CPD CONTINUING

PROFESSIONAL
DEVELOPMENT

Developing nursing care plans

NS832 Ballantyne H (2016) Developing nursing care plans. Nursing Standard. 30, 26, 51-57.
Date of submission: August 31 2015; date of acceptance: October 16 2015.

Abstract Aims and intended learning outcomes

This article aims to enhance nurses’ understanding of nursing care plans, This article aims to enable you to develop
reflecting on the past, present and future use of care planning. This a comprehensive understanding of nursing
involves consideration of the central theories of nursing and discussion care plans so that you may begin to
of nursing models and the nursing process. An explanation is provided of critique, adjust, develop and adapt them
how theories of nursing may be applied to care planning, in combination to suit the requirements of different contexts
with clinical assessment tools, to ensure that care plans are context of care. After reading this article and
specific and patient centred. completing the time out activities you should
be able to:
Author  Outline the concepts and processes of
planning care that enable you to use nursing
Helen Ballantyne Staff nurse, Transplant Continuing Care Unit, care plans effectively.
Papworth Hospital NHS Foundation Trust, Cambridge, England.  Discuss how nursing models and the nursing
Correspondence to: hballantyne@nhs.net process relate to nursing care plans.
 Describe how nursing care plans can benefit
Keywords patients and nurses.
care bundles, care pathways, care plan, care planning, critical thinking,  Identify potential problems with nursing
models of care, nursing process, nursing theory, patient-centred care care plans in practice.
 Outline the advantages and
Review disadvantages of using nursing care plans
in practice.
All articles are subject to external double-blind peer review and checked
for plagiarism using automated software.
Introduction
Revalidation Nursing care plans are based on nursing
Prepare for revalidation: read this CPD article, answer the questionnaire theory, which is taught throughout nurse
and write a reflective account. www.rcni.com/revalidation education, but is seldom revisited thereafter.
Nursing care plans are complex, involving
Online many aspects of nursing theory and practice.
Therefore, nurses may find it difficult to
For related articles visit the archive and search using the keywords above. understand how these aspects relate to care
To write a CPD article: please email gwen.clarke@rcni.com planning in practice.
Guidelines on writing for publication are available at: The terms ‘care planning’ and ‘care plan’
journals.rcni.com/r/author-guidelines. are often used interchangeably. This
contributes to misunderstanding of the theory
of care plans, encouraging some nursing staff
to dismiss them as irrelevant to practice.
‘Care planning allows a nurse to identify a
patient’s problems and select interventions that
will help solve or minimize these problems’
(Matthews 2010), and ‘Care plans are the
written records of this care planning process’
(Barrett et al 2012). Essentially, care planning
is the action, while a care plan is a record of
that action.

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CPD care planning

Evolution of planning nursing care nurses to identify with the patient’s potential and
In 1978, the planning of nursing care was actual health problems (Aggleton and Chalmers
becoming a common topic for discussion in the 2000). Assessment may be considered the first
nursing profession (Clarke 1978). In contrast, stage in the planning of nursing care, since it starts
a nurse job analysis in 1953 did not recognise the process of gathering information to make
or include care planning as a nursing task decisions about suitable interventions.
(Goddard 1953). Reflecting on past ways of In general, planning nursing care is
working, Lelean (1973) observed that nursing the process of setting goals that provide
care was often dictated by ward routine. benchmarks for evaluating care. These goals
It was a functional, activity-based method of may be adapted after the nursing intervention
nursing where patients became names on a list has been implemented. Modifications to this
according to the procedures they required. process may be used, depending on factors
There are anecdotal stories of care being such as the culture of nursing, the context or
provided by word of mouth, via bath books, the patient. A nursing diagnosis stage may be
TPR (temperature, pulse, respiration) books, inserted between the assessment and planning
dressing books and work lists. This reflected stages. Carpenito-Moyet (2009) stated: ‘a
a task-based system of nursing, where the nursing diagnosis is a clinical judgment about
emphasis was on the activity rather than the individual, family or community responses
patient. However, by implication, there was to actual or potential health problems/life
planning of care using these lists, since care processes.’ Therefore, a nursing diagnosis
was provided and patients’ needs were met. acknowledges the actual or potential health
The aim now is to provide individualised care, problem and labels it. ‘A nursing diagnosis is
with emphasis on the patient’s unique needs. commonly referred to as a diagnostic statement
This evaluation of care planning in nursing or identification of problem or need’ (Matthews
history does not make the assumption that 2010). This stage is not often used explicitly
nursing in the 1960s and 1970s was poor in the UK. However, it may be argued that
and nursing in the present day is better, nor it is used implicitly throughout the nursing
does it reflect the level of care given or the process since patient needs are identified and
outcomes experienced. Nurses have always addressed. For example, consider a patient
planned, carried out and documented that handover, where nursing diagnoses are often
care, albeit in varying levels of detail. It is the made after a formal assessment, and several
method of planning care that has changed over nursing diagnoses, for example, anxiety, risk
time (Walsh 1998). For example, consider a of impaired skin integrity and disturbed sleep
dressing change. In the 1970s, the care was pattern, may be used routinely.
planned in the dressing book, the task ticked If one applies the nursing process to a
off once completed and plans made to repeat familiar life activity, such as buying a house,
the care if required, with a further entry in it is possible to understand its usefulness. A
the dressing book. One can speculate that family plans to move house; the assessment
care plans may be required now more than consists of a list of needs, for example a garden,
ever, given the increased complexity of care, a primary school nearby and three bedrooms.
access to information and changing healthcare The process is planned; visiting estate agents
environments. or using online tools. The intervention is when
the family moves in. Evaluation of the situation
The nursing process is continuous, as the family assesses the house,
1 Make a note of all The development of the nursing process lives in it, adapts it, reassesses and possibly
the nursing models you (Yura and Walsh 1967) may be considered the moves out once their needs change.
can think of. Consider most influential change in approaches to thinking Complete time out activity 1
them individually and about nursing care. The nursing process is a clear
try to remember the and straightforward cyclical model, consisting of Other nursing models
basic principles of each. four concepts of nursing: assessment, planning, The next aspect of nursing theory to consider,
Is there any particular implementation and evaluation. The central while keeping the nursing process in mind, is
model which you believe consideration of the nursing process is that it nursing models. These models offer a range of
applies best to your looks first at the patient and then thinks about the beliefs and values to guide nurses through the
place of work? Discuss care that is required, rather than deciding what stages of problem-solving and provide direction
this with a colleague to care the patient needs and then looking at the regarding that which is relevant and important
find out if you agree. patient and how this might be implemented. The (Barrett et al 2012). Walsh (1998) described the
emphasis is on patient assessment, encouraging nursing process as a tool to provide structure to

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care delivery and models of nursing as tools to example, a patient with a supportive family,
instruct us on how care should be given. no comorbidities and an effective relationship
Several definitions of nursing models refer with their GP may recover more quickly from
to their use in the nursing process. They often a myocardial infarction than a patient who
provide detail to be used in conjunction with is recently divorced and has type 2 diabetes
the nursing process to facilitate care. Many and a history of missed GP appointments. In
nursing models fit into one or more of the this model, nursing is required when the line
four stages of the nursing process. However, of resistance has been diminished and can no
several nursing models were published before longer protect a person. The emphasis is on
the nursing process was formalised. This lends preventive health to ensure that the patient is
validity to the nursing process, since it indicates well-equipped to resist any stressors that may
that the process was in use informally before it arise as a result of their diagnosis.
was formally documented. Each of these models of nursing has different
Models of nursing can be abstract and priorities. By including selective aspects of
difficult to measure, yet are practised daily, each of the models, it is possible for the nurse to
usually without a formal label. Different develop patient centred, context-specific care
models prioritise different aspects of care and plans that enable high quality care planning
reflect the care priorities of the nurse. Nurses and comprehensive documentation. For
in different environments provide care in a example, a care plan encompassing aspects of
structured and detailed way, but their priorities the Roper-Logan-Tierney, King and Neuman
and action points differ. For example, the models might adopt a holistic approach to the
priority in a critical care unit is to manage patient to ensure physical symptoms are assessed
the needs that patients are unable to manage and self-care goals are set, and to initiate a
themselves, while the emphasis in an outpatient therapeutic relationship to facilitate interventions
clinic may be on assisting patients with self-care and further assessment as required.
and self-medication. Despite their long history, models of nursing
Certain models of nursing prompt nurses to are still debated. Bakker and Mau (2012) stated
ensure they are assessing the whole patient and that it is essential to incorporate the opinions
nursing holistically. The Roper-Logan-Tierney of the main partners in care to develop a
model of nursing based on activities of daily model of nursing that best reflects professional
living is frequently used in assessment and nursing practice. This approach encourages
admission documentation (Roper et al 2000). the development of models of nursing, where
King (1981) developed a model that emphasised patients and the multidisciplinary team are
the importance of therapeutic relationships, the consulted. Care pathways are one application
ability of all humans to interact meaningfully of this theory.
with one another in pursuit of a common goal.
This led to a shift from the four-stage nursing Care pathways
process towards developing a goal-oriented Care pathways were first used in the 1990s in
nursing record. King (1981) identified the the United States and have been employed in the
importance of communication and information NHS in a range of clinical settings since 1992.
sharing when setting goals, since without They were introduced as a means of assisting
communication, goals are unlikely to be met. healthcare professionals to deliver high quality,
Therefore, King’s (1981) model emphasises the evidence-based and cost effective care (Kozier
importance of excellent communication skills et al 2008). Walsh (1998) explained that in
to establish a beneficial interaction to achieve developing a care pathway, all professionals
the goals of care, rather than a checklist of involved in patient care are bought together
aspects to cover in the patient assessment. and come to a consensus about the standards of
The Neuman systems model focused on the care and expected outcomes for selected patient
person as consisting of a core of resource, with groups within an agreed time frame.
several lines of resistance or defence (Neuman Care pathways stimulate debate and
and Fawcett 2010). The model suggests that discussion. Some patients meeting certain
these lines of resistance fluctuate according to criteria will require the same general treatment.
physiological, sociocultural, psychological, These treatments may be pharmaceutical, for
spiritual and developmental variables. A person example pain relief or they may be clinical, such
experiencing an extreme level of any of these as the placement of an intravenous cannula. The
variables may find it difficult to resist their effects care pathway provides a stimulus to deliver and
and may experience symptoms of ill health. For record such interventions. The idea of all patients

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CPD care planning

receiving the same treatments contradicts the the nursing process. Nurses plan their care,
concept of holistic patient-centred care that gathering equipment and thinking it through;
nurses are encouraged to deliver. However, intervene, performing the care; and continually
if patients meet relevant criteria, standard evaluate, ensuring the patient remains stable.
interventions can be performed, freeing up time In this way, the care bundle is applied to the
for individual care in other areas. intervention aspect of the nursing process,
linking specialist clinical knowledge with
Clinical assessment tools fundamental nursing theory.
Clinical assessment tools are often used National Service Frameworks are extensions
as a part of the nursing process and care of the care bundle. They have been developed
pathways. They may be considered as a at government level to address high priority,
modern addition to nursing models that high mortality diseases. They directly affect the
enable the nursing process. Clinical tools, care provided since they set clear requirements
for example the Glasgow Coma Scale (www. for care based on the best available evidence
glasgowcomascale.org), aim to ensure that (Kozier et al 2008). Moreover, they provide
care is consistent, considered and appropriate guidance and support for organisations to
to each patient. Using clinical assessment enable them to achieve these requirements.
tools also provides a baseline from which Complete time out activity 2
to measure variation, improvement or
deterioration in the patient’s health status as Critical thinking
care progresses. There are many useful tools and models that
Assessment skills may vary widely between assist in the planning of nursing care and
staff and clinical tools provide guidance and consequently the production of useful, patient
objectivity to counter instinctual assessment. centred, contextual care plans. To date, the
A patient with a normal blood pressure, heart development of standardised care plans for
rate and respiratory rate may still feel unwell, individual nursing diagnoses or conditions
and the nurse should be able to reassure the has been the next step in the process of care
patient and perform an assessment based on planning. Not every model or clinical tool will
different priorities. The nurse may perhaps be used in each care plan. Equally, every patient
question the feelings of the patient; are they is different. Critical thinking skills should always
scared, confused or anxious? be applied to practice to ensure that nurses do
not make assumptions or work unquestioningly.
Care bundles Price and Harrington (2016) described
The use of care pathways is a departure from a critical thinking as a process in which
patient-specific nursing care plan. This may be information is gathered, sifted, synthesised
redressed in part by including definite clinical and evaluated, to understand a subject or issue.
instructions for specific problems. Care bundles They applied this in practice, explaining that
were created by the Institute for Healthcare critical thinking enables the nurse to function
Improvement (2016a) to meet this requirement. as ‘a knowledgeable doer, someone who
A care bundle is a group of evidence-based selects, combines, judges and uses information
best practices related to a disease or set of to proceed in a professional manner’. Nurses
2 Refer to the symptoms that result in improved outcomes cannot apply standard care plans to all patients
Institute for Healthcare when they are implemented together than and, therefore, critical thinking ensures that
Improvement (2016b) when they are implemented individually care is patient centred and adapted
document on using (Norman 2010). For example, the Institute for as necessary.
care bundles to Healthcare Improvement (2012) developed an Complete time out activities 3 and 4
improve health care. evidence-based list of interventions that were
In particular, source linked to reductions in ventilator-associated
statistics on how care pneumonia in patients in intensive care units. Role of nursing care plans
bundles have improved These interventions included positioning of When applying critical thinking to nursing care
patient outcomes for the patient’s head, regular assessment for plans, it should not be assumed that care plans
aspects of acute care. extubation, oral care and daily sedation breaks. are always beneficial because they have been
Discuss with a colleague Care bundles promote efficiency and patient around for years. Kaufman (2012) described
how you could improve safety, establish high quality care, and are cost nursing care plans as the common language of
patient outcomes in effective and reason based, thus contributing nurses, indicating a clear familiarity with them
your clinical area. to improved patient outcomes (Norman 2010). and potential reliance on them. However, this
They are usually used in conjunction with should not prevent nurses questioning the use

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of nursing care plans and their role in clinical Lastly, and perhaps most controversially, a
practice. When asking: ‘What is the role of the nursing care plan allows care to be measured.
nursing care plan in practice?’ there are three The requirement to measure care and
main answers: ensure that it meets essential standards and
1. To facilitate standardised, evidence-based, benchmarks may be seen by some nursing
holistic care. staff as time-wasting. Historically, nursing
2. To record care. has been seen as a vocational act, noble and 3 Nursing and
3. To measure care. self-sacrificing. The requirement to assess Midwifery Council
A nursing care plan can facilitate holistic care the care given may sometimes be seen as (NMC) revalidation,
for patients, when used by nurses throughout an affront to the experience, expertise, which comes into
their career. A nursing care plan can be used disposition and personality of a nurse. effect on April 1 2016,
as a learning tool (Kaufman 2012), whereby a However, measurement of care is essential encourages nurses to
novice nurse may rely on such a plan to guide to ensure that patients are receiving the consult their code of
their practice. Experienced staff may rely same level of care, despite being cared for conduct and reflect
more on their experience. However, providing by different nurses with different levels of on how it links to
nursing care is challenging and there are several education and experience, and with different their professional
potential barriers to care. priorities and models of working. practice. Read The
Shorter lengths of patient stay, higher patient One important criticism of nursing care Code: Professional
acuity and technological advances are factors plans is the difficulty in maintaining their Standards for Practice
that may restrict the amount of time available relevance as patient needs change. LaDuke and Behaviour for
to care for patients (Norman 2010). Other (2008) remarked: ‘Today’s nurse continually Nurses and Midwives
issues that may affect patient care include receives and analyzes new data, rapidly (NMC 2015). Which
staffing levels and an increasing number of transforming them into action amid crushing parts of The Code may
complex patients with multiple comorbidities. workloads. Any care planning document that be directly related to
A useful and relevant nursing care plan requires constant manual revision to reflect the use of nursing care
may help a member of the nursing team to this changing information is a problem, not plans? Reflect on how
acknowledge these barriers and work around a solution.’ LaDuke (2008) concluded that your practice adheres to
them. Moreover, such barriers mean that the nursing care plans belong in nurse education these parts of The Code.
standard of care cannot always be relied on; and should not be used in clinical practice Compare your answers
omissions may be made and human error is unless they can be guaranteed to provide to the points mentioned
more likely. A documented care plan can offer real-time information with test results and later in this article.
guidance and clarity and may also provide specific instructions for implementation.
justification for using nursing time to ensure a Care Planning in the Treatment of Long Term 4 Nurses are required
thorough patient assessment. Conditions: Final Report of the CAPITOL to keep a portfolio of
Nursing care plans can also be used to Project (Department of Health (DH) 2012a) evidence for revalidation.
record the care that has been given. This provided interesting insights. The report Planning activities and
allows nursing staff to acknowledge the acknowledged that: ‘Care plans are designed to identifying development
care provided, share it to ensure continuity provide a record of agreements between patient aims is an essential
and reassess its effects and patient needs and professional about goals and preferences, part of preparing for
as required. This documentation enables and to help to organise services around the needs revalidation. Using a
nurses to demonstrate that they are working of individual patients and ensure that needs are nursing care plan or
within the professional standards of practice regularly reviewed’ (DH 2012a). The report nursing process format,
outlined by the NMC (2015). The Code: was designed with the aim of assessing the write a plan for the
Professional Standards of Practice and implementation and outcomes of nursing care upcoming year. Assess
Behaviour for Nurses and Midwives (NMC plans within the NHS. The DH (2012a) report your development needs,
2015) states: ‘nurses must keep colleagues found that there were so few care plans in place plan goals, and include
informed when sharing the care of individuals that part of the CAPITOL project was shifted courses you might like
with other healthcare professionals and staff’. to focus on identifying the perceived and actual to participate in, and the
It requires registered staff to keep ‘clear and barriers that prevented care plans being put in people you might need to
accurate records relevant to their practice’ place, rather than evaluating their usefulness. speak to, to realise your
and states that this documentation should be The DH (2012a) report identified plans. Use the document
contemporary, kept secure and attributed to ambivalence concerning the effectiveness and throughout the year to
the professional in question. A comprehensive relevance of care plans and a lack of clarity monitor your progress
nursing care plan that has documented care on how the care plan should be structured, and re-evaluate the skills
meets these requirements, and may protect especially in relation to comorbidities and and knowledge you need
the nurse in the case of a complaint or the contributions of multidisciplinary staff to acquire.
disciplinary action. at separate locations. Where limited time

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CPD care planning

was available, the report established that It is difficult to reach a conclusion on the
care plans were given lower priority when benefits of nursing care plans. The evidence is
compared with other markers of care. For contradictory and differences in the information
example, there was increased understanding and structure between healthcare organisations
of the Quality and Outcomes Framework make direct comparisons difficult. Perhaps we
(QOF) programme (Health and Social Care are attempting to standardise aspects of nursing
Information Centre 2016) – a voluntary care that cannot be standardised. Considering
programme that awards achievement points the 6Cs of nursing: care, compassion,
to GPs when managing long-term conditions competence, communication, courage and
such as asthma or diabetes. When combined commitment (DH 2012b) as a set of goals for
with incentives, the QOF was used more nursing, is it possible to equate a clear, accurate
readily. The DH (2012a) report demonstrated nursing care plan with a compassionate and
that the effects of effective care plans and caring nurse? Comprehensive nursing care plans
care planning were unclear and that further may not compensate for the absence of beneficial
5 Design a nursing work was required to improve levels of care personality traits that patients would like to see
care plan using the 6Cs planning which may result in patient benefits. in nursing staff.
of nursing as a basic Complete time out activity 5 Complete time out activity 6
framework for a group of
patients you are familiar
with. Try to ensure Discussion Conclusion
that all their needs are Keogh (2015) stated that the essence of Nursing care plans may be used as a tool
accounted for. professionalism is being able to describe the to promote holistic care. The care
services you provide and define how well you planning process is central to patient-centred
6 Critique a nursing do it. A clear, accurate and contemporary care, enabling nursing staff to plan the
care plan that you use nursing care plan should enable nurses interventions and, where possible, discuss
in practice. Attempt to to achieve this, maintaining professional them with the patient. However, health care
identify its strengths integrity while providing excellent is complex. Different groups of patients
and limitations. Does it evidence-based care. require different interventions and different
provide patient-centred There are many unanswered questions care goals. A care plan for one patient may
care? Is there anything regarding care plans. Further investigation not suit another, even if they have the same
missing? Is the format is required to determine if wards that are needs. Therefore, care plans should be used
easy to use? How would failing to deliver basic care use care plans with consideration.
you change it? routinely. Radcliffe (1999) observed that Nurses should continually question the care
care plans for children under five years have they provide and evaluate their plan of care.
7 Now that you have been held in their home with their parents for Selective use of tools by nurses, for example care
completed the article, many years. This ‘red book’ has documented plans, care bundles, care pathways, and clinical
you might like to write nursing care, providing healthcare goals, assessment tools, can result in a patient-centred
a reflective account as guidelines and care notes. Therefore, would care plan that facilitates the delivery of care,
part of your revalidation. optimum care planning be achieved when ensures that nothing is forgotten, and records
Guidelines to help you patients are able to write their own care plan and measures the quality of care, to the benefit
are on page 62. with the help of the nurse, read it at the end of of the patient and the nurse NS
their care and evaluate it for themselves? Complete time out activity 7

References
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Improvement (2012) How-to Guide: Opinion: Health and High Quality Planning Made Incredibly Easy! Matters, Exeter.
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CPD assessment

Nursing care plans

TEST YOUR KNOWLEDGE BY COMPLETING SELF-ASSESSMENT QUESTIONNAIRE 832

1. Care planning enables nurses to: 7. Which of the following do UK How to use this assessment
a) Identify a patient’s problems ❏ National Service Frameworks
This self-assessment questionnaire (SAQ)
b) Select interventions that will help address?
will help you to test your knowledge. Each
solve a patient’s problems ❏ a) H igh priority, high mortality week you will find ten multiple-choice
c) S elect interventions that will help disease ❏ questions that are broadly linked to the
minimise a patient’s problems ❏ b) H igh priority, low mortality CPD article. Note: there is only one
d) All of the above ❏ disease ❏ correct answer for each question.
 ow priority, low mortality
c) L
2. Which is not a concept in the disease ❏ 
You could test your subject knowledge
nursing process? d) Low priority, high mortality by attempting the questions before
reading the article, and then go back
a) Implementation ❏ disease ❏
over them to see if you would answer
b) Evaluation ❏
any differently.
c) Discharge ❏ 8. Critical thinking ensures that:
d) Assessment ❏ a) Nurses make assumptions 
You might like to read the article to
safely ❏ update yourself before attempting
3. Which is prioritised in King’s b) C are is patient-centred and the questions.
nursing model? adapted as necessary ❏ When you have completed your
a) Therapeutic relationships ❏ c) I ndividual judgement is self‑assessment, add it to your professional
b) Individual resources ❏ unnecessary ❏ portfolio. You can record the amount of
c) Activities of daily living ❏ d) Alternatives are not considered ❏ time it has taken. Space has been provided
d) Preventive health ❏ for comments.
9. Which of the following is not a
4. Care pathways: function of nursing care plans? You might like to consider writing a
a) Apply to all patients with a a) To assist standardised reflective account, see page 62.
given condition ❏ evidence-based holistic care ❏
b) Involve standard interventions ❏ b) To co-ordinate multidisciplinary
c) I nvolve clinical interventions care ❏ Report back
only ❏ c) To measure care ❏ This activity has taken me _­­____ hours to
d) I nvolve pharmaceutical d) To record care ❏ complete.
interventions only ❏ Other comments:
10. What is the main purpose of
5. Care bundles: measuring care?
a) Apply to the evaluation phase a) To ensure all patients receive the
of the nursing process ❏ same level of care ❏
b) A re a group of evidence-based b) To identify staff training needs ❏
best practices that result in c) To justify staffing levels ❏
improved outcomes when d) To ensure all staff are competent Now that I have read this article and
implemented individually ❏ to practice ❏ completed this assessment, I think
c) Promote efficiency and patient my knowledge is:
safety ❏ This self-assessment questionnaire Excellent ❏
d) A re based on specialist clinical was compiled by Beth Knight Good ❏
knowledge ❏ Satisfactory ❏
The answers to this questionnaire Unsatisfactory ❏
6. Clinical assessment tools: will be published on March 9 Poor ❏
a) Are subjective ❏ As a result of this I intend to:
b) Provide a baseline from which to The answers to SAQ 830 on
measure variation, improvement discharging patients from acute care,
or deterioration ❏ which appeared in the February 10
c) Depend on the level of skill of issue, are:
the nurse ❏ 1. d 2. a 3. c 4. b 5. d
d) Depend on the nurse’s intuition ❏ 6. c 7. b 8. b 9. a 10. c

60  february 24 from

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