Multi-disciplinary care plans--a key to reclaiming nursing passion: overworked nurses need to work in partnership with their clients, their families and other health professionals, developing with them goals of wellness and rehabilitation. These goals are best recorded in o client-held, multi-disciplinary care plan, a mark of true professionalism.

The nursing profession is in disarray, judging by the stories one hears regularly of advanced practitioners and nursing leaders leaving nursing, disillusioned and burnt out. I myself resigned from my clinical leader role at Waikato District Health Board (DHB) over a year ago, when I felt my efforts to promote quality practice were being met with resistance and undermining. It seems professional standards, client-centred care, job satisfaction and collegiality are being lost in the scurry to cope with unrealistic, everyday workloads.

I believe we need to adapt the nursing process to be relevant to today's world, without compromising our professional standards. This is where client-held, multi-disciplinary care plans come into their own. These are essentially nursing care plans, that include client and other service or team member input, and are particularly relevant to primary health and secondary community-based care.

To begin, we need to carry out an holistic assessment, because our clients are people ... and individuals. This is the only credible foundation for safe practice. The next stages of the nursing process is planning, implementation and evaluation, ie the development of a care plan. Before embarking on this plan, we need to challenge ourselves and examine our way of relating with our colleagues and clients. Do we build healthy team relationships based on equity, respect, support, reflective listening, valuing diversity, etc? And do we stay focused on the professional issues, not the personal? This will help us identify our internalised beliefs and habitual behaviours that may limit our working relationships.

The nursing process also needs to evolve with the times, and aspects of it need updating to today's nursing, political and social environments. Over the past decade or so, nursing theory and health policy have been moving away from sickness orientation towards wellness, from problem diagnosis to support needs analysis, and from dependency to empowerment. Alongside this, the public has grown to expect information, the right to informed consent, partnership in all aspects of care delivery, and choices in service providers around their health needs. These changes have occurred for varying reasons--some constructive and others from necessity. Whatever the reason, New Zealand can no longer afford a dependency model of health care--financially or socially--and successive governments have been retracting funding so that rapid patient turnover and early discharge have become a way of life. Nurses cannot cope emotionally or practically in this environment, especially with current staffing shortages, unless they can let go of the dependency model of health care delivery. This is where the nurse or other health professional is seen as the expert, with the client totally dependent on the professionals advice and knowledge.

My suggestion is to turn this crisis into an opportunity for developing creative reform. Many nurses recognise the benefits of working with clients in equal partnership towards goals of wellness, rehabilitation and empowerment, and nursing leadership needs to be developing models of practice that preserve the integrity of the nursing process. Client-held, multidisciplinary care plans is one such model.

Beginning with the client and family

Mindless, task performance is not an option, and not the action of a professional Care planning begins with client and nurse, and significant others/whanau as desired by the client, reviewing the holistic assessment and negotiating the overall goal for them to work towards. This is an appropriate, achievable and measurable potential for wellness for that individual client, but is expressed in everyday language. For example, for the accident or surgical client: "B's wounds will heal so he can return to work within six weeks"; or for the cardiac client: "C will regain full independence with daily living within eight weeks"; or the elderly client who may be becoming increasingly frail:

"T wishes to continue living in her own home while still safe and able to do so with support. Review monthly." Palliative and terminal clients can still set positive goals towards wellness around comfort, dignity, etc and can benefit from this process.

Client-centred support needs

The next plan of the nursing process is normally to formulate nursing diagnoses and problem identification. However, by taking these one step further, we can rephrase them as client-centred support needs, agreed to by both client and practitioner. This not only reframes client's needs positively towards their overall goal, but aligns the process more towards a partnership model of health care. A positively focused support need allows the client to retain their power, is more likely to engage their will and hence compliance, and makes for a subtle shift in responsibility of the partnership. These support needs also need to be written in everyday language. The client retains a copy of the care plan, which further reinforces their "ownership" For example, for "T" above, whose goal is 'to remain living in her own home while still safe and able to do so with support", we would then discuss what support she needed to achieve the goal Where once we might have written a nursing diagnosis around "deficit in mobility and/or balance, and potential for falls", we can now reframe this as "support to be able to walk indoors/outdoors safely to meet the needs of her everyday living".

Identifying agreed actions

The next stage involves identifying the actions to achieve this outcome. These further expand the partnership commitment by listing the mutually agreed actions of all parties--the client, nurse and significant others. As the client retains the central copy (ie a carbon copy of the original), it can then be added to by other disciplines, and is accessible by all. This is particularly useful in the community, where various private health practitioners, support agencies and DHB multi-disciplinary team members may be involved in the client's care. Each addition to the care plan helps build a picture of support towards the client goal and all participants must follow the same process of negotiation and consent (by signature) with the client.

The agreed actions not only include practitioners' interventions (assessments, monitoring, treatments, liaison, referrals, education etc), but also those of the client and significant others. These may include healthy living changes leg cessation of smoking, dietary changes), commitment to physiotherapy programmes, elevation or splinting of limbs, use of crutches, taking prescribed medication, self-monitoring leg blood glucose levels, wound drainage) and self-care or family support. Outcomes are reviewed according to the time frame of the goal or when significant change or achievement occurs. These need to be dated and signed by the client and practitioner.

A record of information

Practitioners can then include in their discipline's file, brief notes as relevant to each visit. These are preferably written in the client's presence. A brightly coloured file cover can be provided for the client's copy, so clients can readily find it, and for storage of other relevant health information, eg client appointments, exercise or dietary advice, medication sheets, service provider information, health and disability rights pamphlet, etc. A front sheet with each practitioner's name, role and contact numbers is also useful, as many people get confused with who's who, and what they do. The primary caregiver, who is often a nurse, may be identified as the key practitioner who initiates and oversees the overall package of care.

A living contract of care

Client-held multi-disciplinary care plans are primarily about supporting our clients and each other in meeting client needs, but become more than that. They are a living contract of care that records planning, delivery and evaluation, throughout the duration of service. I believe they meet all professional practice and service delivery standards and support nurses in documenting this, be it for accreditation, performance appraisal or career pathway purposes. Nursing care plans have traditionally been viewed by some practitioners as rather wordy, academic exercises that are irrelevant to everyday practice. Consequently they have either been done poorly, or not at all. Worse still, with today's current workload pressures, there are those who have regressed to writing delegated "task sheets" listing what is to be "done to" clients, which bear no resemblance to the negotiated, individual care planning that is required for safe, professional nursing practice. These actions undermine our professional process, and render nurses to the level of lay practice.

If nursing is to survive as a profession, it is essential that the nursing process be preserved and applied in practice. Reclaiming it not only supports our safety of practice, which is under threat in the current health service environment, but it can in fact improve care standards for our clients when adapted in this way. Meanwhile, we as nurses also need to reflect on, and acknowledge our responsibilities for the current scenario. We can change and we are certainly not powerless, if we work together. I hope this article may trigger informed and constructive debate among nurses, whatever field you work in, about how we can protect ourselves, each other, and our professional processes and practice in today's health climate. Hopefully it will provoke debate that will support empowerment for nurses. We need to work together to defend our colleagues and professional boundaries, rebuild our inner strength, and reclaim our passion and pride in our work.

This article was reviewed by Kai Tiaki Nursing New Zealand's editorial review committee in September last year.

Liz Allen, RN, Cert Rural Health, was working for Waikato District Health Board as a district nurse clinical leader when she wrote this article last year. She now lives in Northland, working three days a week as a diabetes nurse and spending the rest doing gardening and lawnmowing. The pay rate for the latter is the same as for senior nursing clinicians, she says, but without the stress.