Transitions

Road cones
Road cones (Photo credit: Christchurch City Libraries)

Transitional care: part of care coordination across time and settings, specifically for patient populations at high risk for poor and costly outcomes as they cross health care settings.

There is the ideal (smooth, patient and family-centric) transitional care and then there is reality.

Case in point is my elderly father with congestive heart failure—the diagnosis associated with the highest Medicare health care costs. My father has been in four different health care settings over the past six weeks. These include an inpatient acute care hospital, a skilled nursing care/rehab facility, home nursing care, and as of today, home hospice. I have worked as a nurse in three out of four of the specific health care systems he has moved through. I know something about how they work—the key people to contact—the questions to ask—the code words to use to get things done. In spite of all that—plus flying cross-country to do much of this care coordination in person—it has been more than just difficult. As my father says, “There’s been a mix-up everywhere I go—it’s as if none of them communicate with each other.” Indeed, it shouldn’t be this hard. I keep wondering: how do people with fewer resources do this?

The metaphor for ‘good enough’ healthcare transitions that has occurred to me are those orange safety cones lined up re-directing traffic. Knowing the more ideal freshly paved road of smooth health care transitions is a ways off in the future, all I’ve yearned for are orange safety cones. I did finally see one bright orange safety cone today. It came in the form of a wonderfully compassionate male hospice nurse who spent over an hour patiently and respectfully talking to my father about quality of life–about what matters most to him and how hospice can help support him to pursue those things. Finally! Sanity and clear, direct communication from someone in the health care system. I thanked this nurse and asked him how long he’d been in nursing–14 years–and what he did before nursing–he owned/operated a bar. There are many paths to becoming a really great nurse.

Why Nursing Care Plans Refuse to Die

Social Security: Public Health nursing made av...
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Today I was simultaneously searching for appropriate guidelines for case study presentations for nursing students working in public health settings, and wondering where nursing care plans came from. The two seemingly disparate threads of inquiry converged in a stranger than fiction way.

The earliest origins of the nursing care plan seem to be attributed to Ellen L. Buell, a public health nurse and nursing instructor at Syracuse University, NY in the 1930s and 40’s. In 1930 in the American Journal of Nursing, she published an article: “The Case Study: As a Method of Teaching Students and Graduates the Principles of Public Health Nursing.” She presented the public health case study as a way of teaching comprehensive and systematic thinking and care planning to new nurses. It was based on home nursing, so included all the family members, their health status, socioeconomic status, housing conditions, and nationality/citizenship status. Some of the nursing diagnoses she uses are shyness and temper tantrums (for the children). Recommended nursing interventions include more fresh air and play out of doors. Her public health nursing case study approach then led to a codification of nursing theory, nursing process, nursing diagnoses and the nursing care plan. The development of all of these occurred within baccalaureate nursing programs. Nursing care plans originally were considered ‘higher thinking’ and planning possible by BSN prepared nurses, and were also meant to guide delegation of nursing duties to the ‘lesser’ diploma-trained and LPNs.

Nursing care plans took on a life of their own in the 1960s and 70s in the US, and then spread virally to other parts of the planet. They became an established requirement within BSN programs, as a way of indoctrinating nursing students into thinking like a nurse. Nursing care plans were a way of differentiating nursing practice from medical practice. All of the current nursing faculty in our country had to do 6-page nursing care plans in nursing school—it is an unquestioned part of becoming a nurse, so it is continued.

What is amazing is the lack of any evidence to support the usefulness of nursing care plans, either to teach nursing students systematic thinking, or to improve patient outcomes. And nursing care plans are not required for hospitals or long-term care facilities by the Joint Commission for certification. Interdisciplinary care planning and coordination is a Joint Commission requirement, but not nursing care plans. Nursing is the only health care discipline to continue to insist on having its own separate care plans.

Most nursing students abhor nursing care plans and find them simply busy work. Most real nurses out there practicing in hospitals and long-term care facilities find them tedious, and say they detract from and don’t aid good patient care. The advent of EMRs and electronic checklist nursing care plans have streamlined the process to some degree. Luckily, public health nurses—who started this whole crazy nursing care plan idea in the first place—don’t do nursing care plans.

Most useful relatively recent article I found on this topic was: Interdisciplinary Care Planning and the Written Care Plan in Nursing Homes: A Critical Review, by Mary Ellen Dellefield, The Gerontologist, 2006, 44(1): 128-133.