Noa Mbunya

Nursing Care Plans: Documenting Nursing Care Noa Mbunya

Documenting nursing care provided to patients is an essential component of the nursing profession and it is best achieved through a nursing care plan. A nursing care plan is used to document and communicate nursing care. In the care of patients, each patient is regarded as unique. Therefore, a care plan demonstrates individualized patient care that is, care based upon changing and revised patient needs and coping abilities reflected in diagnoses, goals and interventions in the physical, psychological and socio-cultural areas of functioning. Furthermore, it helps professional nursing staffs to refine their understanding of nursing diagnoses and charting skills, to identify nursing problems in need of care and propose appropriate care plans. Despite the aforesaid advantages, nursing care plans remain largely unutilized by nurses in many healthcare institutions. This study sought to identify those factors (nursing work characteristics, nurse? characteristics, nursing administration characteristics, and care plan characteristics) that hinder nurses from using nursing care plans. This will help the nursing fraternity to improve documenting care in nursing care plans.