hate most about their job, and a good many will say the same thing as the special needs parent, "IEP's."
As a parent, I despise IEP meetings for several reasons. My very first memorable experience with an IEP meeting was my son's transition meeting from preschool to elementary school. While I had attended a few of his IEP meetings prior to that one, I was still lost in the logistics of special education, and struggling to come to terms with my son's disability; I was stumbling through life. However, at the transition IEP, I was finally alert and educated. I knew my son's rights, and I knew that I was going to have to advocate like I had never imagined. At the advice of other special needs parents (they are your friends, find them, love them, cherish them!!), I had learned a great deal of the Individuals with Disabilities Education Act (IDEA), which has more pages than the King James Bible, AND is written in legalese. Immediately, as the meeting commenced, I was met with resistance. The principal of our local school did not want Jon at their school because they had never had an autistic child (this was in 2005). Instead, her choice, as well as that of the local school board, was to bus him across town to our self-contained special education program. I wanted Jon mainstreamed because, well, he is autistic. I felt he needed typical peers to model after, not peers with disabilities as severe or worse than his. Long story short, because I was familiar with IDEA, and the school's principal was not, and she made some very offensive (and stupid) comments, that I happened to catch on tape (again, thanks to fellow special needs parents, I was recording the meeting), we won the battle. Jon attended our local school and was provided a 1:1 paraprofessional (aka, aide). He attended that school for six years, along with his typical peers, and was loved and cherished by most everyone. It is a success story. However, my dislike of IEP meetings began there, and continue to this day. The next reason I despise them, and this is the main reason my opinion has not changed, is that they do not work in the way they are intended. 
My worst memory of nursing school is nursing care plans. The countless nights spent sitting up until 2 am crafting care plans only to have the instructor to humiliate me by slicing, dicing, and tearing them apart three hours later, in front of classmates. The only saving grace was that the instructors were not picking on me, they thoroughly critiqued every student's care plans. It took me about six years of floor nursing to understand why on earth those care plans were so important in nursing school (hello, critical thinking!). I still, nineteen years later, do not understand how I learned better by being humiliated, but again, I will save that issue for another day. So, what are care plans? They are patient specific (remember the "I" in IEP?), care plans (goals) developed by nurses for each patient.
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| Google Search Results of "Nursing Care Plans" - Individualized? |
In viewing IEP's and care plans, and their lack of true intervention, I am left wondering why we do them at all, but I already know the answer; regulatory agencies and lawsuits. While I do understand that nursing care plans serve as an excellent educational tool that encourages critical thinking for the student, I fail to see where it benefits the individual patient on the typical inpatient unit.
A study published in the Journal of Gerontological Nursing shows that including family in the planning of patient care benefits the patient, family, and staff (Dijkstra, 2007). The family showed decreased anxiety, a better understanding of expected patient outcomes, and greater involvement in patient care when they were included in plans of care. The staff found that the family was able to offer information about the patient, such as typical or non-typical behaviors, and because they were interacting with family members, they had a greater and more accurate understanding of the patient in which to base the patient's care plan. The patient, of course, benefited because there was a fluid multidisciplinary approach to their plan of care. The staff did mention that the problem-focused style of care plans were a disadvantage because it did not enable them to focus on positive aspects of the patient's care.
While the above study was set in a nursing home, and focused on gerontological nursing, the same findings can be applied to any patient care area. When I worked inpatient rehabilitation, we had weekly interdisciplinary team meetings. The team consisted of everyone who took a part in caring for the patient (nurses, physicians, PT/OT/ST, social workers, nutritionists, chaplain, etc.). Because of the interdisciplinary approach taken with these patients, and the fact that the people actually providing care to the patient were at the meeting (instead of a care coordinator being the planner for all disciplines), these patients received the best care I have ever witnessed. Also fascinating is that while these patients had more disciplines working with them than most patients, the flow of care was rarely stressful or interrupted. Because of the weekly team meetings, everyone knew the plan, understood the reason for the plan, knew their part in assisting the patient to optimal health, and understood when and how each treatment would be administered. Following this interdisciplinary team meeting, the physician and at least one other representative from the team would meet with the parent(s) to update them on the plan of care and receive feedback from the family. While this type interdisciplinary team approach is absolutely vital for complex patients, there is no reason this type approach can not also be used for routine patients on an inpatient unit; a scaled down version. It is our duty as nurses to advocate for out patients. Assuring that vital information is shared throughout all disciplines of care, understanding the true needs of the patient and creating patient specific plans of care is vital to patient outcomes.
In another study to evaluate the realistic feasibility of carrying out patient care plans on a nursing ward, the author reflected, "In the observations, I was looking for instances of individualized care" (Waters & Easton,1999, p. 83). As I read that line, I felt a pang of guilt. Not because our care plans are standardized, but because the author went on to point out how our patient care is typically arranged around our schedules, rather than allowing flexibility for the patient's wants and needs. The author made a point to distinguish the written care plan from what we actually do; he noted that care is provided based on "knowing what to do" which is knowledge gained through education and experience. He noted that written care plans were rarely used by the staff caring for the patient, but were simply standardized plans that were routinely written out (often were not done by the care providers, but by a supervisor), with no regards to individualized patient assessment. Another finding of the study was that those who did in fact use the care plans to organize and assess patient needs, were most often nursing students. I had to smile as I read this, as it goes back to the critical thinking involved in care plans while in nursing school, as opposed to the robotic like clicking/writing most of us apply to care plans, after nursing school.
Studies on the effectiveness of parental/student involvement in the planning of a student's IEP have show that although this is legally required, and we want to believe this is what happens (because after all, the parent does receive the required letter stating the date and time of the meeting!), that in reality the involvement of the parent and student is passive (DeFur, 2010). The reasons for this passive participation are very similar to those reasons that families feel left out patient care plans: They feel the meetings are professionally driven, are unfamiliar with the lingo used, feel the environment is unwelcoming, and like me, feel that the process is documentation driven, rather than individualized focused with outcomes focused goals.
The state of IEP's or patient care plans are not the fault of those creating them, or charged with following them. Both documents, through the institutionalization process of education and healthcare, have become tools by which we document something to avoid litigation, or to be able to show patient or student progress. As parents, teachers, nurses, students, and citizens, we must find a way to integrate these meetings and documents into a realistic plan that we can use to assist our patients and students toward optimal outcomes. Perhaps it is time for all of us to step back and remember our care plans from nursing school, what they meant, or our teaching plans from undergrad school, and how they applied to our students, and step away from the documentation nightmare that our society has become. This may be the only way we can integrate these plans into our practices so that they serve the purpose they are intended to provide; individualized, goal oriented outcomes.
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