|Recording Care is a regional project which NIPEC has led since 2009. The project has developed a number of successful products along the way such as: an online audit tool and a method of improving record keeping practice through learning and development activities; a number of regional person-centred nursing assessment and plan of care documents; and Person-centred Standards for Nursing and Midwifery Record Keeping Practice.|
Report of the Care Planning Summit January 2015:
Attendance at the summit was by 30 individuals across all fields of practice, and full range of organisations within statutory and independent sectors. Education providers and staff side organisations were also represented.
The methodology was designed to provide an environment in a World Cafe style event, where five tables each hosted a question related to care planning. The morning was divided across two exercises, to gain the maximum amount of feedback.
At the end of the second exercise, a consensus opportunity was provided to enable colleagues to ‘vote’ by placing coloured stickers next to statements which were, in their opinion, broadly representative of a potential way forward, encompassing principles and suggestions for a future model.
Outcome of Exercise 1: It was agreed there was a disconnection between the care plan and the record or assessment of need. In regard to the current format, there was consensus that care plans are not a reflection of the responsibilities of the nurse.
A key driver for enabling the current system to work well was audit - the value of lifting records and reviewing as part of practice. It was agreed that senior nursing staff should be encouraged to do this and to role model the art of record keeping practice.
There was general agreement that where there was time to write the care plans individually they were generally of a better standard. Care bundles were also mentioned as a positive solution to care planning.
Having goals and evaluations in the one place was deemed helpful and also treating the plan as a contract of care with the patient. There was also a lot of comment about protecting a record of the unique contribution of the nurse within the journey of the patient.
Three themes appeared to emerge in the section related to the efficacy of evaluative/progress notes:
- the importance of being linked to the care plan – true evaluation of the care plan
- the impact of recording care at the bedside of the patient in discussion with the person and recording what they say in the record, particularly when used as a contract of care
- the potential for using the evaluation section for handover rather than a further written record specific to handover.
Delegates provided a clear message that knowledge and skills to undertake the practice of planning nursing care were not demonstrated in the current record. One of the reasons offered was related to the variety of systems currently in use which may be confusing to the workforce. The issue of care being planned away from, and not in collaboration with the patient, was also mentioned multiple times. Finally the time required to complete records was mentioned several times.
In relation to what is not working well with the current system of evaluating care/ recording progress notes there were some interesting answers:
- perceived difficulties related to the environment which might be about what the nurse thinks and not what the patient feels
- lack of engagement with the patient and family/carers
- the value nurses place on the record and drive to make a record
- evaluation not linked to plans of care.
Outcome of Exercise 2: This exercise required a ranking at the end of the morning – the results shown are an analysis of the ranking exercise, plus other comments.
The main themes identified through this exercise revealed important messages. Such as:
- care should be planned at the bedside
- the patient and his/her family/carer where appropriate should be involved in planning care and that should be reflected in the record including discussions with and opinions of the patient and/or family where relevant
- nurses should be suitably skilled in facilitation and interviewing
- a framework or structure to provide guidance on what should be recorded for nurses in plans of care would be helpful
- priorities for the next shift should be recorded
- summary of care and evaluation of effectiveness of care should be evident
- there should be movement towards using care plans for handover at the bedside
The last question in this exercise asked about a new system and what it might look like. High ranking answers included:
- Needs to be at the bedside
- Involving patient/ family/carer
- Daily assessment
- Plan of care and evaluation linked
- Links to handover and safety briefs
Following this event, analysis of the findings was presented at the Working Group Strand 1 meeting at the end of January 2015, where it was agreed to provide an opportunity for a small sub-group to debate the way forward for presentation back to Steering Group 2nd March 2015.