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“Is it just me” or are we asleep on care planning?

Is it just me,

Or does anyone else notice that the one document that we spend an incredible amount of time and energy in preparing to get right is the care plan and the one document that frontline workers (direct care workers) don’t seem to read or at least find the time to read is the care plan?

I ask this question on a continuous basis, to establish for myself (at least) that I have identified a gap in the practice that can be improved. The care plan is the document that takes a considerable amount of expertise and time to complete as part of the nursing process. Whether it be a “Care Support Plan (in community) or a Care plan (in residential) there are still legal and ethical requirements that need to be met. An application of standards across many domains including the aspects of risk management, clinical governance, meeting the client’s needs and not to mention attracting and validating the funding instrument that swings in the balance of getting it right.

The pressure is always continuous for any provider and care manager to ensure that the care plan contains the right information that is up to date and validated through its review process and in essence is a directive for others who apply the services to have an evidence based platform to work from and can identify any need for change. Why is it that I continuously notice and am informed that it’s the one document that is rarely utilised (as it should be) by the direct care staff. Yet, they will inform you that they “know the client” or they “don’t have the time” or they can’t get access to it. I know that this is the case and the culture around it to simply ignore it and don’t look behind the curtain.

Regardless of the numerous environmental, cultural and subcultural (workplace/operational) issues that sit around care planning, it is and still remains a fundamental value in the nursing process, and one that requires some critical thinking and clinical leadership in regards to effective management. Nurses have deep ethical and professional concerns when it comes to applying and implementing the outcomes of our focused work, particularly when we realise that it could all be in vain as the true value is not being recognised or respected. Nevertheless, I would advise all nurses to build some emotional intelligence when reflecting on your practice and ask yourself some critical questions.

  1. How can I apply some values leadership to my care team in regards to care plans?
  2. How can I utilise transactional leadership to get feedback mechanisms into place so that collaboration is active and continuous on care plans?
  3. How can I apply transformational leadership through education and mentoring the team more positively to take ownership in the care plans?


For me, the answer is in taking advantage of the clinical review process and develop a Care Plan Assessment Tool (CPAT) as a method of feedback from the direct care workers who undertake 80% of the service delivery. A well designed CPAT tool is an excellent feedback mechanism from those that are doing the care, and who have probably not read your care plan in detail, to inform you of what it is they are doing with the client on a daily basis.

The CPAT should be well set out as simple feedback questions for carers to inform you how they undertake their tasks in each domain of the plan. The analysis of the data can then be compared against the current care plan and will inform the nurse (or Care Coordinator) that the service is congruent or that there are gaps in the care that need to be addressed. The nurse can use this tool for screening risk management and quality of indicators so that care is congruent with planning and customer service is always a focus.

Here are some of my “HOT TIPS” on Care Planning

  • Make sure the care directive is written by a Registered Health Professional;
  • Insure a nursing risk assessment is linked to intervention for validation;
  • Be prescriptive in intervention for staff that demonstrate a commitment for physical assistance.
  • I do go further into all of the above mentioned tips, plus much more when I present Care Planning Master Course for Frontline Care Solutions.

Transformation comes in the empowerment of staff through learning and development, and in this case for staff to value the document and its rationale. The CPAT is a great communication tool for reporting, auditing and continuous improvement on the frontline of your service. Its an easy model for a call to action to engage and transact with staff to gain their feedback and input into the care of their clients. Staff will see the value in the work that they do, and the value we give them in our teams through collaboration. Its also the time for frontline leaders to get proactive and improve their own workplace tasking and environments./p>

I know I am not the only person that thinks about this issue around care plans, as I face it everyday in my own professional life. Everyone is screaming that “it’s time for change” in the sector, so how about we all wake up, smell some coffee and apply some focus on closing some of the biggest gaps in our care culture……..the stuff that is behind that curtain needs to be lead into the light.

Here are my Paulatim..

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