1. LaDuke, Sharon BSN, RN


There are better ways to communicate.


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In school, writing nursing care plans was an excellent way to learn the nursing process. But it's hardly a newsflash that practicing nurses don't value such care plans, and the Joint Commission hasn't required them for more than a decade.


In the 1930s the nursing care plan developed as a way for nursing team leaders to guide the care provided by less-educated members of the team. These individualized, handwritten plans were worthwhile: hospital stays were long enough, and the pace slow enough, to actually implement them. But by the time of the nursing shortage of the mid-1980s, preprinted plans had come along to ensure that there was a plan and that it reflected the physician's. So we pulled our preprinted plan out of the file drawer, put it on the patient's chart, and never looked at it again. An echo of the medical plan, it had already ceased to matter.


Enter the 1990s. Reimbursement changed, acuity soared, and hospital stays shortened. The Joint Commission began to emphasize interdisciplinary care plans. Yet even today, many facilities still require a traditional nursing care plan. What real purpose does that serve? None, as I have heard from nurses at many facilities. Often, nurses use the care-planning features of computerized programs only to activate and inactivate documentation forms. Some facilities even find that the tables of problems, goals, and interventions-built into the software to help nurses create "perfect" care plans-are more burdensome than helpful.


Of course, good documentation itself demonstrates proper use of the nursing process more effectively than any care plan could. To emphasize that point, some facilities now label the entire documentation record "the plan of care." That enables creativity, as facilities consider options other than a single document called the "care plan."


If possible, care planning should be documented with a tool that the interdisciplinary team already uses. It might be called a care plan or a problem list, action plan, assessment, or intervention. It's electronically accessible to all, and it uses everyday language to outline major patient problems of interdisciplinary concern. Part of it serves as a figurative bulletin board where team members post key information about problems they need to work on together. At a glance, for example, a nurse should be able to see that physical therapists are pushing for the patient to walk longer distances. Likewise, a physical therapist should be able to see that nurses are trying to manage the patient's postexertion pain and nausea.

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To this bulletin board, nurses should add only activities that are under the nurse's control, would concern other members of the interdisciplinary team, and aren't scripted by physician order. They shouldn't regurgitate the medical plan of care, painstakingly translated into nursing verbiage and speckled with the instruction, "do such-and-such as ordered."


Today's nurse continually receives and analyzes new data, rapidly transforming them into action amid crushing workloads. Any care-planning document that requires constant manual revision to reflect this changing information is a problem, not a solution. Useful care-planning tools include the real-time information nurses need to provide safe, effective care; minimize manual entries; and update automatically as orders are entered, documentation is filed, and diagnostic results are posted. In my work, I have seen dozens of new documents and processes springing up in hospitals across the country. These support not only interdisciplinary care planning and communication but also mounting regulations and safety and quality initiatives-precisely because the traditional nursing care plan doesn't meet these needs.


Some nursing leaders think we need nursing care plans to guide our actions and critical thinking. But we know what to do the same way we always have, using knowledge, experience, assessment findings, diagnostic results, Kardexes, physician orders, protocols, medication records, and many other resources.


Despite its rightful place of honor at the center of student nurse education, the nursing care plan-as we've known it-belongs to yesterday.