| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
| ||||||||||||||||||||||||||||||||
Correspondence: Address correspondence to Mary Ellen Dellefield, VA San Diego Medical Center, 3350 La Jolla Village Dr., San Diego, CA 91617. E-mail: Mary.dellefield{at}med.va.gov
 |
Abstract |
|---|
 TOP Abstract HistoryInterdisciplinary Care Planning...Implications for Practice...References |
|---|
Key Words: Care plan • Clinical documentation • Interdisciplinary practice • Nursing home • Coordinating care
The interdisciplinary care plan evolved from the discipline of nursing, where care planning has had a long and controversial history (Palisin, 1971). Given the current interest in evidence-based practice and the centrality of the care-planning process and written care plan in the contemporary nursing home, it is important to examine these processes critically, including their historical evolution, related research evidence, promise, and reality in clinical practice (Eddy, 2005). In this article, I present implications for the practice of interdisciplinary care planning and the written care plan in the nursing home.
|
History |
|---|
|
TOPAbstractHistoryInterdisciplinary Care Planning...Implications for Practice...References |
|---|
During the post–World War II era, two important developments in nursing influenced the use of the written care plan as something other than a didactic technique. In response to nursing shortages and the possible draft of registered nurses (RNs) into the war effort, auxiliary nursing workers, or practical nurses, were incorporated into the nursing workforce. In 1948, Dr. Esther Lucile Brown wrote Nursing for the Future, commissioned by the National Nursing Council (Brown, 1948), and recommended baccalaureate education for professional nurses. This began the long and contentious decline of hospital-based diploma schools as an essential component of nursing education. The concept of team nursing was promoted, with the baccalaureate-educated nurse as the supervisor and leader of the team that consisted of diploma nurse graduates as "technical" nurses, practical nurses, and attendants (Melosh, 1982). Thus, the evolution of the nursing case study into the written care plan continued in the context of the developing professional identity of the registered nurse who was baccalaureate prepared, and a more rigid division of labor between the manual labor performed by the bedside nurse and the intellectual work performed by the baccalaureate nurse (Leighow, 1996).
During the 1950s and 1960s, several articles were written about the care plan, its proper format, and its assumed benefits, both for nursing students and staff nurses. Mauksch and Mauksch (1950) wrote about adding the care plan to the nursing case study for student nurses, with the goal of using the care plan to enable students to understand the patient as a whole person, to communicate clinical information to the entire team, and to promote continuity of care. Wagner (1961) bemoaned the staff nurse's emphasis on nursing tasks as ends in themselves rather than means to ends, recommending the care plan as the antidote to task-oriented nursing practice. Kelly (1966) emphasized the promise of the written care plan as a means of promoting continuity of care and sharing of information about patient needs with all clinical team members. She attributed the poor quality of nursing care plans to nursing leadership's not helping staff nurses understand the difference between the uses of the care plan as a didactic tool versus a practical clinical tool and the registered nurse's lack of understanding about how to use the care plan to assist nursing aides in applying routine care to specific patients.
In the latter part of the 1960s, the nursing care plan was codified into the fabric of the American hospital because it became a regulatory requirement in Medicare in 1967 and a part of the Joint Commission on Accreditation of Hospitals' accreditation process in 1969. The nursing care plan was incorporated into professional nursing practice standards, with emphasis on assessment, data collection, development, implementation, and evaluation of a care plan. The nursing care plan became the focus of nursing textbooks (Little & Carnevali, 1969, 1971). Both Mansfield (1968) and Little and Carnevali (1969) wrote about the need to better integrate the nursing care plan into the routine operations of a nursing unit.
The evolution of the nursing care plan to a patient care plan occurred in 1974, with a change in the language of the standards for certification and participation in Medicare and Medicaid programs (Gray & Aldred, 1980). An interdisciplinary focus was mandated, with an emphasis on the documentation of goals and approaches for nursing home care by each discipline. This emphasis was complimentary to the American Nurses' Association professional standards of practice that emphasized assessment, planning, implementation, and evaluation as basic components of professional nursing practice. This standard of practice is commonly referred to as the nursing process within the discipline of nursing (American Nurses' Association, 2004). Others recognize this as the problem-solving process.
In spite of its codification as a standard of practice, both in terms of a process to be used by the interdisciplinary team and as a written document, patient care planning continued to be debated within the nursing literature. Although care planning and the written care plan were believed to be effective clinical processes, they continued to be characterized as processes that working nurses did not use. Reasons for this included a lack of administrative support for the care-planning activity, lack of skill to produce care plans, and working nurses' lack of belief in the efficacy of the care-planning process (Ciuca, 1972; Harris, 1970; Henderson, 1973; Little & Carnevali, 1971; Palisin, 1971). During this time, the care-planning process and the written patient care plan continued to be taught as basic competencies of baccalaureate nursing education.
In the 1980s, nurses wrote about the benefits of standardized and computerized care-planning systems, including those for the nursing home setting (Gray & Aldred, 1980; Walters, 1986). Shea (1986), a Canadian nurse, used Lewin's value-expectancy theory to explain why nurses in both the United States and Canada did not use patient care plans, in spite of their purported benefits to the patient, the nurse, and the nursing unit. Shea noted that there was no evidence that the written care plan was associated with higher or lower quality care. She recommended further study of the puzzling and apparently widespread phenomenon that practicing nurses persisted in not writing or using care plans, in spite of the various ways in which the care-planning process had been institutionalized in both American and Canadian hospitals. Pease and Guhde (1991) described the process of automating a care-planning system in a nursing home in New York State, with the hope of reducing the amount of clinician time spent on care-plan production.
|
Interdisciplinary Care Planning in the Nursing Home |
|---|
|
TOPAbstractHistoryInterdisciplinary Care Planning...Implications for Practice...References |
|---|
Hawes and colleagues (1997) used two independent groupings of nursing home residents in a random sample of 254 nursing homes in 10 states to study the effect of implementation of the Resident Assessment Instrument (RAI) on process quality. Using a quasi-experimental study design with data collected before and after implementation of the RAI (1990 and 1993, respectively), they found that the comprehensiveness of care plans and selected care processes increased. However, RAI implementation had minimal impact on physician participation in care planning. The percentage of facilities in which a physician, including the medical director, participated in developing or attending the plan of care increased from 2% in 1990 to 4% in 1993. As a component of this same study, Fries and colleagues (1997) found that four health conditions, of which three had care-planning guidelines in the RAI, declined in prevalence.
Using 7 years' worth of data from the Online Survey, Certification, and Reporting system, known as OSCAR, Harrington and colleagues (2001) found that the percentage of nursing facilities receiving deficiencies for substandard comprehensive care plans ranged from 29% in 1994 to 17% in 2000. Daly and colleagues (2002) studied how standardized computerized care plans versus traditional care plans affected patient outcomes and organizational processes. They found that computerized care plans were more comprehensive than non-computer-generated care plans. However, there were no statistically significant differences in patient outcomes.
Taunton and colleagues (2004) described the care-planning process in three nursing homes, examining how the RAI/MDS was integrated into care planning. They found that the care-planning process and facility approach to the RAI/MDS process were linked. Facilities differed in how much they involved direct caregivers in the care-planning process. The researchers reported that some staff believed that they knew what to do in providing care to residents without looking at residents' plan of care. This theme of the working staff's lack of belief in the instrumental value of the care plan is reminiscent of the descriptive writing of nurses in the 1970s.
Research findings provide support that computerized care planning and the use of the RAI/MDS assessment framework have contributed to the development of more comprehensive care plans and more effective interdisciplinary care-planning processes for selected health conditions. The need remains to find ways to integrate the care-planning process and the written plan of care into the daily operations of nursing homes and to involve direct care providers.
Contemporary Care
Clinical guidelines regarding a contemporary interdisciplinary care-planning process are included in the Federal Register: Medicare and Medicaid Requirements for Long-Term Care Facilities (HCFA, 1999), the Revised Long-Term Care Resident Assessment Instrument User's Manual, Version 2.0 (Centers for Medicare and Medicaid Services [CMS], 2002), and the Comprehensive Accreditation Manual for Long-Term Care (JCAHO, 2004a). Consistent with the historical goals of the nursing care plan, the contemporary goals of the interdisciplinary care-planning process and the written care plan include individualized care, continuity of care, and team communication. The language of the federal regulations regarding the comprehensive care plan is fairly specific, as shown in regulation 42 CFR 483.20(k; American Health Care Association, 2005):
The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following:(1) services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.25; and (2) any services that would otherwise be required under 483.25 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(b)(4; pp. 124–125).
Regulation CFR 483.20(k)(2) specifies that a comprehensive care plan must be: (1) developed within 7 days after completion of the comprehensive assessment; (2) prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family, or the resident's legal representative; and (3) periodically reviewed and revised by a team of qualified persons after each assessment (pp. 127–128).
The RAI user's manual (CMS, 2002) describes the care plan as an "interdisciplinary communication tool" that "should be revised on an ongoing basis to reflect changes in the resident and the care the resident is receiving" (p. 2–20). The assessment and care-planning processes are identified as the foundations on which individualized care is delivered and continuity of care is ensured. The written care plan is derived from the completion of the Minimum Data Set, a functional assessment instrument, and the use of 18 problem-focused resident assessment protocols (RAPs) that provide more focused assessment guidance for each of the 18 clinical RAPs that address common clinical conditions found among nursing home residents.
The JCAHO (2004a) long-term-care standards describe the linkage of the resident assessment to interdisciplinary care planning. An individualized and dynamic care-planning process is emphasized, one that identifies services offered, their frequency, team members responsible for each intervention, discharge planning, evaluation of the plan of care, and timelines for its completion. The statements used to describe the interdisciplinary care-planning process in the JCAHO standards are more general than those included in the RAI user's manual, however.
|
Implications for Practice Development of Interdisciplinary Care Planning |
|---|
|
TOPAbstractHistoryInterdisciplinary Care Planning...Implications for Practice...References |
|---|
Redefine the Written Care Plan
It is important to distinguish the interdisciplinary care-planning process from the written care plan. The former is a dynamic process that is experienced by individual clinicians, residents, and their significant others. The latter is inherently a more static process that, although the document may be routinely updated, will never capture the complexity of the care-planning process. Too much has been expected from the written care plan in a practice setting known for restricted resources, routines, and regulation (Kane & Caplan, 1990).
The format and content of the written care plan has to be redefined to more efficiently fulfill related federal regulatory requirements for documentation of measurable objectives and timetables, services furnished to the residents, and evidence of a periodic review. Specifically, each of these regulatory requirements is already mandated as components of discipline-specific documentation of clinical assessments and progress notes. Redefining the care plan to include all documented interdisciplinary assessments and progress notes will reduce duplicative charting and may improve the accuracy and perceived value of clinical documentation in the nursing home (Schnelle, Bates-Jensen, Chu, & Simmons, 2004; Shea, 1986). This more expansive definition of the written care plan is now the standard in acute-care settings accredited by the JCAHO (2004b).
The redefined care plan would include a listing of the headings of the triggered RAPs for which care plans will be written, as well as other clinical priorities identified during the interdisciplinary assessment process. The specific content of the care plan that accompanies each listed item would be developed with the assumption that all clinicians have access to the clinical record, composed of interdisciplinary assessments and progress notes and that includes the specific objectives, time lines, and clinical services offered.
Although the care-plan document has been characterized as beneficial because it provides individualized interventions for residents, it often contains standardized interventions. This is illustrated in sample care plans provided in the RAI/MDS clinical user's manual (CMS, 2002). This characteristic of the written care plan may have contributed to longstanding nursing staff perceptions that the written care plan was an ineffective instrument for improving delivery of care (Palisin, 1971; Shea, 1986; Taunton et al., 2004). Although the listing of standardized interventions may have been helpful at one time as a didactic technique, it is not surprising that it is not perceived as useful to experienced nursing staff members. Standardized interventions are best described in policies and procedures, through in-service education, and in job descriptions rather than written care plans.
Only information about technical or interpersonal care processes unique to the resident that all clinicians need to know to efficiently and effectively provide services on a 24-hr basis has to be included in the written care plan. For example, a resident may wish to see a specific religious television show each day in the dining room. Ideally, this resident preference will be taken into account as interdisciplinary team members construct their work routines for each shift. Including genuinely individualized information in the care plan might increase the perceived value of the care plan and provide a managerial tool for holding the nursing home staff accountable for providing individualized care, regardless of discontinuities in caregiving associated with staff turnover.
If an electronic clinical documentation system is used, the content of discipline-specific forms may be linked with the care plan. For example, nursing assignment sheets, certified nursing assistant (CNA) flow sheets, medication, and treatment records used by nursing staff members may be linked with the content of the care plan that identifies individualized care processes.
Invest in RN On-the-Job Education
The baccalaureate-prepared RN is uniquely qualified educationally to provide integration of the care plan into the daily operations of the nursing home. However, the reality is that in 1994 only 19.2% of registered nurses had this degree (American Health Care Association, 1994). The level of educational preparation of the typical director of nursing and RN working in the nursing home may contribute to persistent deficiencies in integrating interdisciplinary care planning and producing meaningful written care plans in the American nursing home (Strahan, 1988).
Furthermore, regardless of educational preparation, the RN is a scarce resource in the nursing home, given the current Medicare and Medicaid program requirements that the services of a RN are mandated for at least a consecutive 8 hr a day, 7 days a week, and that the director of nursing is a full-time RN. On average nationally, the total RN hours of all aspects of care per resident day were 0.6 hr in 2000, representing only 12 min per 8-hr shift (Harrington, Carrillo, Mullan, & Swan, 1998).
Completion of the care-plan document has become the unique burden of the RN, particularly the RAI/MDS nurse coordinator, and the interdisciplinary team, with apparently little physician involvement (Hawes et al, 1997; Institute of Medicine, 1986). Integrating the interdisciplinary care plan into the daily operations of the nursing home, or implementing the written care plan, is difficult work, even if the RN had sufficient time to accomplish this work. It is likely that the RN as care coordinator and team leader does not have sufficient knowledge, skill, and time to effectively work with the licensed vocational nurse (LVN), licensed practical nurse (LPN), CNA, and interdisciplinary team members to accomplish this. The literature on the relationship between CNA turnover and clinical management practices provides evidence to support this perspective (Anderson, Corazzini, & McDaniel, 2004; Bowers, Esmond & Jacobson, 2003; Eaton, 2001).
Narrow focus on the importance of the written care plan may be a red herring designed to avoid dealing with a more uncomfortable reality. As Kelly (1966) insightfully noted almost 40 years ago, many RNs have failed to understand the use of the care plan as a practical clinical tool designed to assist nursing aides in applying routine care in individualized ways to patients. This failure is especially evident in the nursing home setting, where CNAs comprise the majority of direct care providers. It suggests that too many RNs working in nursing homes do not have the skills to interact and deliver care in partnership with a largely paraprofessional nursing staff. Registered nurses practicing in the nursing home need to develop professional self-identities and organizational skills to enable them to constructively resolve the tensions between nursing as manual labor and nursing as intellectual work (Leighow, 1996).
Given the likely continued limited presence of baccalaureate-prepared RNs in American nursing homes, the nursing home industry has to invest in providing directors of nursing and registered nurses with the intellectual skills required to perform their care-planning job responsibilities competently. Classes on critical thinking, care planning, and integrating these into basic supervision and management behaviors would be useful. Although some nursing home providers will voluntarily act to enhance the skills of their RN workforce, others may not. A federal mandatory requirement to teach this content to non-baccalaureate-prepared RNs working in the nursing home is recommended. In contrast to mandated in-service education requirements for CNAs, there are no federally mandated in-service education requirements for RNs working in nursing homes.
Value the Exchange of Information About Individualized Technical and Interpersonal Care Processes for Residents
An organizational framework that conceptually integrates interdisciplinary care planning into the routine operations of the nursing home is needed (Willging, 2004). For example, Tushman and Nadler (1977) view organizations as information-processing systems. Information processing refers to the gathering, interpreting, and synthesizing of information in the context of organizational decision making. The resident assessment process, interdisciplinary care-planning process, and the written care plan are designed for the gathering, interpreting, and synthesizing of clinical information to use with nursing home residents for achieving goals related to quality of life and quality of care.
All clinical meeting processes, including change of shift conferences, could be examined to identify how information about individualized aspects of technical and interpersonal care could be better exchanged within the organization. For example, direct caregivers, such as CNAs, may write down effective individualized or customized care processes that they have used to include in the written care plan, if time constraints do not allow them to directly participate in care-plan meeting. Interdisciplinary rehabilitation-team members could think about ways to more effectively share information with staff members on the evening and night shift regarding effective strategies to use to enhance the functional mobility of residents receiving rehabilitation. Residents having clinical characteristics contributing to incidence and prevalence rates of quality indicators that are potentially suggestive of quality problems could be identified. Specific information about each resident's individualized technical and interpersonal care processes could be exchanged to identify alternate processes that might be more effective.
Conclusion
A critical examination of the interdisciplinary care-planning process and the written care plan is important from a clinical, organizational, fiscal, and policy perspective. A significant amount of valuable but scarce clinical time is invested in these processes. It is hoped that the valuable interdisciplinary care-planning process operationalized within the RAI/MDS framework as documented in the written plan of care will come to be defined more effectively. The critical role of the RN in coordinating interdisciplinary care will be recognized. Promotion of effective organizational information-processing strategies will be useful in examining traditional work practices of the nursing home. Residents, families, and nursing home staff will benefit as we discover effective strategies for integrating the interdisciplinary care-planning process into the routine operations of the American nursing home.
|
Footnotes |
|---|
Decision Editor: Nancy Morrow-Howell, PhD
Received for publication February 27, 2005. Accepted for publication May 2, 2005.
|
References |
|---|
|
TOPAbstractHistoryInterdisciplinary Care Planning...Implications for Practice...References |
|---|
This article has been cited by other articles:
 |
|
 |
|
  D. L. White, L. Newton-Curtis, and K. S. Lyons Development and Initial Testing of a Measure of Person-Directed Care Gerontologist, July 1, 2008; 48(suppl_1): 114 - 123. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||
| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
