Nurses have been through a lot over the past 3+ years, from a global health crisis to skyrocketing staffing shortages. But as care teams emerge from the chaos, they’re taking lessons from the pandemic. One such lesson? Creating a well-constructed care plan is the best way to move forward. A comprehensive nursing care plan is essential in providing practical, holistic, and individualized evidence-based patient care. It outlines the nursing interventions and strategies necessary to achieve the patient’s goals and address their healthcare needs.
However, during the pandemic, as hospitals were filled to the brim with patients, nurses were left without extra time to develop care plans and execute care plan strategies. Some nurses may also view an official care strategy as redundant since much of the information is already required in a patient’s electronic health record (EHR). Even before the pandemic, nurses argued that despite all the time spent learning how to make a nursing care plan, they never do it again after graduating from nursing school. However, a care plan is still a vital component of clinical workflows, and here’s why.
Improve nursing communication and prevent burnout with smarter clinical workflows
Developing a comprehensive nursing care plan is of utmost importance in clinical workflows, as it serves as a vital tool for effective communication and ensures holistic patient-centered care. In a fast-paced and demanding healthcare environment, nurses often face challenges in conveying critical patient information to the interdisciplinary team. This is where nursing care plans play a crucial role, acting as a standardized roadmap that guides the delivery of care.
By meticulously documenting patient assessments, nursing diagnoses, interventions, and evaluations, care plans provide a clear and concise overview of a patient’s condition, goals, and individualized care requirements. This not only aids in efficient communication among healthcare professionals but also facilitates continuity of care, reduces errors, and enhances patient safety. By having a well-developed nursing care plan in place, nurses can effectively collaborate with other team members, anticipate and address potential complications, and ensure a holistic approach to patient care throughout the clinical workflow.
Long-term care providers such as nursing homes, mental health facilities, and home health nurses typically use formal care plans, and they are often required to do so by governing bodies like the Joint Commission. Yet, in hospitals, care plans often fall by the wayside.
For hospitals that successfully implement care plans, there are many benefits, including:
Continuity of care: Nursing care plans act as a vital link that maintains continuity of care throughout clinical workflows. They ensure that nurses from different shifts or floors have the same patient data, are aware of the patient’s nursing diagnoses, and collaborate towards the same goals.
Interprofessional collaboration: Nurses, physicians, social workers, nursing assistants, physical therapists, and other care providers must be on the same page in understanding the patient’s health problems, goals, and progress. A nursing care plan enhances communication and puts all pertinent information in one place, providing a clear roadmap to the desired outcomes.
Patient-centered care: Care plans help to ensure that patients receive evidence-based, holistic care. Nursing diagnoses are standardized to ensure quality care, but nursing interventions are tailored to meet the physical, psychological, and social needs of the individual patient.
Engaged patients: Setting achievable goals for and with patients helps to guide and measure nursing care. Goals also help motivate patients to become more involved in their recovery because they can understand exactly what they need to do to achieve the desired outcomes.
Compliance: Beyond providing quality of care, the care plan serves as proof of receipt and helps payers determine how much they should reimburse for care.
What Is a Nursing Care Plan?
A nursing care plan is the written manifestation of the nursing process, which the American Nurses Association defines as “the common thread uniting different types of nurses who work in varied areas … the essential core of practice for the registered nurse to deliver holistic, patient-focused care.”
The nursing process includes five key steps:
Assessment: Collecting and analyzing data to gain a holistic understanding of the patient’s needs and risk factors.
Diagnosis: Using data, patient feedback, and clinical judgment to form nursing diagnoses.
Outcomes/Planning: Setting short-term and long-term goals based on the nurse’s assessment and diagnosis, ideally with input from the patient. Determining nursing interventions to meet those goals.
Implementation: Implementing nursing care according to the care plan based on the patient’s health conditions and the nursing diagnosis. Documenting care the nurse performs.
Evaluation: Monitoring (and documenting) the patient’s status and progress towards goals and modifying the care plan as needed.
A nursing care plan is formal documentation of this process, and most care plans are organized into four columns that closely mirror the steps of the nursing process. Care plans include:
Nursing diagnoses
Desired outcomes/goals
Nursing interventions
Evaluation
NurseLabs notes that some healthcare providers use only three columns, combining “desired outcomes/goals” and “evaluation” into the same column, whereas other providers use five columns, including one for “assessment cues.” Care plans for nursing students typically include another column for “rationale/scientific explanation,” where they are asked to explain the reasoning behind their proposed nursing interventions.
In case you haven’t seen one in a while, here’s what a nursing care plan looks like:
How to Write a Nursing Care Plan
To create a plan of care, nurses should follow the nursing process:
Assessment
Diagnosis
Outcomes/Planning
Implementation
Evaluation
1. Assess the patient.
The nurse starts by reviewing all relevant data, including (but certainly not limited to): medical history, lab results, vital signs, head-to-toe assessment data, conversations with the patient and their loved ones, observations from other care team members, and demographic information. The nurse uses this data to assess the patients:
Physical, emotional, psychosocial, and spiritual needs
Areas for improvement
Risk factors
2. Identify and list nursing diagnoses.
After a thorough assessment, the nurse identifies nursing diagnoses — health problems (or potential health problems) that nurses can handle without physician intervention. For example, acute pain, fever, insomnia, and risk for falls are all nursing diagnoses. The North American Nursing Diagnosis Association (NANDA) curates an official nursing diagnosis list, which includes definitions, features, and commonly applied interventions for each diagnosis.
3. Set goals for (and ideally with) the patient.
What are the desired outcomes, and how will the patient get there? The nurse answers these questions based on the assessment, nursing diagnosis, and feedback from the patient. Together, the nurse and patient set reasonable goals that can be achieved with nursing interventions and (in some cases) effort by the patient. Goals can be short-term (e.g., resolve acute pain after surgery) or long-term (e.g., lower the patient’s A1C with better diabetes management). Then the nurse prioritizes goals based on urgency, importance, and patient feedback. Nurses can also use Maslow’s hierarchy of needs to help prioritize patient goals.
4. Implement nursing interventions.
Nursing interventions are actions taken by the nurse to achieve patient goals and get desired outcomes — for example, giving medications, educating the patient, checking vital signs every couple of hours, initiating fall precautions, or assessing the patient’s pain levels at certain intervals. This is also where the nurse documents care as they perform interventions, including dependent nursing interventions ordered by physicians.
5. Evaluate progress and change the care plan as needed.
Finally, the nurse monitors and evaluates the patient and the nursing care plan on a regular basis to answer the question: Are the nursing interventions helping the patient reach their goals and desired outcomes, and should those interventions be changed, terminated, or continued?
How to Implement Nursing Care Plans in Your Hospital
For care plans to be useful, they need to promote effective communication in nursing. They need to be shareable, easy to access, and always up to date. That means they need to be electronic and preferably integrated into the EHR for cloud access and real-time interprofessional collaboration.
Leading EHR providers have care plan functionality built into their systems, with lists of nursing diagnoses and interventions. Finding these resources is not always intuitive, but with a little help from IT, you can build custom care plan forms that are part of each patient’s record and each nurse’s workflow. With the right integrations, you can even automate parts of the care plan so certain fields get automatically populated with information. That means fewer fields for nurses to fill out and regularly update.
Nurses are also more likely to comply with care plan requirements if they don’t have to track down an available computer first. If they can access the care plan from secure mobile devices, they can review and update care plans at the patient bedside, refer to them regularly to help guide patient care, and even use them as a patient education tool.
How TigerConnect Streamlines Nursing Care Plan Communication
Smartphone-wielding nurses can do more than manage care plans on the go. They can also use HIPAA-compliant clinical workflow solutions that let them securely talk, text, or have a group conference about the plan of care. Care teams can leverage clinical communication and collaboration technology from TigerConnect to securely message, call or start video conferences with other care team members to collaborate on the nursing care plan. This collaboration is further enhanced with TigerConnect Patient Engagement Software, which allows care teams to bring patients and their families into the conversation via a secured group message.
TigerConnect automated workflows make it easy for nurses to share and implement their care plans across the continuum of care. By collaborating with all involved, nurses can better ensure the plan is being adhered to, focus on what’s needed for recovery, and prioritize patient outcomes. Nurses can coordinate plans with care teams through role-based messaging with a scheduling integration, pull in relevant patient data from EHR integration, and keep families in the loop with a patient engagement solution.
Supported by technology and a secure communication platform, a patient care plan becomes a resource for nurses to get all the information they need in one place, a roadmap for recovery, and a collaboration tool that helps ensure continuity of care.
Download the eBook to learn how smarter, optimized clinical workflows can help nurses manage care plans, improve nursing workflows, and better support nurses.
Nikki Manuel, MSN, RN-BC, is a Clinical Consultant at TigerConnect. With more than 20 years of post-acute, critical care, and nursing informatics experience, Nikki helps develop essential systems to improve clinical workflows.
