Against the backdrop of the Care Quality Commission (CQC) (2019)State of Care report, which highlighted the importance of providing person-centred and accessible care, this article examines the nurse's role in ensuring that all patients have a care plan tailored to their personal needs.
During any hospital inspection, CQC auditors seek assurances that all patients experience care or treatment that is individually tailored and that meets their needs and preferences. At the heart of this requirement is the care plan, and fundamental to this is the robustness of the nursing assessment. This is crucial for planning and delivering nursing care. A holistic assessment generates the information nurses need in partnership with the patient and/or family to plan care delivery. All nurses need to acquire the clinical acumen to enable them to interpret assessment data and formulate the evidence-based interventions necessary to alleviate or modify the patient's problems.
However, some hospitals have insufficient numbers of nurses, leading to suboptimal care planning. This has led the CQC to take action against some NHS trusts, mandating them to review nurse care planning to achieve compliance with Outcome 21, Regulation 20, of the Health and Social Care Act 2008, ie that people who use services can be confident that their personal records, including medical records, are accurate, fit for purpose, held securely and remain confidential.
Background
Before the introduction of the nursing process, which is the systematic problem-solving approach to planning nursing care for the individual patient, the delivery of nursing care was via task allocation based on the medical model (Stonehouse, 2017).
I remember commencing work as an orthopaedic nursing student in 1969 and seeing my name in the ward workbook for the first time. As was common in those days, junior nurses were initially allocated to sluice duties. I must have spent hours in the sluice, boiling steel bedpans and urinals—the steam from the bedpan boiler would hang in the air like fog! Later, as I became more senior, I was allocated bed baths and dressings, with the final accolade, towards the end of my training, being allocated to medicine administration.
Task allocation was seen as the most efficient way to manage a traditional Nightingale-style ward but, on the downside, it reduced individual patient care to a series of tasks far removed from the holistic stance of 21st century nursing. Before the introduction of the personalised patient care plans via the nursing process, the Kardex record system was used by nurses as a way to communicate important information about their patients. It was a shift-by-shift summary of what was happening to individual patients, but gave little information on their individual needs (Georgopoulos and Jackson, 1970).
The nursing process originated in the USA during the 1960s and was subsequently adopted by UK nursing in the late 1970s. England's first professor of nursing, Baroness McFarlane of Llandaff of the University of Manchester is credited with its introduction. The nursing process was designed to help nurses focus on the assessment of each individual patient and his or her needs and to help nurses plan, deliver and evaluate the care they deliver to their patients.
The patient assessment is the basis for making decisions or formulating plans of action. There are a number of steps to assessing and planning care for patients. These can be configured by using the acronyms APIE or SOAPIE. The primary four APIE steps of using the nursing process are:
Many nurses prefer to use the more detailed SOAPIE model:
S + O: subjective and objective (data)
SOAPIE allows the nurse to consider both subjective and objective criteria when planning care. For example, objective observations such the patient's temperature is noted, in addition to subjective criteria such as the individual's general demeanour—a nurse's sixth sense that something might be wrong, something that is not always obvious (Glasper et al, 2010).
Some nurses find it useful to use specific conceptual nursing models. The Henderson and Roper et al activities of daily living models are based around those tasks that human beings would do for themselves unaided if they had the necessary strength, will or knowledge. (Henderson, 1978; Roper et al, 2000)
The introduction of the nursing process was widely embraced by the UK nursing profession, which was seeking new ways of enhancing its academic profile, especially as it worked toward becoming a degree-level profession. A working party was set up by the Royal College of Nursing (RCN) in 1979 to promulgate the advantages of personalised care facilitated by the nursing process rather than traditional task allocation. The nursing process was rolled out across many hospitals. Initially, this was perceived as a panacea to what was missing in the aspirational nursing profession, hungry for greater professional standing.
An administrative burden
The growing number of university nursing studies departments that offered degrees in nursing began using conceptual models and the nursing process as a method of teaching undergraduate nursing students the complexities of nursing. However, it quickly become apparent that nursing students were finding that this approach was not followed in practice in their clinical placements. Maben et al (2006) attributed much of this to time pressures, role constraints, staff shortages and work overload. Ward managers began to complain that the time spent composing handwritten care plans was undermining the delivery of hands-on nursing care to patients.
To alleviate the bureaucratic burden imposed by the writing of individual care plans, Glasper et al (1987) explained how the use of core or standardised care plans could save time and yet still promote individualised care. Core care plans provide a template that can be easily adapted into a personalised care plan, where care strategies are predetermined for specified interventions linked to common admission diagnoses. For example, Richardson (1992) developed a series of core care plans for nurses caring for patients with cancer that could be amended to create individualised care plans.
In many respects these core care plans were the forerunners of contemporary care pathways, integrated care pathways or clinical pathways, which are used to systematically plan the care for a particular patient with a specified clinical condition. They identify the objectives and key elements of care and are based on best evidence and practice. Many of these are now held on NHS trust intranets and can be downloaded and printed out by nurses.
However, an increase in the number of acutely ill patients, especially during the winter months, coupled with chronic staff shortages, has affected nurses' ability to plan individualised care for each patient. This is especially true for patients with multiple chronic conditions where care planning has become very complex and time-consuming. Some institutions have been able to develop software, which takes the form of a care plan management tool that interacts with the electronic patient record and will make recommendations for evidence-based care interventions that can be embedded within the patient's personalised care plan (Laleci Erturkmen et al, 2018). The modern day care plans utilised in NHS trusts are increasingly electronic, but some continue to use paper documentation. Plans should be evaluated and amended throughout the patient day and, in addition to addressing the essentials of care such as skin integrity and nutrition, should also include more complex aspects of care. These might address area such as falls prevention interventions or strategies to use with patients with dementia (RCN, 2019).
Although the care planning process promotes patient-centred care, Mukoro (2011) suggested that recipients of care experience significant variation in the actual implementation of care.
Effective personalised care planning
The RCN has suggested that care plans have three important goals (RCN, 2019), which are to:
Johnson et al (2018) suggested that optimal care planning can be enhanced when nurses use a framework of standardised nursing language (SNL) to label the clinical judgements involved in nursing assessment. SNL improves nursing content in care plans (Hardman, 2019).
NHS England (2015) has published guidance on delivering personalised care.
There is evidence that personalised care planning can lead to better patient outcomes with, for example, reduced hospital readmission rates when inpatients are provided with individualised discharge plans rather than routine discharge care.
However, anecdotal evidence from academics and senior nurses suggests that care planning in clinical practice has deteriorated, that the use of care pathways has become a tick-box exercise and that the personalised care plan exists in name only. Many believe that this is attributable to winter pressures, a rise in patient acuity and a decrease in overall skill mix and, especially, a lack of registered nurses.