospital stays, leading to cost-effective health care (Kozier et al, 2008).
Care clusters
Care clustering is a needs assessment tool that is used to rate a patient's care need against specific scales:
‘A cluster is a global description of a group of people with similar characteristics as identified from a holistic assessment and then rated using the Mental Health Clustering Tool (MHCT).’
This framework is used to plan and organise mental health services, including the care and support provided to individuals based on their illness and individual needs. One of the care clustering tools used in the NHS is the Health of the Nations Outcome Scales (HoNOS) (Wing et al, 1998; Yeomans, 2014; NHS England, 2016b).
Mental health services were brought under the scope of Payment by Results (PbR) in the NHS in 2012-2013.
‘Payment by Results (PbR) is the transparent rules-based payment system in England under which commissioners pay healthcare providers for each patient seen or treated, taking into account the complexity of the patient's healthcare needs.’
Consequently, as part of the care planning process, nurses need to take into account the cost-effectiveness of any interventions in order to consider how much funding is likely to be available for an initial completion of assessments, during scheduled reassessment and at any subsequent reassessment after a significant change in the patient's needs.
Box 2.Importance of complying with guidelines when undertaking assessment and planning care
- You must be compliant with the Nursing and Midwifery Council (2018b; 2021) guidelines for record and record-keeping
- Adhere to the employing local organisation's policy on record-keeping, eg local trust policy
- Follow the NHS trust Care Programme Approach (CPA) policy (Department of Health, 2008)
- Collaborate with all those involved in a patient's care planning process
Importance of record-keeping
Accurate record-keeping is essential in the assessment of needs and planning care. This complies with the NMC (2018b) which states that record-keeping is fundamental to nursing practice, emphasising that records must be accurate and precise.
Health professionals should be aware of the need for legal accountability when documenting care in a written record because such records could be used in any legal proceedings (Dimond, 2005). A record refers to not only a patient's record, but encompasses all records related to an individual nurse's range of practice. It is important to include the person being cared for in the record-keeping process, who should be asked to sign the plan of care, if they have capacity to do so (NMC, 2021).
It is good practice to make an entry in the care documentation if a service user is unable to sign or agree to their planned care and state the reason for this (Butterworth, 2012). In addition to paper-based records, care plans can be entered into the electronic health/patient record system used in the practitioner's service (NHS website, 2019).
Best practice in writing care plans
There are some critical factors to consider when writing a focused person-centred care plan. One of these is to clearly document in detail the needs of the patient and to use the patient's language whenever possible, for example: ‘Mr D likes to dress smart every morning, but has been finding it difficult to make the choice of clothing to wear.’ An example of a poor way to record the same issue might be: ‘Mr D is unable to dress by himself’ and the aim is ‘Mr D will appear to dress smartly’.
The documented goal/aim of the care plan should be determined by applying the SMART acronym. It is therefore vital to ensure that the aim is specific by focusing on issues that can be measured, with goals that are achievable and realistic. It is also important to suggest and record a time frame within which a patient's short-term and long-term goals could be achieved. In relations to Mr D's clothing, a daily time frame might be appropriate. To come to an agreement over this issue, Mr D might be asked: ‘Mr D, would you like to be able to make your own choice of clothes to wear every day with the support of staff?’ The projected daily goal would then be recorded as part of the care plan documentation.
An intervention must specify how a goal/aim will be achieved, including who will be responsible for implementing each task. This could be the staff nurse on duty, team nurse, team leader, the nurse in charge and/or the patient (please put the patient's name). Evaluation should be carried out regularly and documented, and should conform with the proposed time frame outlined as part of the suggested intervention. Evaluations should be undertaken whenever actions are performed in accordance with each proposed intervention, and details of the progress of the patient's problem/needs documented.
Conclusion
In conclusion, the article has discussed the importance of assessing patients' needs, emphasising person-centred care using the VIPS acronym devised by Brooker (2007). It has stressed the notion for all nursing interventions to be evidence based. The stages of care planning were discussed, and the application of the SMART goal-setting approach was highlighted. Record-keeping is an integral part of care planning in the communication of patient's care and progress. The benefits of care planning in improving quality of care and outcomes, respecting individual wishes, thereby empowering the patient was recognised.
LEARNING OUTCOMES
- Nurses must ensure that assessment of patient needs and care planning are always focused on the person
- All nursing interventions must be evidence based
- The goals set out in a patient's care plan must be achievable and measurable, and should include time frames within which both short- and long-term goals can be achieved
- Record-keeping is a vital component of care planning and is part of communicating aspects of a patient's care, and their progress towards their goals, with other health professionals involved in their care
CPD reflective questions
- In the context of a patient's health, what should you aim to do when care planning?
- Who should you involve in the care planning and why? Should the patient have a copy of the care plan?
- Is it acceptable to destroy care plans or other records?
- When should care plans be reviewed?