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Care Planning
Awareness Session
P E A C
Origin
NIPEC Recording Care Project
SINCE 2009……..
Improve the standards of nurse record keeping practice in the region
Recording Care......
What’s the point?
Why Keep Records
I Integral part of practice
Evidence of partnership with people in our care
Communication
Support delivery/continuity of care
Evidence clinical judgement/decisions
Identifies risks
Requirement
Co-production – being person centred
Regulatory – NMC
Legal - Improves accountability and provides evidence
Employer - Policies
What it’s not.....
What it is.....
CARE PLAN
What is a Care Plan
It is.. A written record of the ‘care planning process’.
This process identifies the persons needs , plans the nursing intervention to achieve the desired outcomes and evaluates
the effectiveness of delivered care.
Care planning – Action
Care plan – Recording
Can be viewed as a negotiated contract laying down both parties’ responsibilities
Care plan should..
be Person-centred
Involve person in decision making
be in Partnership
be Collaborative
enable Information Sharing
be Regularly Reviewed
Caution….
Over reliance – not questioned
Difficultly to keep updated as person changes
Constant revision costs time
Not always individual
Not flexible
Reduced critical thinking
Is there a better way The development of the way forward to improve
the quality of care planning within the nursing profession began January 2014
START NOV 2014
CARE PLANNING SUMMIT – January 2015
Presentation to EDoNs April 2015
Meetings June, July and August 2015
Product PACE
Pilot September 2015
Presentation to EDoNs Nov 2015
Larger Pilot Feb-April 2017
Presented to CNO/ EDoNs July 2016
PROCESS OF PLANNING ROLLOUT
What did the literature tell us
Highly skilled
Dynamic process
Variety models underpin care plans
Ongoing reflection required
Complex/ inflexible Difficult to understand
Safety issues
Record keeping not reflective of
delivered care
Involving person and family
Current practice
• Nursing process
• Models
• Care pathways
• Care bundles
• Clinical assessment tools
PACE – What's possible
Passive recipients PARTNERSHIP
Paternalistic
EMPOWERMENT
Informed of care
INFORMED CONSENT
Comprehensive ‘it wasn’t recorded
it wasn’t done’
SIMPLICITY FACTUAL/CONCISE
PACE PERSON
ASSESSMENT
PLAN OF CARE
EVALUATION
When to record
P - At the beginning of a shift and throughout shift
A - Depending on the need - ongoing care/episodes of
care/emergency & critical care
C - Following assessment of needs
E - Throughout the shift, after a plan is in place and the
action has been carried out or if unable to be carried
out
Champions
Champions Role
WHAT
HOW
Motivator
Educator
Facilitate/
Mentor
Embed
Change culture
Evaluator/
Feedback
Role model
Good practice
Promote awareness
Resource
Embracing barriers/
Monitor
Educator Train their peers, tailoring this to their area of
practice.
Can be formal or informal. Run short sessions or work with staff during the shift.
Work through resource pack.
Feedback on the resources and possible development of new materials such as posters, leaflets.
Guide to other resources
Become familiar with NIPEC site with resources and tools for practice improvement
PACE
Embracing Barriers
BARRIER ENABLER
New approach – increase time to record
Given adequate time from nurse leaders
Inadequate training preparation
Adequate training preparation
BARRIER ENABLER
Lack of explanations of change/expectations
Given adequate explanation
Lack of feedback to department level
Facilitate feedback to department level.
Misunderstanding of PACE Training/Resources
Reluctance from patient Explanation
BARRIER ENABLER
Lack of training/ preparation at all levels Lack of awareness
Support from NIPEC
Attendance at training workshops.
Involvement of department champions to cascade
Resource pack.
Training audit tool
BARRIER ENABLER
Fear -not writing enough/change of entire style
Training/on going support at ward level
Fear of legal/professional repercussions
Addressing these issues Revalidation
Staff attitudes - sceptical Communication / Discussion
Challenging department environment
Creative thinking to current processes
Staff levels Appropriate reporting Understanding
Resources
• Resource pack
• NIPEC website http://www.nipec.hscni.net/
• NIPEC microsite
http://www.nipec.hscni.net/resource-section/improve-record-keeping/
• NMC Code
• Standards document
