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Chapter 6 Phase Two
work but find it difficult to document it in a formal way (a care plan). A care plan
“is a written, structured, plan of action for patient care based on holistic
assessment of patient need, identification of specific patient problems and the
development of a plan of action for their resolution” (Mason, 1999, pp.380). The
care given should be reflected in the care plan thus demonstrating a level of
professionalism as it clearly shows how care is approached in a rational,
evidence-based, and holistic manner. The written plan is thus goal-orientated,
efficient, effective and individualised. According to Cheevakasemsook et al
(2006) nursing documentation serves many purposes including ensuring
continuity and quality of care through communication, furnishing legal evidence
of the process and outcomes of care, supporting the evaluation of the quality,
efficiency and effectiveness of patient care, providing evidence for research,
financial and ethical quality-assurance purposes, providing the database
infrastructure supporting development of nursing knowledge, assisting in
establishing benchmarks for the development of nursing education and standards
of clinical practice, and providing the database for other purposes such as risk
management and protection of patients rights. For residential care, Lidz, Fischer
and Arnold (1992) suggest that personalised care plans are essential for resident
autonomy.
I gave my co-researchers hard copy examples of care plans which are in use both
nationally and internationally in other health care settings. We then collectively
reviewed the literature with the aim of identifying what care planning approach
might contribute to enhancing the residents’ autonomy. The literature encouraged
new and imaginative designs (Cheevakasemsook et al, 2006; Mason, 1999)
which could be developed at ward level, tailored to meet the needs of the resident
as a human being and the needs of the staff, and recognise the context of care and
the world outside the care environment (Nolan et al.2004; Tutton, 2005, Pearson
and Peels, 2009; Kellet et al. 2010). The new HIQA quality standards for
residential care for older people in Ireland recommend that the residents care
plan should meet each resident’s assessed needs which are set out in an
individual care plan, developed and agreed with each resident, or in the case of a
resident with cognitive impairment with his/her representative. Nolan et al
(2004) support the view that care planning with older people is underpinned by