Barriers that prevent nursing staff on a non-critical care unit from effecting individualized documentation of patient care plans

Abstract

Historically, patient care plans were introduced in the academic arena to teach a process that nursing students could use to identify and define a patient-centered problem. This method has evolved to a five step process known as the nursing process. The five steps include assessment, diagnosis, planning, implementation and evaluation. The nursing process is fundamental to providing quality, safe and individualized care that results in positive patient outcomes (Doenges, Moorhouse, & Murr, 2006). A major tool within the nursing process is the patient care plan. Patient care plans are multidisciplinary and are used to communicate and document patient care. They are required by government agencies, third-party payers and are part of hospital policy (Doenges et al., 2006). The impetus of this project was an audit by The Joint Commission of an acute care hospital. The audit revealed a deficit in compliance in regards to documentation of individualized care plans. Changes were instituted within the acute-care hospital however; it was felt by staff that these changes did not address the root cause of the problem. The purpose of this project was to identify barriers that prevent nursing staff on a non-critical care unit from effecting individualized documentation of patient care plans. Three focus groups assembled to discuss their insights regarding the barriers professional nurses face that prevent them from documenting on and making a patient's care plan individualized. This project proposed using the data from the focus groups for further investigation and research to develop nursing processes and technology that can truly benefit patient outcomes.