161. CCA Study Notes: The Care-Planning Process and the Support Worker’s Role

The Big Picture

Care in a facility follows an organized process. The health care team gathers information, identifies needs, sets goals, carries out planned care, and checks the client’s progress.

Support workers take part throughout this process. What support workers notice about the client provides important information to the team. They also provide assigned care and report and record what they do and observe.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

The Five Steps of the Care-Planning Process

The care-planning process, also called the nursing process, is the method nurses use in facilities to plan and deliver care. Its purpose is to meet the client’s needs for care and support.

The five steps are:

1. Assessment
2. Nursing diagnosis
3. Planning
4. Implementation
5. Evaluation

Some facilities and agencies use a client-centred approach. This approach involves the client more closely and also includes other health care providers, including support workers, throughout the care-planning process.

1. Assessment

Assessment means evaluating information collected about the client through observation, reflection, and communication.

In some facilities, the team leader or primary care nurse makes sure the client’s emotional, social, intellectual, and spiritual health has been assessed and documented.

A regulated professional ⓘ performs the client’s formal physical assessment. Support workers have a different role.

Support workers are responsible for:

• observing clients
• making basic assessments
• reporting their findings according to agency policy
• recording their findings according to agency policy

Observation means actively using the senses to gather information about the client’s current condition.

The team leader gathers information from different sources, including other members of the health care team. Depending on the facility or agency, the team leader may be a nurse, social worker, or caseworker.

After the assessment is complete, team members gather to set goals for the client. The client and the client’s family are included in this process.

2. Nursing Diagnosis

The nurse uses information from the assessment to make a nursing diagnosis.

A client may have a specific health issue or be at risk of developing a health challenge. A client may also have more than one health challenge and more than one nursing diagnosis.

A nursing diagnosis describes a health problem treated by nursing measures. Nurses make nursing diagnoses and consider the whole client when doing so.

Examples include:

• low self-esteem
• social isolation
• spiritual distress

Most Canadian nurses use nursing diagnoses from the North American Nursing Diagnosis Association, or NANDA, or from similar diagnosis lists.

Support worker observations and basic assessments are important at this stage. Support workers must report their information so the nurse has as much information as possible when determining the care plan.

Nursing Diagnosis and Medical Diagnosis Are Different

A medical diagnosis identifies a disease or condition. A physician or nurse practitioner makes a medical diagnosis.

Examples include:

• cancer
• pneumonia
• bipolar disorder
• stroke
• heart attack
• acquired immune deficiency syndrome, AIDS
• diabetes

Medications, therapies, and surgery for diseases or other medical conditions are ordered only by physicians or nurse practitioners.

A nursing diagnosis describes a health problem treated by nursing measures. Only nurses make nursing diagnoses.

Medical Diagnosis	Nursing Diagnosis
Identifies a disease or condition	Describes a health problem treated by nursing measures
Made by a physician or nurse practitioner	Made only by a nurse
Examples include pneumonia or diabetes	Examples include social isolation or spiritual distress

3. Planning

Planning means setting priorities and goals and developing actions that help the client meet those goals.

Planning includes three main parts:

1. establishing priorities
2. setting goals
3. determining interventions

The team also establishes the care plan.

Establishing Priorities

The client’s needs are discussed by:

• the client
• the nurse
• the family or loved ones, when involved
• the health care team, including support workers

Together, they decide on the client’s priorities. They may use Maslow’s hierarchy of needs ⓘ when setting priorities.

Setting Goals

After everyone involved agrees on the priorities, the team discusses goals for the client’s care. In some situations, this discussion involves only the client and the health care team.

Goals should be:

• practical
• achievable
• measurable
• linked to a specific time for evaluating results

If the client does not meet a goal by the agreed date, the client must be the first person consulted when establishing a more realistic goal. The team should then develop a plan to help the client meet the new goal.

SMART Goals

SMART is one way to remember important features of client-care goals.

• Specific: The goal is simple enough to understand and centres on the individual client. Example: the client will grasp a tennis ball with the affected hand.
• Measurable: The team must be able to evaluate whether the goal has been met or is being met. Example: walk 10 steps two times a day.
• Achievable: The client must be able to attain the goal. Example: the client will pick up a fork with the affected hand.
• Realistic: The goal must be reasonable for the client. Example: the client will reach the end of the corridor using a walker.
• Time-framed: The goal must include a time limit for checking the client’s progress. Example: the client will complete the stated goal after 3 days.

RUMBA Goals

RUMBA is another way to remember important features of client-care goals.

• Realistic: The goal is reasonable for the client to attain.
• Understandable: The goal is simple enough to understand and centres on the individual client.
• Measurable: The team is able to evaluate whether the goal has been met or is being met.
• Behaviourable: The goal describes the client’s behaviour. For example, “The client will walk…” rather than “The staff will walk with the client….”
• Achievable: The goal is attainable by the client.

SMART and RUMBA share several ideas, including realistic, measurable, and achievable goals.

Determining Interventions

After goals are set, the team discusses interventions.

An intervention is an action or measure taken by the health care team to help the client meet a goal.

For example, a physician or nurse practitioner may order that a client walk 100 metres twice a day. The nurse then includes that order in the care plan so the health care team follows it.

Establishing the Care Plan

A care plan is a document that details the care and services the client must receive during each shift.

Facilities use different systems to provide this information. Some still use a Kardex ⓘ or paper system. Most use a computer-generated care plan.

The care plan includes:

• the client’s diagnosis
• the client’s goals
• the interventions required to meet each goal

The care plan serves several important functions.

It lists the care and services the client must receive. It also helps keep care consistent, even when different people provide it.

The care plan also helps the health care team communicate details about the client’s care.

Care Plans Change as the Client’s Needs Change

A care plan is not a finished document. The team continually reviews and revises it based on the client’s needs, condition, and progress.

Usually, only the case manager, who has overall responsibility for the client’s care, makes changes to the care plan.

Support workers provide important information about changes in the client. Their observations of the client’s abilities and needs may alert the case manager that further assessment or a care-plan change is required.

4. Implementation

Implementation means carrying out or performing an action. During this stage, the actions listed in the care plan take place.

The nurse in charge assigns or delegates tasks to health care team members.

As a support worker, you are only assigned or delegated tasks that fall within the legal limits of your role and job description.

The nurse communicates assigned or delegated tasks according to facility or agency policy. This communication tells the support worker which tasks to perform for each client.

Four Main Functions of Implementation

Implementation has four main functions:

1. Provide the care.
2. Observe the client during the care.
3. Report and record that the care has been completed.
4. Report and record observations made during the care.

Observing the client is an important part of implementation.

After completing care, support workers must report and record their actions and observations according to employer policy.

5. Evaluation

Evaluation means assessing and measuring the client’s progress toward the goals agreed on by the team.

A goal may be:

• completely met
• partly met
• not met at all

The nurse assesses why a client has made only partial progress or no progress toward a goal.

Support worker observations help the nurse decide whether interventions need to change, whether further assessments are needed, and whether the care plan needs to be altered.

Changes to the care plan are made in consultation with:

• the client
• family members
• other members of the health care team

Team meetings take place according to facility or agency policy. The team uses these meetings to share information, set or change goals, and suggest changes to the client’s care.

Support workers are important team members because they spend a great deal of time with clients.

The Support Worker’s Role Across the Process

Support workers contribute important information throughout care planning.

Their role includes:

• observing clients and making basic assessments
• reporting and recording findings according to policy
• contributing information when client needs, priorities, and goals are discussed
• carrying out assigned or delegated tasks within the legal limits of the support worker’s role and job description
• observing clients during care and reporting and recording completed care and observations
• providing observations that help the team evaluate the client’s progress

Role limit: A regulated professional performs a formal physical assessment. Nurses make nursing diagnoses. Physicians or nurse practitioners make medical diagnoses and order medications, therapies, and surgery.

Role limit: Support workers provide observations and information about changes in the client, but usually only the case manager changes the care plan.

Common Mix-Ups

Wrong Idea	Better Idea
A nursing diagnosis and medical diagnosis mean the same thing.	A medical diagnosis identifies a disease or condition. A nursing diagnosis describes a health problem treated by nursing measures.
A support worker performs the formal physical assessment.	A regulated professional performs the formal physical assessment. The support worker observes and makes basic assessments.
The support worker makes nursing diagnoses.	Only nurses make nursing diagnoses.
The support worker changes the care plan when the client changes.	The support worker reports observations. Usually, only the case manager changes the care plan.
Implementation means only providing care.	Implementation also includes observing, reporting, and recording.