May 28, 2020

Morning Vitals: Nursing Goals and Plans of Care a Window into Health Care Culture

I ended my last Monday morning post by asking you to consider what strengths and obstacles you might have with respect to your New Year’s resolutions. As the same thoughts apply to goals in general, this week I’ve been thinking about goals in nursing life.

There are many examples of the establishment of goals in nursing, perhaps the most prominent of which is related to plans of care. During nursing school, I was told more than once by faculty that nurses in professional practice don’t utilize care plans, at least not in the same ways I did as a nursing student. I never believed them then, and I don’t know.

Our problem is not that we ask nursing students to do things they will never do later in their careers. Rather, nurses post-licensure are so burdened with unmanageable workloads that most choose completion of plans of care as the least detrimental task to neglect. Each of them secretly hopes that, if caught failing to comply with policy, all he or she needs to do is point out the sheer number of nurses who fail in the same way.

Sooner or later, the health care organizations with which many nurses are affiliated will host accreditation surveyors. Within the past year, my organization has renewed its emphasis on plans of care in part to prepare for such surveyors. This renewal has included a laminated job aid posted at each nurses’ station, which lists charting requirements for plans of care.

One of the major emphases of these requirements is the establishment of nursing goals for patients and the utilization of these goals to guide care. As difficult as it is for bedside staff to update these plans of care on any given shift, I believe they’re important, even if I do think we need to consider them in the light of everything else expected of nurses. Still, what I generally hear from bedside staff is consistent with the idea that there are simply too many things on their plates to do justice to them all.

Goals based on requirements set by others have a tendency to degenerate into grudging compliance. That compliance is often true to the letter of a particular interpretation of the law but woefully divergent from the rationale for that law. Those who establish such a requirement so often look for a way to increase compliance by enticing staff to meet the expectation in exchange for some benefit.

The benefit typically represents some cost to the organization in terms of productivity. As I’ve mentioned before (see here and here), there is all too often a dilemma facing health care organizations between patients and productivity. The easier road to travel for leadership is that of productivity, partly because success on that road so often involves the deceptively effortless step of issuing decrees coupled to the organizational employer-employee and superior-inferior relationships.

I wonder what health care would be like if we all acted according to our respective core beliefs, but instead of tacitly demanding a benefit in payment for policy compliance, we simply conformed to the expectations established for us to the extent we were capable and trusted those in positions of leadership to establish more humane expectations.

Is this a pipe dream? I’ll admit it may be exactly that, given the cultural system of health care as it is. But wouldn’t it be worth the effort to try, starting with an honest soul-searching on each of our parts?

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