The nursing care plan - fact or fantasy?
AEJNE Volume 4 - No.2 March, 1999.
As part of developing evidence based teaching practice in nursing, the question is asked is there a place for nursing care plans in an undergraduate program? Whose purpose do they serve? There are many clinicians that find the use of nursing care plans unwieldy and unnecessarily verbose. It would appear that the care plan is more a teaching tool than an actual guide to the nursing care required by one individual.
As an educator who was marked many student care plans of variable standard which demonstrate difficulties with the whole concept, I ask is it valid to continue the process? Where has this practice come from? Is it realistic to require students to develop the lengthy written nursing plan for individual patient care? Often students will discover the reality of care provided bears little relation to care planned - the care plan allows no avenue for challenging the reasons for this nor the appropriate actions thereby reinforcing the powerlessness of the student. This intensifies for students the questionable value of the nursing care plan and its relationship to nursing care (Fonteyn & Cooper, 1994).
The technical-rational model of professional practice supports the idea that practice is the place to apply research-based knowledge and science. Clinical learning in this view is promoted by reliance on nursing care planning, with the aim of assisting students in application of theoretical knowledge to a particular patient situation (Benner, Tanner & Chesla, 1996).
There are three main objectives for the use of the written nursing process (the care plan) are seen as:
1) promote problem solving skills
2) means for fostering the art of creativity of nursing
3)method for individualising patient care (Fonteyn & Cooper, 1994)
The difficulties in analysing the use of the nursing process begins with the varied definitions and lack of clarity amongst writers in defining the concept (Varcoe, 1996). Tanner (1991, cited Fonteyn & Cooper, 1994) asserts that in reality, the formalised nursing process is ill suited to expertise in practice.
Some of the conflict in the debate over the use of the nursing process arises from the language that is required. The increasing requirement for the use of nursing diagnosis as the basis for our practice has been welcomed by the academic but not wholly embraced by the clinician (Maeve, 1995). Some clinicians have seen this as a devaluing of bedside nursing and find the language offensive and unworkable (Maeve, 1995). Techendorf (1996) terms nursing diagnosis as quasi-medical terminology and suggests that the inception of this system aims to make us closer to doctors. Part of the behaviour of oppressed groups is a desire to emulate their oppressors (Freire, 1972) - for nursing to emulate the medical profession is not inconsistent with this.
Studies have found little evidence of use of formal nursing diagnosis in the language of expert nurses when discussing their nursing care (Fonteyn & Cooper, 1994). The danger arises that the use of rigid nursing diagnoses links nursing care to mechanistic practice and devalues individual patient situations. There is also a chance that studentís will, in attempt to accommodate faculty, adapt their assessments to support specific nursing diagnoses (Fonteyn & Cooper, 1994). Thus the formal and reductionist language of the nursing care plan restricts the art and creativity of nursing.
The value for nursing care plans would seem to lie in their facility for acting as an introductory framework to be abandoned as expertise develops (Fonteyn & Cooper,1994), conceptualised as ëtraining wheelsí by some (Varcoe, 1996). Benner et al (1996) caution that the implicit message students may receive from the use of care-plans is that planning and anticipation is valued over adaptation to unfolding clinical situations. The ready availability of standardised care plans works against the promotion and development of personalised care.
There is a paucity of research into the effectiveness of nursing care plans in developing analytic thinking (Benner et al,1996). Which leaves us to consider the validity of the written nursing process as it patently fails to meet the desired outcomes previously mentioned; individualising patient care, promoting the art of nursing and developing problem solving skills. Knowledge and understanding essential to planning of appropriate nursing care is contextual and value laden. The value free, neutralised language inherent in the nursing process decontextualizes care and negates social and political influences and thus does not reflect reality of practice (Hiraki (1992), cited Fonteyn & Cooper, 1994). However, before we abandon the process altogether consider the redeeming features - there is no value in the abandonment of the nursing process without the consideration of alternative constitutive patterns.
Nursing practice requires some way of conceptualising a plan for the nursing care of patients. The nursing process may be a beginning point that can be developed in a direction more congruent with contemporary philosophies of nursing (Varcoe, 1996). As educators we need to move from the potentially oppressive linear dogmatic care model to a care focus that integrates both the intuitive and scientific nature of nursing practice. Dialogue needs to occur around this issue between nursing clinicians and academics. The dramatic changes that are occurring in our health system require a flexible and contextual tool with which to provide excellence in care. Thus care planning can be moved from academic fantasy to practice reality.
List of References
Benner, P. Tanner, C. & Chesla, C. 1996 Implications for Basic Nursing Education in Clinical Judgement and Ethics. Philadelphia:Springer Publishing Company.
Fonteyn, M.E. & Cooper, L.F. 1994 The wrtitten nursing process:is it still useful to nursing education? Journal of Advanced Nursing, 19, pp315-319.
Freire, P. 1972 Pedagogy of the Oppressed. Penguin Books:Australia.
Maeve, M.K. 1994, The carrier bag theory of nursing practice. Advances in Nursing Science, 16:4, pp9-22.
Techendorff, J. 1996. Emancipation - is it just a dream? Australian Journal of Advanced Nursing. 13:2, pp3-4.
Varcoe, C. 1996, Disparagement of the nursing process: the new dogma? Journal of Advanced Nursing, 23, pp120-125.
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