Since inception, the value of a nursing care plan (NCP) has been controversial.1 Bedside nurses are often informed that that the NCP is required by the Joint Commission (TJC) and that the NCP is important to providing comprehensive care. With an understanding that the NCP is one of many formats in which healthcare providers communicate a plan of care,2 we were unable to find documentation that TJC specifically requires that the plan of care is presented in the NCP format.3,4 We did find evidence that a plan of care (but not necessarily an NCP) is required by the Centers for Medicare & Medicaid Services (CMS).5 We also found no studies exploring the value of NCP for nurses working in a neuroscience intensive care unit (NSICU). In many NSICUs, a multidisciplinary rounding plan (MDRP) is developed during multidisciplinary rounds.6 The purpose of this study is to explore the utility of the NCP and MDRP to provide contextually relevant information for NSICU nurses.

Background

The NCP was first introduced almost 100 years where the exercise of writing an NCP arose from attempts to provide nursing students with instruction on how to include family in care.7 During the first half of the 20st century, NCPs were increasingly common in baccalaureate nursing programs.7 Roughly 60 years ago, state boards of nursing began acknowledging that writing NCPs fell within the Nursing Scope of Practice.7 In the 1970s, standard NCPs spread from nursing schools to hospitals, and clinical practice now posits that an NCP is essential to the nurse in individualizing patient care.8

Nursing care, medical care, and documentation have significantly evolved over the past century. Neurocritical care became a recognized specialty in the 1990s and, since inception, has embraced a multidisciplinary approach to care.6 This is embodied in multidisciplinary rounding and the MDRP.6,9–11 The medical record has evolved from a physician-to-physician communication tool to a more holistic record that goes beyond simply observations and is shared across disciplines and with the patient.12 Nurses are now expected to manage increasingly complex patients who are hospitalized for shorter spans of time than decades ago when NCPs were adopted. Documentation, much of which is repetitive, may take up to 50% of a nurse's time and contribute to burnout.13,14 Nursing care plans are increasingly seen as an outdated, inefficient, and ineffective tool.14 The MDRP (see Supplemental Digital Content 1, https://links.lww.com/JNN/A441) capitalizes on technological advances to autopopulate preidentified fields from other parts of the medical record (eg, the highest intracranial pressure value in the last 24 hours).

External regulatory agencies such as TJC and CMS require evidence of interdisciplinary planning and go beyond requiring only the standard NCP. CMS §482.23(b)(4)5 stating, “The hospital must ensure that the nursing staff develops and keeps current a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. The nursing care plan may be part of an interdisciplinary care plan.” Although we know that NCP documentation does meet this requirement,15 the MDRP may also meet this requirement.6 Testing the value of the MDRP compared with NCP in providing contextually relevant information is an important step in identifying best practice for multidisciplinary planning.

Methods

This prospective single-blind randomized pilot study was approved by the university institutional review board. Before any data were collected and before any NCPs or MDRPs were obtained, the investigators developed 7 short scenarios common to the NSICU and 5 answer options for each question (Table 1). To provide some content validity, the scenarios and questions were developed through conversations with NSICU staff and represent real-world scenarios common to the NSICU.

TABLE 1 - The 7 Scenario Questions Answered for Each of the 70 Patients Question Answer Options The patient has a blood pressure of 143/88 mm Hg.
What should you do? A. I do not have enough information to answer this question
B. Administer a medication to reduce the blood pressure
C. Administer a medication to increase the blood pressure
D. Notify the provider in anticipation of new treatment orders
E. Do nothing On assessment, you note the patient has right-sided arm weakness 3/5.
What should you do? A. I do not have enough information to answer this question
B. Call a Stroke Code
C. Notify the provider that the patient has a new deficit
D. Notify the provider that the patient has improved
E. Do nothing On skin assessment, you note nonblanchable redness to the coccyx.
What should you do? A. I do not have enough information to answer this question
B. Perform proper wound care consult, event report, other documentation, and notify provider
C. Perform appropriate wound care instructions as directed
D. Notify the provider that the patient's skin injury has improved
E. Do nothing The patient hits the call bell and needs to void.
What should you do? A. I do not have enough information to answer this question
B. Ambulate the patient with proper ambulation equipment
C. Remind the patient they are on bed rest and prepare a bedpan
D. Remind the patient they have a Foley catheter present
E. Do nothing The patient is attempting to remove their peripheral IV.
What should you do? A. I do not have enough information to answer this question
B. Ensure restraints are properly applied
C. Request an order from provider for sitter and/or restraints
D. Notify provider of new-onset confusion and restlessness
E. Do nothing The patient wants a glass of water.
What should you do? A. I do not have enough information to answer this question
B. Give the patient a glass of water
C. The patient is NPO; do not give the patient a glass of water
D. Give the patient moist oral swabs for comfort
E. Do nothing You observe a heart rhythm with atrial fibrillation.
What should you do? B. I do not have enough information to answer this question
C. Notify the provider of new finding
C. Ensure that scheduled antiarrhythmic medications are given
D. Check BP to ensure patient is maintaining adequate perfusion
E. Do nothing

Using admission data from January to December of 2021, a list was generated to identify all patients 18 years or older, admitted to the NSICU in 2021, who had both an NCP and an MDRP written by the same nurse during 1 shift. Seventy patients were selected from this list using a random number generator. The electronic version of the NCP and the MDRP for each of the 70 patients was then copied verbatim into MS Word. To provide additional blinding (so that nurses could not recognize patients by name), patients were deidentified by changing their name, age, and gender. To develop an objective scoring rubric, the research team used electronic chart review to identify the correct answer for each of the 7 scenario questions for each of the 70 patients. Each correct answer was scored as 1 point; incorrect answers were scored as 0 points.

For the prospective portion of this pilot study, 14 scoring packets were created. Each packet contained the NCP for 5 patients and the MDRP for 5 different patients. To prevent recall bias, no packet contained the NCP or MDRP for the same patients. To promote independent sampling, each NCP and each MDRP was used only once, and only by 1 nurse, to answer the 7 scenario questions. In this manner, we obtained 140 independent responses (70 scored using and NCP and 70 scored using an MDRP).

Each of the 14 NSICU nurses who consented to participate were blinded to the study purpose. Nurses were instructed to answer all 7 scenario questions for each of the 10 patients (5 with NCP and 5 with MDRP) in their packet. The responses were then scored as correct or incorrect using the aforementioned rubric (scores ranged from 0 to 7). This strategy allowed us to obtain 2 independent set of scores for each of the 70 patients, 1 in which a nurse used an NCP to answer the scenario questions and 1 in which a different nurse used an MDRP to answer the scenario questions.

Data were first explored using simple measures of central tendency. Test scores are considered interval and expressed as mean (SD). Analysis of variance was first used to compare the mean number of correct responses to the 7 scenario questions. Because each patient provided paired data (scores using NCP and scores using MDR), we then constructed a paired t-test model to confirm the results.

Results

As planned, the 14 nurses provided 140 scores for the 70 patients—precisely 2 scores for each patient, 1 obtained using an NCP and 1 obtained using an MDRP. Scores could range from 0 to 7, with 0 indicating all incorrect answers and 7 indicating all correct answers. Scores using NCP ranged from 0 to 3 with a mean of 0.31 (0.71). Scores using MDRP ranged from 1 to 7 with a mean of 4.51 (1.5), and this difference was statistically significant (P < .0001; Table 2). A paired t-test model was constructed to fully explore NCP and MDRP scores for the 70 patients, which confirmed that scores were statistically significantly different (P < .0001).

TABLE 2 - Mean Number of Correct Answers per Patient for Each Nurse When Using a Nursing Care Plan (NCP) or Multidisciplinary Rounding Plan (MDRP) NCP (n = 70) MDRP (n = 70) P Nurse 1 0.2 (0.44) 3.2 (1.10) .0005 Nurse 2 0 (0) 3.8 (1.64) .0009 Nurse 3 0 (0) 3.8 (1.92) .0022 Nurse 4 0 (0) 5.0 (1.41) <.0001 Nurse 5 0.2 (0.45) 4.8 (1.64) .0003 Nurse 6 1.2 (1.30) 4.8 (0.84) .0008 Nurse 7 0.2 (0.45) 4.4 (0.89) <.0001 Nurse 8 0.4 (0.89) 5.8 (1.30) <.0001 Nurse 9 0.6 (0.55) 2.6 (1.14) .0077 Nurse 10 0.6 (1.34) 5.0 (1.87) .0027 Nurse 11 0.8 (1.10) 4.6 (1.67) .0028 Nurse 12 0 (0) 5.4 (0.55) <.0001 Nurse 13 0 (0) 5.0 (1.22) <.0001 Nurse 14 0.2 (0.45) 5.0 (1.22) <.0001 All nurses combined 0.31 (0.71) 4.51 (1.50) <.0001

Each nurse answered 7 questions for each of 5 NCPs and 5 MDRPs.

Discussion

The results suggest that the MDRP is superior to the NCP in providing relevant data for nurses working in the NSICU. The MDRP addresses 2 important criticisms of the NCP.14 Unlike the MDRP, the NCP lacks specificity to a patient condition (eg, to treat systolic blood pressure if >160 mm Hg); the MDRP provides more concrete data points. The MDRP autopopulates specified data fields (eg, laboratory values) directly from the electronic medical record and from charted assessments.6 Healthcare communication often uses jargon and may benefit from plain communication.16 The formal writing style of the NCP makes it difficult to capture the dynamic status of the NSICU patient in written form.14 The standard NCP style uses phrases such as “…progress toward functional goals as expected…,” whereas the MDRP benefits from a more plain speech style, “…out of bed to chair x2 today….”

Generally, nursing documentation can aid in making sure all team members are moving toward the same goals of care, through interdisciplinary planning and communication.17 In our NSICU, the MDRP is used as a communication tool during daily multidisciplinary rounds, and any decisions about patient goals and plans are updated in the MDRP in real time.6 This provides a platform for nurses to facilitate collaborative care because all NSICU team members, including patient and family, are made aware of the MDRP. Interdisciplinary planning fosters better patient outcomes, strengthens team communication, and improves nursing and physician job satisfaction.18

The requirement of having a plan of care may not be synonymous with requiring an NCP. The definition of a care plan is contextually interpreted.19 The CMS guidelines5 note that “hospitals have the flexibility of [having] the nursing care plan [be] part of a larger, coordinated interdisciplinary plan of care.” In the NSICU, the MDRP more readily meets the requirement of being an interdisciplinary plan than does the NCP. The information contained in a plan of care is generally agreed as vital to keeping the plan of care on track; however, the exact format of a care plan remains in debate.20 Because of the dynamic status of an NSICU patient, the NCP should not necessarily be considered an accurate reflection of the patient's status at any given point in time.21

The personalization of the MDRP has both benefits and drawbacks. As indicated previously, the MDRP benefits from the use of plain speech and may include jargon. Thus, the data from the MDRP would require extensive harmonization to be included in multicenter trials.3,22 Staff new to the NSICU may have more difficulty interpreting the MDRP if they are not familiar with the jargon. There are known barriers to implementing new evidence-based practice models.23 Whereas the NCP has become an ingrained practice widely taught in nursing schools, new paradigms must be developed to adopt tools such as the MDRP if we are to further improve patient care and the nursing experience. Although there is often resistance to change of practice, the dissemination of evidence and findings is the first step of initiating a change.24

Limitations

This study is limited in that there were only 14 nurses who were recruited to answer the scenario questions. However, a strength of this study is that we were able to maintain independent samples: there are no nurses who answered questions using the same patient's MDRP and NCP. The assignments for each participant were randomly selected; therefore, each NCP and MDRP sample is independent. It is also a limitation that the study was conducted at only 1 NSICU. The NCP was designed for nursing students (novices), and it is a limitation that we did not measure the experience of the nurse evaluators. Future iterations should examine whether NCP and MDRP provide contextual information for novice (new to NSICU) nurses. This was a pilot study, and a larger more robust study would provide additional generalizability and a better understanding of how these variables might impact nurse decision making. In addition, future research can address specifically nurse decision making or a more robust survey for MDRP versus NCP.

Conclusion

For NSICU nurses, the MDRP holds potential to provide information not currently available in the NCP. The MDRP was designed to address the modern-day communication needs and styles by leveraging technological advances. Although it is not contested that planning care is integral for patient safety and improved patient outcomes, the best mechanisms to communicate a multidisciplinary plan of care have not been adequately studied. In this pilot study, the MDRP provided uniquely relevant information for bedside nurses to make clinical judgments. Following confirmation that the MDRP meets external regulatory requirements, future studies should aim to prospectively examine the MDRP as a replacement for the NCP in the NSICU.

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