SEPTEMBER 1990. VOL. 52. NO 3
Editorial An obituary for the nursing care plan
t does my heart good to know that future students of nursing will not be subjected to the task of writing boring six-page nursing care plans that contain esoteric nursing diagnosis and do not in any way resemble the real world of patient care. The Joint Commission on Accreditation of Healthcare Organizations has given up. It has written the nursing care plan’s death certificate. The Commission’s new set of nursing standards, which will be published in the A M H / 9 I Accreditation Manual for Hospitals, does not require nursing care plans in the traditional sense. Gone are the KardexsTHfull of blatantly basic nursing principles that any first-year nursing student incorporates into his or her everyday practice automatically. Will you miss them? I don’t think so. Professional nursing educators and practitioners should have rung the death knoll a long time ago, but they didn’t. They held on to the concept and the ritual despite student difficulties in writing them and obvious noncompliance by most busy staff nurses. Now, after more than 30 years of browbeating students and staff nurses into writing meaningless and repetitious nursing care plans, they are no longer deemed necessary. According to the Commission, as long as registered nurses have a plan of care based on patient needs, and the delivery of that care is documented appropriately, quality nursing care can be given. Some of us knew that all along. Because I have been closely involved with the nursing care plan for 25 years, I believe it only right that I write a proper obituary.
The nursing care plan was born in the late 1950s or early 1960s to proud parents who worked diligently in the ivory tower. Its grandparents were the nursing process and the problem-solving approach. The exact date of birth is unknown, but we do know it was conceived so that the nursing profession could define its unique, independent contribution to patient care. For the first decade of its life, the nursing care plan did not leave the tower. It grew slowly, and those who were not busy with patient care played with it for hours on end. Eventually, it made its way out into the world and established residency in the nation’s hospitals. As an adolescent, the nursing care plan hung around schools of nursing. It made itself useful by teaching students how to conceptualize nursing care as very different from medical care. Like most adolescents, the nursing care plan strived for independence. It fought endlessly to have nursing diagnoses, nursing interventions, and patient outcomes within its domain. If a medical diagnosis snuck in, it was made to feel unwelcome and was quickly ostracized. As a result, students did indeed learn nursing care, albeit with painstaking attention to interventions such as “allow patient to verbalize his feelings.” As an adult, the care plan roamed around the nursing units, making its appearance known only when the Commission accreditation surveyors visited. For the most part, it was totally ignored. As it grew older, it was cloned endlessly and lost its individuality. Nurses, especially experienced nurses, took it for granted. The nursing care plan was a member of every 499
SEPTEMBER 1990, VOL. 52, NO 3
nursing staff in every hospital. It maintained its honorary status within the ivory tower, and many say it had a special place within the North American Nursing Diagnosis Association. The cause of death is said to be years of neglect. It is survived by short, useful checklists for nurses to assess patients, plan care, and document the outcomes of that nursing care, as well as structure,
process, and outcome standards. The upcoming generation appears to be universal practice guidelines aimed at contributing to a national nursing data base. Contributions may be made to the ivory tower of your choice. PATNIESSNERPALMER,RN, MS EDITOR
Lithotripsy May Cause Rise in Blood Pressure
Job Applicants Face Background Investigation
Most physicians agree on the health benefits of lithotripsy to break up kidney stones, but a recent study raises warnings that lithotripsy may increase the diastolic blood pressure of some patients. The study was reported in the April 4, 1990, issue of the Journal of the American Medical Association. According to the researchers, lithotripsy patients experienced a small but significant average annualized increase of 0.78 mm Hg in diastolic blood pressure two years after treatment. This compares with an annual calculated increase of approximately 0.33 mm Hg for the general population of white men aged 25 to 54 years in the United States. Researchers stressed that more studies are needed to determine the long-term clinical significance, but initial results are worrisome because the patients showed higher diastolic blood pressures after only a few shock waves. Researchers suggest that higher doses of shock waves should be discouraged because evidence does not indicate that they are more effective. Researchers studied 765 patients who received one or more lithotripsy treatments. The 196 control subjects were patients who had their stones removed in other ways. The lithotriptor was used for stones in either the kidney or ureter. The authors found the most significant rise in blood pressure was seen in patients treated for stones in the ureter. That contradicts an earlier hypothesis that blood pressure changes occur as a result of trauma to the kidney caused by the shock waves.
More hospitals are interested in ways to limit their hiring risks to avoid negligent-hiring lawsuits, according to the May 14, 1990, issue of American Hospital Association News. Using a background checking program, the Dallas-Fort Worth Hospital Council has identified escaped felons, convicted murderers, sex offenders, and nurse imposters. This includes a pharmacist convicted of prescription forgery and Medicaid fraud and a convicted child molester who applied for a position in a pediatric ward. None of these job applicants reported their criminal histories on their applications. More than one third of the states recognize that the employer is liable for negligent hiring because he or she knew or should have known that the potential employee posed a threat to patient care. The Hospital Council gives any information on the potential employee to the employer. It is his or her decision whether to hire the applicant. Before investigating an applicants’ background, the hospital should review its state laws before determining the scope of such an investigation. Even after hiring, employers should consider checking into employees’ activities to identify any theft or fraud. The Hospital Council charges its members for conducting this service. Hospitals with 100 employees or less are charged about $1,000 a year; hospitals with 2,500 employees are charged $13,650 a year.