Care Planning in Health and Social Care

Executive Summary

A care plan is a written document which is used and altered on a continuous basis so that the defined needs and demands of the service users are met and it acts as a direction of care for the nurses and service providers to ensure quality and satisfactory care. In health and social care, care plans helps to provide direction to the nurses regarding the way individual care is to be offered to the service users. In this report, the policy and legislation related to care planning are to be identified and stages involved in planning care is to be discussed. The Health and Social Care Act 2014, regulation 12 and regulation 9 are related to care planning. Further, the information required for executing impeccable needs assessment is to be discussed. Later, service user’s involvement in planning of care process with relation to anti-discrimination practice and significance of multi-professional working in the process of care planning progress is to be explained.

Introduction

In the field of health and social care, care plan indicate the nurses regarding the way individual care is to be offered to the service users. The care plan is framed based on the unique list of diagnosis of the patient’s health and their individual needs. In this report, the policy and legislation related to care planning are to be identified and stages involved in planning care is to be discussed. The data required to make proper needs assessment and way service users are to be involved in care planning are to be discussed. Lastly, the importance of multi-professionals in the progress of the care planning is to be explained.

LO1 Identifying policy and legislation related to care planning and the stages and design in the process of care delivery in health and social care

A care plan is a written document which is used and altered on a continuous basis so that the defined needs and demands of the service users are met and it acts as a direction of care for the nurses and service providers to ensure quality and satisfactory care (rcnhca.org.uk, 2015). According to Health and Social Care Act 2014, the regulation 12 informs that people are to be prevented from unsafe care and treatment so that any risk can be avoided and the care planning is to be done timely so that the health, safety and well-being of the patients is maintained and protected (cqc.org.uk, 2014). This legislation influences the nurses to make proper diagnosis of the patients in a timely manner to develop a proper care plan so that safe healthcare to be patients can be assured as per the legislation. The Health and Social Act 2014 through regulation 9 informs that capability and consent of the service users are to be considered while planning care and they are to be involved intricately to make decisions regarding their management and planning of care (cqc.org.uk, 2014). This regulation influences the nurses in making care plan for the patients by considering their preferences and decisions.

According to Knowledge and Skills Framework (KSF) and Quality Assurance Agency (QAA), there are four phases of care planning process which are identification and assessment of health and social care needs of individual patients, development of focussed intervention, implementation of plans and critical evaluation of plan (wales.nhs.uk, 2004; mheducation.co.uk, 2019; rcnhca.org.uk, 2015). In identification and assessment phase, the patients for whom the care plan is to be developed is identified and examination of their health condition as well as surrounding environment is performed to identify the health issues as well as needs and demands of the patients that are to be fulfilled in the care plan (McCreedy et al. 2018). This phase includes mainly collection of information based on which the care plan is to be made for the patient. As commented by Rashid et al. (2016), improper health diagnosis of the patient during care planning leads to implement hindered healthcare intervention that is not required by the patients to ensure their well-being. This leads the nurses to deliver care to patients in wrong direction. As argued by Worthy et al. (2016), proper identification of care needs through health diagnosis of the patients leads the nurses to develop care that is focussed to ensure better health condition of the patients. This is beneficial for the patients as such care plan keeps the value of the patients at utmost position to ensure them effective improvement in health condition creating person-centred approach. For instance, while formulating care plan for a patient who was admitted to the hospital due to hypoxia and had previous incidence of breast cancer, the individual’s health diagnosis reports were examined.

In care planning process, at development of focussed intervention stage, the health professional and nurses discuss the gathered information from the first stage. This is to determine the nature of intervention to be provided and the way they are to be delivered so that the health and personal needs and demands of the individual patient are properly fulfilled (Lum et al. 2015). Thus, this stage acts to provide knowledge and direction regarding the way person-centred care is to be provided to the service user by the nurses to ensure their health and well-being. As asserted by Möhler et al. (2015), in development of focussed intervention stage of care planning the decision and perspectives as well as capability of the service users are to be considered. This is because it would help to frame a person-centred care plan where the individual patient’s consent regarding care ability to participate is taken into account. As argued by Wiener et al. (2015), inclusion of patient’s decision while identifying the intervention to be included in their care plan helps to avoid conflict or resentment from the service users while the care plan is implemented by the nurses. This is because the care is provided according to the person’s choice and which is justified for meet their health needs, in turn, assisting to accomplish person-centred approach. (Refer to Appendix 1)

In stage of implementation of plan, the nurses are to ensure they properly follow the direction mentioned in the care plan to deliver care to the patient (McAllister et al. 2018). This is because it would lead the nurses to deliver focussed care and meet the individual needs as well as demands of the service users establishing person-centred approach. As mentioned by Gagnon et al. (2016), during implementation of care plan the nurses are required to deliver the care as per directed in the plan by respecting the dignity of the service users. This is required to make the service users feel valued and would make the nurses deliver satisfactory care. In the critical evaluation of plan stage, the service providers and nurses require evaluating the effect of the care plan on health of the patients (Brennan et al. 2015). This is because the evaluation would help the nurses determine whether or not the developed care is effective to improve the health of patient or which changes are required to be implemented to ensure successful person-centred care. As commented by Ab Latif et al. (2017), for evaluating the progress of the care plan follow-up of the patient’s health is to be made. This is because it would help nurses understand which aspects changes required to be made in the care plan to ensure successful care. As argued by Sowan et al. (2019), timely revision of the care plan by evaluating its impact on the health progress of the patient deteriorates the health of the patients. This leads to make the patient experience longer hospital stays as their health problems are not effectively covered through the care plan.

LO2 Identifying information required for making appropriate needs assessment and showing understanding of use of communication and observation skills

The needs assessment the process through which information that is needed to develop appropriate and sufficient care that will address the needs and resolve the gaps of care for the patients are identified (Gardner et al. 2017). This is a critical part of planning care for service users as it informs about the specific and unique requirements of the service users that are to be fulfilled through the care plan. As asserted by Stephens et al. (2019), in order to make appropriate needs assessment effective communication is to be developed between the service users and the carer. This is because through proper communication the carers are able to establish successful interaction with the service users to understand their personal needs and demands for ensuring them better health condition through person-centred approach. As criticised by Koyio et al. (2016), unable to develop proper interaction with the services users during needs assessment leads the carer fails to identify the appropriate and unique demands of the service users. This leads them to fail in fulfilling healthy well-being of the patients.

The observation skill in needs assessment is vital as it leads the service providers to deliver care by evaluating the surrounding environment of the patients. As mentioned by Pitts et al. (2015), observation skill helps the service providers or carer identify the needs of the service users according to their current health performance. This is because through observation the health condition and efficiency of the service users to execute their personal as well as social activities are understood. For instance, during observation of the patient suffering from hypoxia, it was seen that the person experiences shortness of breath after moving certain distance while walking. It was also observed that the patient was facing shortness of breath while talking and often coughed to get in more oxygen to breathe. In addition, it was observed that the patient hands are trembling. The observation led to inform that the patient needs support with mobility and talking that was not mentioned by the patient, in turn, helping to develop a person-centred approach where the needs and care are provided as per individual condition of the patient. As argued by De Los Reyes et al. (2015), lack of proper observation of the patient leads carers unable to identify the needs that are not mentioned by the service users. This is because from the perspective of service users those may not be needs while the carer can understand that the situation through observation and determine unspecified needs of service users.

The information required in needs assessment includes health diagnosis reports and information of the service users along with surrounding resources present around the care environment of the patient (Emilson et al. 2016). This is because the health diagnosis information leads the carers understand the specific treatment, medication and services needed by the patients to ensure their better health condition. Moreover, the information of surrounding resources that is collected through observation is essential to lead the carers to understand what further resources are needed to be arranged for the service users so that their safety and improved health condition can be established. The other information required in needs assessment is that the way service users prefers to avail their care, capability of the service users to perform different activities and wishes of the individuals (Murphy et al. 2016). These data are to be collected by communicating with the service users so that empowerment of the patients, as well as improved health condition, can be assured through needs assessment.

LO 3 Demonstrating knowledge of involvement of service users in care planning process with relation to anti-discrimination practice

The involvement of service users in care planning is vital because it assists to develop successful person-centred care approaches (Grundy et al. 2016). This is because including the service users help the nurses to arrange care practices that fulfil the personal needs, desire and health goals of the service users, in turn, keep them in the middle of the care planning which is key motive in person-centred care. The service user’s involvement in care planning decision as they wish the care plans to be beyond their record of clinical decisions and involve their aspects of life to identify where they need support in daily and social activities (Bee et al. 2015). The anti-discriminatory practice informs that equal opportunity of care is to be offered to service users irrespective of their caste, religion, race and others (Tribe and Lane, 2017). In this respect, the service users are to be included in the care plan to decide their care equally without judging any of their efficiency of making decision on the basis of any discrimination. As asserted by Millar et al. (2016), transparent and open communication is required to be established by the service providers to help service users make meaningful involvement in care planning. This is because clarified information helps service users have detailed information regarding the way certain care is to impact their health, in turn, helping the make valid decision regarding their care.

The service users are able to be included in the care planning process by initially helping them to establish a connection with the service providers which is to be done by the service providers by respecting dignity and rights to decision-making of the service users (Fraser et al. 2017). This is because it makes the service users feel valued and respected in turn helping them to develop trust towards the service providers regarding their care. In addition, it helps to create person-centred approach to develop care planning as valuing service users is one of the principles of person-centred care (Cree et al. 2015). As mentioned by Gurung et al. (2017), the capacity of all service users to be able engage in care planning is not same as they all do not have proper education and information about their care and health condition. This indicates that flexibility is to be provided by the professionals to the service users so that they can be educated regarding care practices, in turn, helping them to make informed decision regarding their care. (Refer to Appendix 2)

In condition, where the service users cannot make own decision regarding care planning due to their health condition the family members are to be included in the process. This is because the family members are the trusted individual of the service users who thinks in a positive way similar to the service users to ensure their good health (Goossen and Austin, 2017). Thus, the family members are to be included in care planning so that on behalf of service users they can make decision regarding their care. The carers of service users are to be included in care planning by asking them the resources they think are vital for the service users in care plan to ensure their good health (Dalton et al. 2016). This is because carers have intricate information regarding care needs of services users and thus their involvement would ensure development of a productive care plan that satisfies the needs of service users.

LO4Considering the importance of multi-professional working in the care planning progress

The Multi-disciplinary team is referred to the group of professionals from more than one critical medical discipline where they together make decision-related to treatment and care of patients (Gosling, 2019). This is important in care planning progress as professional from diverse medical fields would be able to holistically analyse different aspects of health condition of the patient to determine various needs of the service users. It also indicates that service coordination is improved as uniformed decision-making by consulting ideas from various medical fields enhances the way treatment is directed to be delivered in the care plan. As commented by Taylor (2016), multi-professional working is important in care planning progress as it provides patients to get access different experts as well as improves coordination and efficiency of care services. This is because in the multi-professional team each professional analyses the patient from their own perspective which is able to enhance the nature of treatment offered to the individual.

The importance of a multi-professional team in care planning is that it provides opportunity to arrange care by drawing resources from multiple organisation and departments which were otherwise not possible (Pini et al. 2017). Thus, it results to avoid resource shortage in establishing a quality care plan for health improvement of the patient. The other importance of multi-disciplinary team is that through sharing of information they are also to resolve problems and conflicts often faced in care planning progress (Tzortziou Brown et al. 2017). This is because different professionals of diverse field are present who share their expert opinion to cope with the conflict in care planning ensure smooth delivery of carte to the service user.

Conclusion

The above discussion informs that Health and Social Care Act 2014 is the key legislation that influences care planning. There are four stages of care planning which are assessment and identification, development of care plan, implementation and critical evaluation of the plan. The information required in needs assessment includes data regarding surrounding environment of service users, health diagnosis reports, and others. The service users and family members along with carers are to be involved in care planning to develop a successful care plan. The multi-professional working is important to increase service coordination, smooth development of treatment plan, better availability of resources and others during care planning progress.

References

Ab Latif, R., Dahlan, A., Ab Mulud, Z. and Nor, M.Z.M., 2017. The Comparison Between Concept Mapping Care Plan And Nursing Care Plan (Nursing Process). Malaysian Journal of Medical Research, 1(4), pp.45-50.

Bee, P., Brooks, H., Fraser, C. and Lovell, K., 2015. Professional perspectives on service user and carer involvement in mental health care planning: a qualitative study. International Journal of Nursing Studies, 52(12), pp.1834-1845.

Brennan, M.E., Boyle, F.M., Butow, P.N. and Spillane, A.J., 2015. Evaluation of a survivorship care plan: long-term use, care coordination and quality of life in breast cancer survivors. Breast Cancer Management, 4(3), pp.145-157.

Cree, L., Brooks, H.L., Berzins, K., Fraser, C., Lovell, K. and Bee, P., 2015. Carers’ experiences of involvement in care planning: a qualitative exploration of the facilitators and barriers to engagement with mental health services. BMC psychiatry, 15(1), p.208.

Dalton, J., Chambers, D., Harden, M., Street, A., Parker, G. and Eastwood, A., 2016. Service user engagement in health service reconfiguration: a rapid evidence synthesis. Journal of health services research & policy, 21(3), pp.195-205.

De Los Reyes, A., Augenstein, T.M., Wang, M., Thomas, S.A., Drabick, D.A., Burgers, D.E. and Rabinowitz, J., 2015. The validity of the multi-informant approach to assessing child and adolescent mental health. Psychological bulletin, 141(4), p.858.

Emilson, C., Åsenlöf, P., Pettersson, S., Bergman, S., Sandborgh, M., Martin, C. and Demmelmaier, I., 2016. Physical therapists’ assessments, analyses and use of behavior change techniques in initial consultations on musculoskeletal pain: direct observations in primary health care. BMC musculoskeletal disorders, 17(1), p.316.

Fraser, C., Grundy, A., Meade, O., Callaghan, P. and Lovell, K., 2017. EQUIP training the trainers: an evaluation of a training programme for service users and carers involved in training mental health professionals in user‐involved care planning. Journal of psychiatric and mental health nursing, 24(6), pp.367-376.

Gagnon, F., Poulin, P., Leclerc, J.M., Dessau, J.C., Abab, A., Arsenault, P., El-Turaby, F., Lachance-Paquette, G. and Vézina, F.A., 2016. Implementation of a radon measurement protocol and its communication plan by child care centre managers in Québec. Canadian Journal of Public Health, 107(3), pp.e319-e325.

Gardner, A.K., Waters, V. and McLaughlin, R.J., 2017. What Do Faculty in Health Professions Need to be Competent Educators? Results from a School-Wide Needs Assessment. Journal of allied health, 46(4), pp.77-80.

Goossen, C. and Austin, M.J., 2017. Service user involvement in UK social service agencies and social work education. Journal of Social Work Education, 53(1), pp.37-51.

Gosling, S., 2019. Securing influence in the advanced practice agenda: enhancing opportunities for physiotherapy workforce development through engagement in multi-professional initiatives. Physiotherapy, 105, pp.e196-e197.

Grundy, A.C., Bee, P., Meade, O., Callaghan, P., Beatty, S., Olleveant, N. and Lovell, K., 2016. Bringing meaning to user involvement in mental health care planning: a qualitative exploration of service user perspectives. Journal of Psychiatric and Mental Health Nursing, 23(1), pp.12-21.

Gurung, D., Upadhyaya, N., Magar, J., Giri, N.P., Hanlon, C. and Jordans, M.J., 2017. Service user and care giver involvement in mental health system strengthening in Nepal: a qualitative study on barriers and facilitating factors. International journal of mental health systems, 11(1), p.30.

Koyio, L., Ranganathan, K., Kattappagari, K.K., Williams, D.M. and Robinson, P.G., 2016. Oral health needs assessment world‐wide in relation to HIV. Themes: Oral health needs and inequalities, oral health promotion, co‐ordinating research and enhancing dissemination in relation to HIV‐a workshop report. Oral diseases, 22, pp.199-205.

Lum, H.D., Sudore, R.L. and Bekelman, D.B., 2015. Advance care planning in the elderly. Medical Clinics, 99(2), pp.391-403.

McAllister, J.W., Keehn, R.M., Rodgers, R. and Lock, T.M., 2018. Implementation of a shared plan of care: A pilot approach to care coordination with children with neurodevelopmental disabilities. Journal of Nursing Research and Practice, 2(2).pp.14-45.

McCreedy, E., Loomer, L., Palmer, J.A., Mitchell, S.L., Volandes, A. and Mor, V., 2018. Representation in the Care Planning Process for Nursing Home Residents With Dementia. Journal of the American Medical Directors Association, 19(5), pp.415-421.

Millar, S.L., Chambers, M. and Giles, M., 2016. Service user involvement in mental health care: an evolutionary concept analysis. Health Expectations, 19(2), pp.209-221.

Möhler, R., Köpke, S. and Meyer, G., 2015. Criteria for Reporting the Development and Evaluation of Complex Interventions in healthcare: revised guideline (CReDECI 2). Trials, 16(1), p.204.

Murphy, C.M., Wilson, C.E., Robertson, D.M., Ecker, C., Daly, E.M., Hammond, N., Galanopoulos, A., Dud, I., Murphy, D.G. and McAlonan, G.M., 2016. Autism spectrum disorder in adults: diagnosis, management, and health services development. Neuropsychiatric disease and treatment, 12, p.1669.

Pini, S.A., Gibson, F., Fern, L.A., Morgan, S.J., Phillips, R.S. and Stark, D.P., 2017. Multi-professional perspectives on adolescent and young adult oncology across Europe: an e-Delphi survey. Journal of adolescent and young adult oncology, 6(1), pp.178-185.

Pitts, S., Borus, J., Goncalves, A. and Gooding, H., 2015. Direct Versus Remote Clinical Observation: Assessing Learners' Milestones While Addressing Adolescent Patients' Needs. Journal of graduate medical education, 7(2), pp.253-255.

Rashid, U., Qureshi, A.U., Hyder, S.N. and Sadiq, M., 2016. Pattern of congenital heart disease in a developing country tertiary care center: Factors associated with delayed diagnosis. Annals of pediatric cardiology, 9(3), p.210.

Sowan, A.K., Leibas, M., Tarriela, A. and Reed, C., 2019. Nurses’ Perceptions of a Care Plan Information Technology Solution With Hundreds of Clinical Practice Guidelines in Adult Intensive Care Units: Survey Study. JMIR human factors, 6(1), p.e11846.

Stephens, K.A., Osterhage, K.P., Fiore-Gartland, B., Lovins, T.L., Keppel, G.A. and Kim, K.K., 2019. Examining the Needs of Patient Stakeholders as Research Partners in Health Data Networks for Translational Research. AMIA Summits on Translational Science Proceedings, 2019, p.363.

Taylor, I., 2016. Multi-professional teams and the learning organization. In Social Work, Critical Reflection and the Learning Organization (pp. 85-96). Routledge.

Tribe, R. and Lane, P., 2017. Anti-discriminatory Practice: Caring for Carers of Older Adults with Mental Health Dilemmas. Anti-discriminatory Practice in Mental Health Care for Older People, p.147.

Tzortziou Brown, V., Patel, I., Thomas, N., Tomlinson, J., Roberts, R., Rayner, H., Ashman, N. and Hull, S., 2017. New ways of working; delivering better care for people with long-term conditions. London journal of primary care, 9(5), pp.60-68.

Wiener, L., Weaver, M.S., Bell, C.J. and Sansom-Daly, U.M., 2015. Threading the cloak: palliative care education for care providers of adolescents and young adults with cancer. Clinical oncology in adolescents and young adults, 5, p.1.

Worthy, S.L., McClughen, D.C. and Kulkarni, S., 2016. Now or Never: The Urgent Need for Action Against Unfair Coverage Denials for Quality Health Care. Loy. U. Chi. LJ, 48, p.1041.

Wright, N., Rowley, E., Chopra, A., Gregoriou, K. and Waring, J., 2016. From admission to discharge in mental health services: a qualitative analysis of service user involvement. Health expectations, 19(2), pp.367-376.

Appendices

Appendix 1:

Moreover, it is required as the NMC code under “Prioritise People” informs that the nurses while delivering and arranging care plan for the patients are require to include them in the decision-making process (NMC, 2015). For instance, in this stage, while developing the care plan for patient with breast cancer who was admitted due to hypoxia the intervention planned was to offer oxygen during breathing problem and to be helped in dressing, cleaning and eating food. This is because the patient reported due to hypoxia the individual is facing difficulty to dress, bath and eat food.

Appendix 2:

The education of service users not only helps inclusion of them in care plan but also fulfil the principle of person-centred approach which is autonomy (Wright et al. 2016). This is evident as education regarding care opportunities and flexibility to decide care by the service users in care planning provides them informed detailed about care, in turn, allowing them to become autonomous to plan their own care.