Does the Nursing Care Plan help in the management of psychiatric risk?

The Nursing Care Plan (NCP) is routinely used to direct the nursing care of psychiatric in-patients, but the impact of NCPs on patient care and clinical outcome is not firmly established. NCPs from 246 patients, chosen at random from admissions to acute psychiatric wards, were analysed. The NCPs were scored for quality and also specifically for the presence of recorded risk assessment and appropriate level of nursing supervision. NCPs were evaluated in relation to psychiatric risk factors present prior to admission, and in relation to risk behaviour during hospitalization. Quality of NCP records was generally poor, with scores in all areas assessed being approximately half of the possible maximum. Patients with a perceived high risk of suicide prior to admission had significantly better NCP quality than other patients, but about a third of these high risk patients had no recorded risk assessment or supervision level in the nursing notes. Patients who had actually self-harmed within 4 weeks prior to admission were more likely to have a recorded risk assessment but did not score more highly than the rest of the patient population on any other measures of NCP quality. Patients who had made suicidal threats prior to admission but who were not deemed to be of high suicide risk before admission had significantly lower quality NCPs and were less likely to have a record of supervision level than the rest of the patients. The highest rate of supervision records occurred in patients who had shown dangerous behaviour prior to admission. Outcome in terms of two risk behaviours during admission (self-harm and violence) was not related to whether or not risk assessment and supervision levels had been recorded. Patients admitted compulsorily to hospital were more likely to have a supervision level recorded but were also more likely to abscond. It is concluded that issues of psychiatric risk were not adequately addressed in this sample of NCPs. Furthermore, the data raise serious questions about the usefulness of the NCP in helping to predict and prevent risky behaviour amongst psychiatric in-patients.