Why Nursing Care Plans Refuse to Die

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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.

4 thoughts on “Why Nursing Care Plans Refuse to Die

  1. Josephine, My understanding of their resurection in the 60 and 70 was the implementation of DRGs and the effort to document nursing care so that it could be reimbursed – not every patient with breast cancer in the hospital needs the same amount of care and the differences are largely nursing care. I admit that as implemented they are largely useless busy work but I think the idea has some validity.

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  2. Interesting article, but you are much too kind to the idiocy of nursing care plans. They came about when nursing decided that to “Be a profession,” nursing was required to have a desperate unique body of knowledge that only its practioners could “access.”. Thus the introduction of “Nursing diagnosis,” and care plans. As a result nurses are saddled with foolish check lists, with such helpful tidbits as “Impaired airway, related to copious secretions”. First intervention? Check airway. Crap like that is an insult to anyone who thinks or has taken basic first aid. Do we really believe this is the only thing standing between our patients and death itself? Apparently a writer over at rncentral.com believe so.

    Don’t believe me? Take a look: http://www.rncentral.com/nursing-library/careplans/Why_Have_Nursing_Care_Plans

    the sad thing is the writer seems to believe care plans are the only thing from nurses giving IV Pavulon in place of pro ASA.

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  3. The final paragraph should read:
    “The sad thing is that the writer seems to believe that care plans are the ONLY thing that stand between a foolish BSN trained nurse giving IV Pavulon and P.O. ASA. That is assuming the poor nurse reads the care plan before giving EVERY medication.

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