Risk Assessment and Care Planning

1. Risk Assessment and Care Planning

2. Principles of care planning • Complete the care plan with the patient whenever possible.Use the patients own words, whatever they are. Good as a baseline to show the patient later on when there has been some improvement. • Gather all relevant information from the patient, their relatives, their notes and previous health care professionals • Keep the language simple and jargon free • Identify a clear goal with clear steps (interventions) aimed at reaching the goal • Make all the interventions SMART. • Specific • Measureable • Attainable • Realistic • Time orientated

3. Nursing Process Nursing Process Complete specific assessment tools with the patient. Develop a plan based on the assessments. Ensure the interventions are SMART, and address any of the concerns raised in the assessment process. Implement the interventions, and record the outcomes, evaluate the plan and make any changes based on the daily outcomes. • Assess • Plan • Implement • Evaluate

4. Nursing Care Planning Process Risk Assessment linked to care plan What worked, what didn’t work, reassess….. Clear, SMART interventions identified

5. The process of completing an assessment and care plan. • The trust uses many different assessment tools to gather the correct information about a persons mental and physical health, social and spiritual well being. • Some tools are specific to certain areas such as Falls Assessment and the HCR 20. • The information collected needs to be discussed with the health care team and the patient, and a care plan can then be formulated. • It is important to recognise clinicians intuition whilst assessing a patient and their ‘gut feeling’ which may be difficult to articulate, however this should also be recorded in the assessment and form part of the care plan.

6. Planning the care from the Risk Assessments • This needs to be completed as much as possible with the patient • Conversation about the risk assessments and the findings need to take place within the health care team. • Clear decisions need to be taken about levels of risk, and this must be effectively communicated both in writing on RIO and verbally to all staff during regular hangovers. • Identify the goal of the care plan and keep the language clear and jargon free. • Regular updates must be completed on RIO to ensure effective communication about levels of risk.

7. Guidelines: Documenting Nursing Care ACTION RATIONALE To distinguish between observation and interpretation To ensure reliable transmission of information and instructions So that it is clear what is an observation and what is an inference by the nurse Such phrases may be misleading, and could lead to mistaken decisions about nursing care and management. • Where possible patients are quoted verbatim • Management decisions and discussions are recorded as they happen. • Description of a patients actual behaviour is recorded separately from interpretations of the behaviour. For example. At 11.15 Tony ran out of the lounge area slamming the door; Tony seemed angry about the TV channel being changed. • Catch phrases, such as ‘slept well ‘are avoided in favour of precise description. For example Sam took his medication at 22.15. He went to bed at 23.00 and slept until 7.00a.m

8. Documenting Nursing Care…continued • Nurses record group activities and processes in the ward/ unit. • Nursing documentation keeps up to date information concerning patients. • The documentation provides a professionally robust record. • To ensure all of the patients behaviours are recorded. • To facilitate the transfer of responsibility for the care of patients. For example on transfer or discharge. • To facilitate retrospective inquiry.

9. Progress notes • Link to the care plan, for example, if building a trusting relationship is one of the goals • Write down what you did to enable this to happen… For example. I stayed in Johns room for 10 minutes letting him know that I was there to listen to him and help him if I could. • John might have had his back to me for the whole time in the room under his bed covers, but as part of the Trust building process I was letting him know I was not going to leave him. This was repeated twice every hour. (SMART) • Evaluate at the end of the shift, with the team, see what has worked and rewrite the care plan accordingly.

10. Person Centred Care Respecting people’s values and putting people at the centre of careTaking into account people’s preferences and expressed needsCo-ordinating and integrating careWorking together to make sure there is good communication, information and educationMaking sure people are physically comfortable and safeEnsuring emotional support is availableInvolving family and friendsMaking sure there is continuity between and within servicesand making sure people have access to appropriate care when they need it.

11. Person Centred Care. • Reviews of research about this topic found that offering care in a more person-centred way usually improves outcomes. (Olsen at al 2013)

12. Audit tool care planning standards. • Is there a care plan in place for any identified risks? • Is medication included in care plan? • Does the care plan include at least 2 patient-defined personal outcomes or goals? • Does the care plan state what support is require to achieve outcomes or goals? • Have goals been reviewed in the last care review/CPA meeting? • Are service user and clinician defined care plans SMART? • Does care plan include both long and short term goals? (Long term goals include education, interpersonal relationships, employment and occupation. Short term goals link to long term goals or are steps to achieve them) • Has care plan been updated since last care review/ward round/CPA meeting? (or indication is made in progress notes that there has been no change/progress in patients problems) • Has a copy of the most recent care plan / CPA /treatment plan been offered to the patient (or carer if patient lacks capacity) ? • Does the crisis plan include out of hours contact details? • Does the crisis plan include individualised plans to manage escalating stages of deterioration? • Is there a contingency plan? (if this is the same as the crisis plan, tick NO) • If yes, is it recorded clearly in their CPA documentation that they are entitled to support under section 117 of the Mental Health Act?

13. Areas we can work on… • When nursing care is observed we see excellent, skilled communication, compassion, support, education, empathy and humour, to mention just a few of the numerous interactions and interventions that take place day to day within all services. • When we read the nursing care plans they often do not reflect what nurses are actually doing to help facilitate a patients recovery. • Taking some of the principles from good care planning and person centred care, develop the care plan with the patient, as much as you can, in itself it then becomes a therapeutic intervention. • Use the audit tool to identify areas that need further work.

14. References • Mein- Johansson.C et al. ( 2017). Clinical Intuition in the nursing process and decision making. A mixed studies review. Journal of clinical nursing. Dec 26 (23-24) • Stein-Parbury.J.(1993) Patient And Person. Churchill Livingstone Press. • Olsson LE, JakobssonUng E, Swedberg K, Ekman I. Efficacy of person-centred care as an intervention in controlled trials – a systematic review. J ClinNurs 2013;22(3-4):456-465.