The following standards of practice and performance are adapted from the American Nurses Association 2010 Nursing: Scope and Standards of Practice, Second Edition.
Standard 1. Assessment
The Nurse Life Care Planner performs comprehensive data collection pertinent to the healthcare consumer’s health and unique situation.
Competencies: The Nurse Life Care Planner:
• Collects comprehensive data including but not limited to physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic assessments in a systematic and ongoing process while honoring the uniqueness of the person.
• Assesses any existing plan of care.
• Analyzes current plan of care for adherence to current standards and clinical guidelines.
• Elicits the healthcare consumer’s values, preferences, expressed needs, and knowledge of the healthcare situation when possible and as appropriate.
• Includes the healthcare consumer, family, and healthcare providers in data collection when possible and as appropriate.
• Identifies barriers (e.g., psychosocial, literacy, financial, cultural) to effective communication and makes appropriate adaptations.
• Identifies unwarranted or unwanted treatment and causes of healthcare consumer suffering in the current plan of care.
• Recognizes the impact of personal attitudes, values, and beliefs.
• Assesses family dynamics and impact on healthcare consumer health and wellness.
• Prioritizes data collection based on the healthcare consumer’s history, current condition and anticipated needs or situation.
• Uses appropriate evidence-based assessment techniques, instruments, and tools.
• Analyzes data and information to prescribe necessary system and community support measures, e.g., home modifications, nursing care, counseling.
• Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances.
• Applies ethical, legal, and privacy guidelines and policies to the collection, maintenance, use, and dissemination of data and information.
• Recognizes healthcare consumers as unique sources of information on their own
health.
• Documents relevant data in a retrievable format.
Standard 2. Diagnosis
The Nurse Life Care Planner analyzes assessment data to determine diagnoses and issues.
Competencies: The Nurse Life Care Planner:
• Derives diagnoses and issues based on assessment data
• Validates the diagnoses or issues with the healthcare consumer, family, and other healthcare providers when possible and appropriate.
• Identifies actual and potential risks to the healthcare consumer’s health, safety, and barriers to health, including but not limited to interpersonal, systematic, and
environmental circumstances.
• Uses standardized classification systems and clinical decision support tools, when available, in identifying diagnoses.
• Documents diagnoses and issues in a way that makes it possible to identify expected outcomes, establish priorities, and develop the Life Care Plan.
Standard 3. Outcomes Identification
The Nurse Life Care Planner identifies expected outcomes for a Life Care Plan individualized to the healthcare consumer or situation.
Competencies: The Nurse Life Care Planner:
• Involves the individual, family, healthcare providers, and others, when possible and appropriate, in formulating expected outcomes.
• Develops culturally appropriate outcomes. For example, referrals to providers with similar language and culture whenever possible.
• Considers the healthcare consumer’s age, developmental stage, values and culture, ethical considerations, and environment when formulating expected outcomes. For example, a child with life-long needs receives age-appropriate occupational therapy in the home, community, or facility appropriate setting
• Derives realistic outcomes for potential functional, emotional, and developmental capabilities. For example, the plan prescribes appropriate nursing care
configuration based on functional potential over life expectancy.
• Considers associated risks, benefits, costs, current scientific evidence, expected trajectory for the condition, and clinical expertise. For example, the patient/family voices understanding of the plan for long-term health maintenance needs, including follow up and treatment with specialists and therapists.
• Includes realistic timeframe estimates for attainment of expected outcomes.
• Derives expected outcomes that provide direction for continuity of care. The plan includes a long-term health maintenance plan that emphasizes continuity of care over life expectancy.
• Modifies expected outcomes according to changes in the status of the healthcare consumer or evaluation of the situation.
• Documents expected outcomes as measurable goals.
Standard 4. Planning
The Nurse Life Care Planner develops a plan that prescribes strategies, interventions, and alternatives to attain projected outcomes.
Competencies: The Nurse Life Care Planner develops a plan that:
• Provides direction to the healthcare team and consumer.
• Reflects current statutes, standards, rules, and regulations.
• Considers the individual’s characteristics and situation, including, but not limited to, values, beliefs, spiritual and health practices, preferences, choices, developmental level, coping style, culture and environment, and available technology.
• Explores suggested, potential, and alternative options and establishes the plan’s priorities with the healthcare consumer, health care providers, and others as possible and appropriate.
• Integrates traditional and complementary health care practices as appropriate.
• Includes strategies that address each identified diagnosis or issue across the lifespan, e.g., probable future needs; strategies for health promotion and/or restoration; illness, injury, and disease prevention; alleviation of suffering;
supportive care for end of life.
• Provides for continuity.
• Incorporates an implementation pathway or timeline, i.e., frequency of need.
• Includes an analysis of the economic effect on the healthcare consumer, family, caregivers, or other affected parties.
• Integrates current scientific evidence, trends and research.
• Provides alternatives, associated costs, and benefits.
• Can be modified according to ongoing assessment of response and other outcome indicators as indicated.
• Documents the plan that uses standardized language or recognized terminology.
Standard 5. Implementation
The Nurse Life Care Planner provides for implementation of the plan.
Competencies: The Nurse Life Care Planner:
• Recognizes and uses technology, community resources, and systems as appropriate.
• Recommends evidence-based interventions, treatments, and strategies specific to diagnoses and issues.
• Consults with others as appropriate.
• Recommends implementation methods and manner.
• Modifies the plan if indicated.
• Provides for holistic care that addresses the needs of diverse populations across the lifespan.
• Provides for health care that is sensitive to individual needs, with particular emphasis on the needs of diverse populations.
• Applies appropriate knowledge of major health problems and cultural diversity in providing for the plan of care.
• Provides for available healthcare technologies to maximize access and optimize outcomes for healthcare consumers.
Standard 5A. Coordination of Care
The Nurse Life Care Planner provides for coordination of the planned care and services throughout the lifespan.
Competencies: The Nurse Life Care Planner:
• Organizes the components of the plan.
• Recommends a nurse case manager and/or qualified other(s) to implement the plan, manage transitions of care delivery, and provide for dignified and humane care by the interprofessional team.
• Assists the healthcare consumer in identifying options for alternative care.
• Incorporates services that maximize safety, independence, and quality of life.
• Advocates for the delivery of dignified and humane care by the interprofessional team.
• Documents decisions and actions related to coordination of care.
Standard 5B. Health Teaching and Health Promotion
The Nurse Life Care Planner employs strategies to promote health and safety.
Competencies: The Nurse Life Care Planner:
• Addresses health and safety issues using data collected in the assessment, diagnosis, and planning processes.
• Provides for health teaching to address such topics as healthy lifestyles, risk-reducing behaviors, developmental needs, activities of daily living, restorative measures, intended effects and potential adverse effects of proposed therapies, and preventive care.
• Provides for health teaching methods taking into account values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status.
• Provides for health promotion and maintenance, for example, weight loss, smoking cessation, support group participation, or exercise programs.
• Provides for education about informed decision-making related to plan options
Standard 5C. Consultation
The Nurse Life Care Planner provides consultation to evaluate, develop, and influence the plan of care, enhance others’ ability, and effect change.
Competencies: The Nurse Life Care Planner:
• Synthesizes data, information, research, and evidence to summarize and share with others.
• Communicates recommendations in a way that facilitates understanding.
• Facilitates the effectiveness of a consultation by involving the healthcare consumers and stakeholders in decision-making.
Standard 6. Evaluation
The Nurse Life Care Planner evaluates progress toward plan outcomes.
Competencies: The Nurse Life Care Planner:
• Incorporates a systematic and evidence-based process for outcomes evaluation in the Life Care Plan.
• Collaborates with the healthcare consumer and other involved persons in the evaluation process when possible and appropriate.
• Uses evaluation findings to revise the nursing diagnoses, outcomes, Life Care Plan, and implementation as needed.
• Communicates the Life Care Plan results to the healthcare consumer and other involved persons as reasonable and appropriate, in accordance with state and federal law and regulations.
• Reviews the Life Care Plan for responsible and appropriate interventions to minimize unwarranted or unwanted treatment and healthcare consumer suffering.
• Documents the results of the evaluation.
Standard 7. Ethics
The Nurse Life Care Planner practices ethically.
Competencies: The Nurse Life Care Planner:
• Uses the current ANA Code of Ethics for Nurses with Interpretive Statements and AANLCP Code of Professional Ethics and Conduct for Nurse Life Care Planners with Interpretive Statements to guide practice.
• Practices in a manner that preserves and protects healthcare consumer autonomy, dignity, rights, values, and beliefs
• Recognizes the centrality of the healthcare consumer and family as core members of any healthcare team.
• Maintains patient confidentiality within legal and regulatory parameters.
• Assists healthcare consumers in self-determination and informed decision-making.
• Provides information on the risks, benefits, and outcomes of healthcare regimens to allow informed decision-making by the healthcare consumer, including informed consent and informed refusal.
• Contributes to resolving ethical issues involving healthcare consumers, colleagues, community groups, systems, and other stakeholders.
• Takes appropriate action to address illegal, unethical, inappropriate behavior, or unsafe practices that can endanger or jeopardize the best interests of the
healthcare consumer.
• Maintains professional relationships in the healthcare, community and legal environments.
• Participates in continuing education that addresses ethical issues.
• Advocates for equitable healthcare consumer care.
Standard 8. Education
The Nurse Life Care Planner attains knowledge and competence that reflects current nursing practice
Competencies: The Nurse Life Care Planner:
• Participates as learner and teacher in formal and informal educational activities related to appropriate knowledge and professional issues.
• Demonstrates an ongoing commitment to learning through self-reflection and inquiry to identify learning needs.
• Pursues learning activities to develop and maintain skills, abilities, knowledge, and competence.
• Uses current healthcare research findings and other evidence to expand Nurse Life Care Planning knowledge, skills, and judgment.
• Consults with nursing and other healthcare professionals to develop and maintain skills, abilities, and knowledge.
• Shares educational findings, experiences, and ideas with peers.
• Maintains professional records that provide evidence of competence and lifelong learning.
• Obtains and maintains professional certification in Life Care Planning and other applicable content areas as appropriate.
Standard 9. Evidence–Based Practice and Research
The Nurse Life Care Planner integrates research findings and evidence into practice.
Competencies: The Nurse Life Care Planner:
• Uses critical thinking skills and current scientific evidence to guide Nurse Life Care Planning practice.
• Actively participates in research activities, such as:
• Participating in a formal research committee, program, or study.
• Critically analyzing and interpreting research for application to Nurse Life
Care Planning practice.
• Formally disseminating research findings through presentations, publications, or consultations.
• Shares findings with peers, colleagues, individuals, families, nurses entering the field of Nurse Life Care Planning, and others.
Standard 10. Quality of Practice
The Nurse Life Care Planner contributes to quality nursing and Nurse Life Care Planning practice.
Competencies: The Nurse Life Care Planner:
• Applies the nursing process responsibly, accountably, and ethically when developing a Life Care Plan.
• Provides leadership in the design and implementation of quality improvements.
• Uses the results of quality improvement to initiate changes in nursing practice and the healthcare delivery system.
• Participates in quality improvement activities. These may include, for example:
• Identifying problems that occur in day-to-day work routines to correct process inefficiencies.
• Seeks healthcare consumer feedback to identify opportunities for improving practice.
• Formulating recommendations to improve practice or outcomes.
• Implementing activities to enhance the quality of practice.
• Maintaining familiarity with current standards of practice.
• Active participation in a professional organization relating to the practice of Nurse Life Care Planning.
• Participating in and/or leading efforts to minimize costs and unnecessary duplication.
Standard 11. Communication
The Nurse Life Care Planner communicates effectively in a variety of formats in all areas of practice.
Competencies: The Nurse Life Care Planner:
• Assesses communication format preferences of healthcare consumers, families, and
colleagues.
• Self-assesses communication skills in formal and informal professional interpersonal encounters.
• Seeks continuous improvement of own communication and conflict-resolution skills.
• Conveys information accurately.
• Questions the rationale supporting processes and decisions that do not appear to be in the best interest of the healthcare consumer.
• Discloses observations or concerns related to hazards and errors in care, practice environment, or individual circumstances to the appropriate level.
• Provides for communication between providers using case managers or qualified others to minimize risks associated with transfers and transition in care delivery.
• Contributes professional perspective in formal and informal inter- and intraprofessional discussions.
Standard 12. Leadership
The Nurse Life Care Planner provides demonstrates leadership in the professional practice setting and the profession.
Competencies: The Nurse Life Care Planner:
• Provides direction to enhance effectiveness of interprofessional team.
• Educates the public about the Nurse Life Care Planning profession.
• Fosters a supportive environment for nurses entering Nurse Life Care Planning practice.
• Communicates effectively.
• Defines a clear vision, measurable associated goals, and a plan for achievement.
• Models expert practice to interprofessional team members and healthcare consumers.
• Uses best practices in the development of policies, procedures and standards of Nurse Life Care Planning practice.
• Demonstrates a commitment to lifelong learning and education for self and others.
• Promotes professional development through mentoring of colleagues for the advancement of nursing practice, the profession, and quality health care.
• Treats colleagues with respect, trust, and dignity.
• Facilitates successful conflict resolution through effective communication.
• Advocates for advancing nursing autonomy and accountability.
• Participates in professional organizations.
• Promotes the specialty and nursing profession through writing, publishing, and formal and informal presentations.
• Works to influence decision-making bodies to improve healthcare services and policies.
Standard 13. Collaboration
The Nurse Life Care Planner collaborates with healthcare consumers, healthcare providers, and others, in the conduct of practice.
Competencies: The Nurse Life Care Planner:
• Partners with others to effect change and produce positive outcomes through the sharing of knowledge of the healthcare consumer and/or situation.
• Communicates the Nurse Life Care Planner’s role to all involved parties.
• Promotes conflict management and engagement.
• Adheres to standards and applicable codes of conduct that govern behavior among peers and colleagues to create a work environment that promotes cooperation, respect, and trust.
• Creates a documented plan and other work product focused on outcomes and decisions related to care and service delivery that reflects communication and collaboration with all involved parties.
• Documents communications, rationales for plan changes, and collaborative discussions as appropriate.
• Cooperates in creating a documented plan focused on outcomes and decisions related to care and delivery of services that indicates communication with healthcare
consumers, families, and others.
• Engages in teamwork and team-building processes.
Standard 14. Professional Practice Evaluation
The Nurse Life Care Planner self-evaluates nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations.
Competencies: The Nurse Life Care Planner:
• Analyzes one’s Life Care Plans for age-appropriate and developmentally appropriate care in a culturally and ethnically sensitive manner.
• Engages in self-evaluation of practice on a regular basis, identifying areas of
strength, as well as areas for professional development
• Seeks feedback regarding one’s own practice from healthcare consumers, peers, professional colleagues, and appropriate others.
• Interacts with peers and colleagues to enhance her or his own professional nursing practice or role performance.
• Takes action to achieve goals identified as a result of self-evaluation, e.g., revising report format, preparing for deposition or trial, improving presentation skills.
• Considers new and emerging technology and tools for improving work flow and products.
• Provides the evidence for practice decisions and actions as part of the informal and formal evaluation processes.
• Interacts with peers and colleagues to enhance her or his own professional nursing practice or role performance.
• Provides peers with formal or informal constructive feedback regarding their practice or role performance.
Standard 15. Resource Utilization
The Nurse Life Care Planner recommends appropriate resources for safe, effective, and financially-responsible healthcare services.
Competencies: The Nurse Life Care Planner:
• Assesses the healthcare consumer’s needs and resources available to address needs and achieve desired outcomes.
• Recommends appropriate levels of care based on complexity and the needs of the individual.
• Identifies healthcare consumer needs when making resource recommendations.
• Evaluates factors such as safety, effectiveness, availability, cost/benefits,
technology, evidence, and efficiencies when considering Life Care Plan component options with the same expected outcome.
• Considers new and emerging technology for inclusion in the plan.
• Provides for delegation of elements of care in the plan to appropriate persons and healthcare workers in accordance with applicable legal, regulatory, or policy
parameters.
• Assists the healthcare consumer and other relevant parties to understand costs, risks, and benefits of treatment, care, and other elements of the nurse Life Care Plan.
Standard 16. Environmental Health
The Nurse Life Care Planner practices in an environmentally safe and healthy manner.
Competencies: The Nurse Life Care Planner:
• Attains knowledge of environmental health concepts, such as implementation of environmental health strategies.
• Promotes practice and care environments that reduce environmental health risks.
• Assesses how environmental factors such as sound, odor, noise, and light affect health.
• Advocates for the judicious and appropriate use of products in health care.
• Communicates environmental health risks and exposure reduction strategies to healthcare consumers, families, colleagues, communities, and others as
appropriate.
• Evaluates scientific evidence to determine if a product or treatment is an environmental threat.
• Participates in strategies to promote healthy communities.
References
Agency for Healthcare Research and Quality (2006) The High Concentration of U.S. Health Care Expenditures: Research in Action, Issue 19. June 2006, Rockville, MD.
http://www.ahrq.gov/research/findings/factsheets/costs/expriach/index.html
American Association of Nurse Life Care Planners (AANLCP ). (2008) Nurse Life Care Planners standards of practice with interpretive statements. Membership Guide. AANLCP. Salt Lake City UT
______. Position statement on the definition of the nurse Life Care Planning. (2008) Membership Guide. AANLCP. Salt Lake City UT www.aanlcp.org/homepage.
______. Code of professional ethics and conduct for nurse Life Care Planners with interpretive statements. (2008) Membership Guide. AANLCP. Salt Lake City UT
American Nurses Association (ANA). (2001) Code of ethics for nurses with interpretive statements. Washington, DC: American Nurses Publishing.
_____. (2010) Nursing’s social policy statement: The essence of the profession. 2nd edition.
Silver Spring MD: Nursesbooks.org.
_____. (2010) Scope and standards of practice, Nursing, 2nd edition. Silver Spring MD:
Nursesbooks.org
Brock, P. From Clinical Nurse to Entrepreneur: Becoming a Life Care Planner. American Journal of Nurse Life Care Planning. Winter 2010; X, (4): 285-291. Available at,
http://www.aanlcp.org/resources/journal.htm; 2010 December.
Centers for Medicare and Medicaid: Workers Compensation Medicare Set-aside Arrangements
Centers for Medicare and Medicaid: Workers Compensation Medicare Set-aside Arrangements