Exploring documentation in Person-centred care: A content analysis of care plans.
Doris Lydahl, Nicky Britten, Axel Wolf and 3 others
PMID 35393772WHAT IT FOUND
Care plans for older people with heart attacks or angina drifted from personal goals to guideline medical goals over eight weeks.
Nurses should re-ask about life-world goals and resources at each handover, not assume the first plan still matches the patient.
Key findings
01Across hospital, outpatient and primary-care care plans, life-world goals fell from 56 to 32, while medical/health goals rose from 28 to 40.
02Patient resources followed the same shift: life-world resources fell from 48 to 23, while medical/health resources rose from 36 to 46.
03The care plans were written by registered nurses, and the paper found no indication patients confirmed the stated goals.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The plans came from an RCT intervention arm written by nurses trained in person-centred care, so they may not show what happens in usual care. Five of 89 patients' care plans were missing, and 84 patients with 252 plans were analysed. The study had only the care plans, not interviews with patients or nurses, so it cannot say why the documentation shifted. There was no indication patients confirmed the goals, so the notes may reflect nurses' interpretation rather than patients' own words.
Declared interests
The authors declare no conflict of interest.
The easy way to misread this
Do not read the drop in life-world goals as proof patients stopped caring about them. The care plans were written by trained nurses, and the paper found no indication patients confirmed the goals.