Definition
- It is the blue print of the care that the nurse designs to systematically minimize or eliminate the identified health and nursing problem through explicitly formulated outcomes of care (goals and objectives) and deliberately chosen set of interventions, resources and evaluation criteria, standards, methods and tools.
Characteristics, which are Based on the Concept of Planning as a Process:
- The nursing care plan focuses on actions, which are designed to solve or minimize existing problem.
- The cores of the plan are the approaches, strategies, activities, methods and materials, which the nurse hopes, will improve the problem.
- The nursing care plan is a product of the liberate systematic process.
- The nursing care plan as with all other plans relate to the future.
- It utilizes events in the past and what is happening in the present to determine patterns. It also projects the future scenario if the situation is not corrected.
- The nursing care plan is based upon identified health and nursing problems.
- The nursing care plan is a means to an end, not an end in itself.
- The goal in planning is to deliver the most appropriate care to the client by eliminating barriers to the family health development.
- The nursing care plan is a continuous process not a one shot deal.
- The results of evaluation of the plan’s effectiveness trigger another cycle of the planning process until the health and nursing problems are eliminated.
Desirable Qualities of a Nursing Care Plan
- It should be based on clear, explicit definition of the problem(s).
- A good plan is realistic.
- The nursing care plan is prepared jointly with the family.
- The nursing care plan is most useful in written form.
Importance of Planning Care
- They individualize care to clients.
- The nursing care plan helps in setting priorities by providing information about the client as well as the nature of his problem.
- The nursing care plan promotes systematic communication among those involve in the health care effort.
- Continuity of care is facilitated through the use of nursing care plans.
- Gaps and duplications in the services provided are minimized, if not totally eliminated.
- Nursing care plans facilitate the coordination of care by making known to other members of the health team what the nurse is doing.
Steps in Developing Care Plan
- The prioritized conditions of the problem
- Goals and objectives of the nursing care
- The plan of interventions
- The plan for evaluating care
Prioritizing Health Problems
Four Criteria for Determining Priorities:
- Nature of the condition or problem – categorized into wellness state/potential, health threat, health deficit of foreseeable crisis.
- Modifiability of the condition or problem-refers to the probability of success in enhancing the wellness state improving the condition minimizing, alleviating or totally eradicating the problem through intervention.
- Preventive potential-refers to the nature and magnitude of future problem that can be minimized or totally prevented if interventions are done on the condition or problem under consideration.
- Salience-refers to the family’s perception and evaluation of the condition or problem in terms of seriousness and urgency of attention needed or family readiness.
Factors Affecting Priority Setting
Nature of the problem
- The biggest weight is given to the wellness state or potential because of the premium on client’s effort or desire to sustain/maintain high level of wellness.
- The same weight is given to health deficit because of its sense of clinical urgency, which may require immediate intervention.
- Foreseeable crisis is given the least weight because culture linked variables/factors usually provide our families with adequate support to cope with developmental or situational crisis.
Modifiability if the problem
- Current knowledge, technology and interventions to enhance the wellness state or manage the problem.
- Resources of the family
- Resources of the nurse
- Resources of the community
Preventive potential
- Gravity or severity of the problem-refers to the progress of the disease/problem indicating extent of damage on the patient/family; also indicates prognosis, reversibility or modifiability of the problem. In general, the more severe the problem is, the lower is the preventive potential of the problem.
- Duration of the problem-refers to the length of time the problem has existed. Generally speaking, duration of the problem has a direct relationship to gravity; the nature of the problem is variable that may, however, alter this relationship. Because of this relationship to gravity of the problem, duration has also a direct relationship to preventive potential.
- Current management-refers to the presence and appropriateness of intervention measures instituted to enhance the wellness state or remedy the problem. The institution of appropriate intervention increases condition’s preventive potential.
- Exposure of any vulnerable or high risk group-increases the preventive potential of condition or problem
Formulation of Goals and Objectives
- GOAL-is a general statement of condition or state to be brought about by specific courses of action.
- OBJECTIVE-refers to a more specific statement of the desired results or outcomes of care. They specify the criteria by which the degree of effectiveness of care is to be measured.
*A cardinal principle in goal setting states that goal must be set jointly with the family. This ensures family commitment to realization.
* Basic to the establishment of mutually acceptable goals is the family’s recognition and acceptance of existing health needs and problems.
Barriers to Joint Goal Setting Between the Nurse and the Family:
- Failure on the part of the family to perceive the existence of the problem.
- The family may realize the existence of the health condition or problem but is too busy at the moment.
- Sometimes the family perceives the existence of the problem but does not see it as serious enough to warrant attention.
- The family may perceive the presence of the problem and the need to take action. It may however refuse to face and do something about the situation.
- Reasons to this kind of behavior:
- Fear of consequences of taking actions.
- Respect for tradition.
- Failure to perceive the benefits of action.
- Failure to relate the proposed action to the family’s goals.
- Reasons to this kind of behavior:
- A big barrier to collaborative goal setting between the nurse and the family is the working relationship.
Focus on Interventions to Help The Family Performs Health Tasks:
- Help the family recognize the problem
- Increasing the family’s knowledge on the nature, magnitude and cause of the problem.
- Helping the family see the implications of the situation or the consequences of the condition.
- Relating the health needs to the goals of the family.
- Encouraging positive or wholesome emotional attitude toward the problem by affirming the family’s capabilities/qualities/resources and providing information on available actions.
- Guide the family on how to decide on appropriate health actions to take.
- Identifying or exploring with the family courses of action available and the resources needed for each.
- Discussing the consequences of action available.
- Analyzing with the family of the consequences of inaction.
- Develop the family’s ability and commitment to provide nursing care to each member.
- Contracting-is a creative intervention that can maximize the opportunities to develop the ability and commitment of the family to provide nursing care to its members.
- Enhance the capability of the family to provide home environment conducive to health maintenance and personal development.
- The family can be taught specific competencies to ensure such home environment through environmental manipulation or management to minimize or eliminate health threats or risks or to install facilities of nursing care.
- Facilitate the family’s capability to utilize community resources for health care.
- Involves maximum use of available resources through the coordination, collaboration and teamwork provided by effective referral system.
Criteria for Selecting the Type of Nurse Family Contact
- Effectivity
- Efficiency
- Appropriateness
Types of Nurse Family Contact
Home Visit
- While it is expensive in terms of time, effort and logistics for the nurse, it is an effective and appropriate type of family nurse contact if the objectives and outcomes of care require accurate appraisal of family relationship, home and environment and family competencies. i.e. The best opportunity to serve the actual care given by family members.
Clinic or Office Conference
- It is less expensive for the nurse and provides the opportunity to use equipment that can’t be taken to the home. In some cases, the other team members in the clinic may be consulted or called in to provide additional service.
Telephone Conference
- May be effective, efficient, and appropriate if the objectives and outcomes of care require immediate access to data given problems on distance or travel time. Such data include monitoring of health status or progress during the acute phase of an illness state, change in schedule of visit or family decision, and updates on outcomes or responses to care and treatment.
Written Communication
- It is another less time consuming option for the nurse in instances when there are large number of families needing follow-up on top of problems of distance or travel time.
School Visit or Conference
- It is done to work with family and school authorities on how to appraise the degree of vulnerability of and worked out interventions to help children and adolescence on specific health risks, hazards or adjustment problems.
Industrial or Job Site Visit
- It is done when the nurse and family need to make an accurate assessment of health risks or hazards and work with employer or supervisor on what can be done to improve on provisions for health and safety of workers.
Implementing the Nursing Care Plan
- During this phase, the nurse encounters the realities in family nursing practice that motivates her to try out creative innovations or overwhelm her to frustration or inaction. A dynamic attitude on personal and professional development is, therefore, necessary if she has to face up challenges of nursing practice.
Implementation Phase: A Phenomenological Experience
- Meeting the challenges of this phase is the essence of family nursing practice. During this phase, the nurse experiences with the family a lived meaningful world of mutual, dynamic interchange of meanings, concerns, perceptions, biases, emotions and skills. Just as the self aims to achieve body-mind integration to achieve wholeness in the experience of “being” and “becoming” in expert caring. Unless there is such a dynamic and active involvement between the nurse and the family in understanding and making choices in this meaningful world of coping, aspirations, emotions and skills the nurse can’t hope to achieve expert caring.
Expert Caring: Methods and Possibilities
- Expert caring in the implementation phase is demonstrated phase is demonstrated when the nurse carries out interventions based on the family’s understanding of the lived experience of coping and being in the world. Expert caring is developing the capability of the family for “engage care” through the nurses skilled practice, the family learns to choose and carry out the best possibilities of caring given the meanings, concerns, emotions and resources(skills & equipments) as experienced in the situation. While the challenge for expert caring is a reality, the nurse is enriched as a result of such an experience (Benner & Wrubel 1989).
- …By being experts in caring, nurses must takeover and transform the notions of expertise. Expert caring has nothing to do with possessing privileged information that increases one’s control and domination of another. Rather, expert caring unleashes the possibilities inherent in the self and the situation. Expert caring liberates and facilitates in such a way that the one caring is enriched in the process.
- While expert caring does not happen overnight to the novice nurse, there are methods and possibilities that can enhance learning towards expert caring. Such methods and possibilities need to be carried out and experienced in real contexts and real relationships to achieve skillfully comportment and excellence in the current situation.
Two such major methods and possibilities:
- Performance-focus learning through competency-based teaching
- Maximizing caring possibilities for personal and professional development
Competency-Based Teaching
- A substantive part of the implementation phase is directed towards developing the family’s competencies to perform the health tasks. Competencies include the cognitive (knowledge), psychomotor (skills) and attitudinal or affective(emotions, feelings, values). The following are examples of these family health competencies using the corresponding health task in our case illustration:
- Health Task: The family recognizes the possibility of cross-infection of scabies to other family members.
Cognitive Competency:
- The family explains the cause of scabies
- The family enumerates ways by which cross-infection of scabies can occur among the family members.
- Health Task: The family provides a home environment conducive to health maintenance and personal development of its members.
Psychomotor Competency:
- The family carries out the agreed-upon measures to improve home sanitation and personal hygiene of family members.
- Health Task: The family decides to take appropriate health action.
Attitudinal or Affective Competencies:
- Family members express feelings or emotions that act as barriers to decision-making
- Family members acknowledge the existence of these feelings or emotions.
- In order to systematically work towards development of the family’s competencies, such competencies need to be explicitly defined. Cognitive and psychomotor competencies are reflected explicitly as objectives in the family nursing care plan. The attitudinal or affective competencies may also be translated into objective of care as feelings, emotions or philosophy in life that enhance the family’s desire or commitment to behavior change and sustain the needed action.
Learning Principles and Teaching- Learning Methods and Techniques that the Nurse Can Use in Competency-Based Teaching:
- Learning is both intellectual and emotional process.
- Learning is facilitated when experience has meaning.
- Learning is individual matter.
Learning is Both Intellectual and Emotional Process
Six General Methods and Techniques:
- Provide information to shape attitude
- Provide experiential learning activities to shape attitudes
- Provide examples or models to shape attitudes
- Providing opportunities for small group discussion
- Role playing exercises
- Explore the benefits of power of silence
Learning is Facilitated When Experience Has Meaning
- Analyze and process family members all teaching-learning based on their grasp on the live experience of the situation in terms of the meaning for the self.
- Involve the family actively in determining areas for teaching-learning based on the health tasks that members made to perform.
- Used examples or illustrations that the family is familiar with.
Learning is Individual Matter: Ensure Mastery of Competencies for Sustained Actions:
Some Techniques to Develop Mastery:
- Make the learning active by providing opportunities for the family to do specific activities, answer questions or apply learning in solving problems.
- Ensure clarity. Use words, examples, visual materials and handouts that the family can understand.
- Ensure adequate evaluation, feedback, monitoring and support for sustained action by:
- Explaining well how the family is doing
- Giving the necessary affirmations or reassurances
- Explaining how the skill can be improved
- Exploring with the family how modifications can be carried out to maximize situated possibilities or best options.