Regardless of where registered nurses (RNs) practise, they are accountable to create a nursing plan of care. The nursing plan of care starts with an assessment of the client and identifies their needs, preferences and abilities and provides a benchmark for ongoing monitoring of their health status including presenting signs and symptoms. It provides the nursing team with the health and social history required for development of a comprehensive plan of care, which includes the discharge plan for that client (Standard 2.3). It also provides the RN with the foundation to work collaboratively with other health care team members and to coordinate client care.
A vital component of the nursing assessment is an assessment of the social determinants of health. The social determinants of health include income, spirituality, housing, food security, social supports, etc. When RNs complete a nursing assessment, they must include the determinants of health regardless of their practice setting in order to create a more comprehensive nursing plan of care based on the client’s individual needs and preferences.
When caring for clients in a variety of settings, including clients in a hospital setting, the information gathered during the nursing assessment supports the creation of a discharge plan that better meets each client’s unique needs.
For example, if an RN determines that a client cannot access services (i.e. physiotherapy) and treatments (i.e. medications) outlined in the medical plan of care because of their financial situation , these challenges could be identified in the nursing plan of care and a discharge plan may be put in place to better support the client. In this example, nursing interventions in the plan of care may include:
- Collaboration with the physician related to the medical plan of care on the discharge plan;
- Collaboration with the social worker to determine if the client qualifies for assistance in obtaining services;
- Collaboration with the inpatient physiotherapist to determine a reasonable discharge treatment plan;
- Collaboration with the pharmacist to determine if the client could be prescribed a more financially accessible medication;
- Collaborating with the client to assist in identifying the social supports that family and friends may be able to provide.
Including the social determinants of health in the assessment and establishment of nursing interventions is a vital role for RNs and represent RNs working to an optimal scope of practice. For more information on the role of the RN in nursing assessment, the nursing plan of care or care coordination, please access the CRNNS Nursing Plan of Care Practice Guideline or contact a CRNNS Practice Consultant at email@example.com.