The development of the plan or the strategies of action prescribed by the professional registered nurse (RN) is a foundational obligation of responsibility and accountability to the patient (ANA, 2001, 2010). The plan is the recorded document of the nurse’s planned or intended course of action to provide professional nursing care to the healthcare consumer to help achieve the outcomes identified in the third step of the nursing process. This planning and the record of it are requirements of the regulatory agencies overseeing the provision of care to every patient in an accredited facility. The documentation of the planning is often referred to as a care plan, or a plan of care.

Three elements precede the planning of strategies for interventions: assessment, diagnosis, and identification of outcomes (see previous chapters). Each of the preceding phases in the nursing process contributes in a unique way to the planning phase. If not approached accurately and systematically, the plan may not be individualized or appropriate, and it may not directly target interventions that will contribute to high-quality patient outcomes. In
the definition of nursing, two elements support the planning phase of care (ANA, 2010, p. 9):

Planning is the cognitive integrative process that relies on the previous steps and is characterized in the standards as a prescription of strategies. A strategy is an approach—a broader view—whereas a tactic is one specific action—an intervention or action for treatment. Planning is the keystone that unifies the initial interface between the nurse and the patient whereby they achieve the expected short-term or long-term outcomes of care. The planning phase is the critical cognitive aspect that prescribes the approach that comprises a set of interventions or treatments; it establishes the blueprint or is the “game-plan.” To establish this plan, the nurse must critically think through an array of nursing approaches or interventions by considering, judging, accepting or rejecting, prioritizing, selecting, and organizing the interventions specific to the patient at that time.

This reasoning process is intangible and is based on the nurse’s personal levels of knowledge, experience, and intuition, as well as the ability to execute psychomotor and psychosocial interventions, either alone or along with a mul-tiskilled team. Inherent in this reasoning is the nurse’s anticipation or projection of the effect of the interventions on the patient’s condition—a focus on the outcomes. As a patient’s condition changes, new assessment data inform the nurse to revise the planning and strategy selection for interventions that will meet the new needs. The plan and planning can be in constant change as priorities emerge.

The documentation of the planning phase relies on the standardized nursing terminologies and languages, such as those of the Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC) (University of Iowa, 2011). Those taxonomies are readily available and are part of content material in general fundamentals textbooks and courses (Craven & Hirnle, 2007). The plan is documented in the patient’s permanent record to inform the interprofessional team members, including the patient, about the plan of action.

The complexity of this phase must be emphasized. In this phase, streams of factors intersect to create a unique plan to protect, promote, and optimize the health and abilities of an individual. The factors in planning are nurse-related, patient-based, resource-based, evidence-based, and environmental. Care planning
is not static, but dynamic. Change occurs as the nurse matures along the novice-to-expert continuum of clinical practice (Benner, 1984), and the patient’s status fluctuates acutely or imperceptibly along the wellness-illness continuum. The nurse’s ability to create individualized planning improves as maturity

Beyond physiologic changes, characteristics of the patient that affect the plan are level of ability; engagement, motivation, and despair; communication literacy; and support from significant others. Intersecting those dynamic continuums are resource factors that may affect the delivery of care designed within the care plan, such as the skill mix of assistive personnel, available supplies and equipment, availability of clinical experts, and unit support structure. The environment of care factors is the geographic design of the nursing unit, the levels of noise, the lighting, the available technology, and others. There is a continual state of inquiry in healthcare practice and delivery; knowledge is continuously being challenged. The nurse is the knowledge resource at the bedside and must translate evidence-proven research to practice the best in the art and science of nursing. The nurse must learn and renew knowledge through lifelong learning in planning and delivering nursing care.

As the nurse gains clinical practice experience, the nurse is better able to sort and filter information rapidly and more precisely. This information may be from the nurse’s assessment of the patient or from assessments by clinical colleagues, which are communicated in the shift report through an SBAR (situation, background, assessment, recommendation report), in medical record documentation, or from the patient and family. In the past, the strategy for selecting interventions to achieve the expected outcome regularly relied on the nurse’s memory and experience with interventions and might have included interventions that were not proven effective in care delivery. Currently, reliance on accepted evidence-based practices, use of collaboratively created critical pathways, incorporation of care taxonomies, and use of available computer technology allow more options for the nurse to select from, thus resulting in increased varieties of interventions (Clancy, Delaney, Morrison, & Gunn, 2006).

The norm today is for use of care plans that are the outcomes of collaborative efforts by interprofessional teams, and the planning enhances continuity of care. As each nurse accepts the responsibility for a patient’s care, either in a shift bedside report or at a point of entry into the healthcare system, the tandem responsibility is to plan, communicate, and record the individualized care strategies. This endeavor is accomplished by beginning an assessment and moving the process forward to the planning phase. The nurse can review the patient’s previous plan and accept or confirm it. Or the nurse can modify the plan so that it remains unique and individualized for the patient at this time. The nurse must actively determine—that is, plan—the strategies and then the interventions necessary to achieve the expected outcomes for the individual. The nurse individualizes the projected outcomes for the patient.

The National Council of State Boards of Nursing (NCSBN), which develops and administers the national licensure examination (NCLEX), tests the integration of nursing material. Skill in planning is essential because as many as 22% of NCLEX test items focus on client management of care (NCSBN, 2009, p. 4). The planning standard of practice (ANA, 2010) provides suggestions for the strategies to address each of the identified diagnoses or issues: