This assignment will investigate a needs orientated approach to care, critically discussing the nursing process. It aims to show an understanding of what a nursing model and the nursing process is, looking in detail at the relationship between this nursing process and the Roper, Logan and Tierney (RLT) model of nursing. This essay will explore how the nursing model and process is implemented in practice, considering how the RLT model assists nurses to adapt a problem-solving technique when developing care plans for individuals.
Strengths and limitations of the RLT model and the nursing process, in relation to developing care plans, will be critiqued along with the effectiveness of Multidisciplinary teams (MDT) using the approach to meet public health needs. To support this discussion, throughout this assignment an example of a formative care plan I devised during this module for a fictitious patient, Annie Laine (See Appendix A) will be utilised, along with knowledge that I have gained throughout the programme surrounding this subject.
By exploring each stage of the nursing process, an understanding of how the RLT model is used by the nurse and MDT to ensure patients receive quality care, will be demonstrated. Aspects of the RLT model will be explored, when discussing each separate stage of the nursing process. The stages will be critiqued in depth and analysed, and the care plan I devised using the RLT model and the nursing process, will again be used as reflective material to support the discussion. For years nurses understood that the best form of nursing was carried out based on intuition, empathy and instinct (Aggleton and Chalmers 2000).
This approach to nursing care and planning has been extensively criticised. Many nursing authors called for a more systematic approach to care, focusing on the needs of the individual also looking at the psychological, physical and behavioural aspects of the patient. In 1967 Helen Yura and Mary Walsh published a book “The Nursing Process” where four stages were identified; assessment, planning, implementation and evaluation, creating a problem solving process which ensured nurse and patient interaction. This enabled the nurse to produce a plan of care individual to the patients needs (Aggleton and Chalmers 2000).
These four stages are a circular problem solving approach which is a continuous process, whereby the patient will be assessed and reassessed until each problem is solved. (Kenworthy, Snowley and Gilling 2002) The RLT model of nursing is a framework based on the activities of living the patient under-takes which guides the care of patients in an extensive range of circumstances (Roper, Logan and Tierney 2001). Pearson, Vaughan and Fitzgerald (2005) suggest that applying a nursing model provides a continuation of care through support, illustrating to other members of the MDT the goals they are hoping to achieve.
The RLT model is centred around the individual. There are twelve activities of daily living which the RLT model is based around, how each individual is able to perform each activity of living and how they live life is considered (Roper et al 2001). There are also four other significant sections that make up the model. These four sections are used by nurses to enhance the care patients receive by enabling cares to meet individual needs (Roper et al 2001).
They guide the nurse and MDTs to see the patient holistically and provide holistic care for each individual, acknowledging the patient as a person and not labelling them as an illness or condition. By providing such guidance, the nursing model helps to ensure a standard of care is achieved within the care setting. Nursing models encourage nurses to gain an understanding of individual needs and underpin practice with evidence based theory; therefore a nursing model cannot be implemented effectively, without using the four stages of the nursing process (Aggleton and Chalmers, 2000).
Using the nursing model in accordance with the nursing process and relating these, creates a ‘Nursing Approach’ (Aggleton and Chalmers 2000). The first stage of the process is assessment. Roper et al (2001) refer to this process as ‘assessing’ indicating an ongoing activity; this encourages nurses to recognise the on-going nature of this initial phase. The assessing stage includes gathering information about a patient, reviewing this information, identifying actual and potential problems and prioritising (Roper et al 2001).
Roper et al (2001) explain the importance for assessing, as early as possible in the patient’s stay. Extensive, in-depth information may not be gathered on an initial assessment, however any information obtained contributes towards individualised care (Roper et al 2001). Ambrose and Wittig (1998) explain that the initial assessment becomes a foundation for ongoing assessing and holistic care. Barrett, Wilson and Woollands (2009) concord with Roper et al and Wittig in that assessing is an ongoing process and elaborate on this explaining that assessment should not be confused with admission.
They state “an admission tends to be a one-off process when you first meet the patient, whereas assessment carries on throughout your relationship with the patient” (pg22). Assessment enables the nurse and patient to identify actual and potential problems. Although, some problems can be directly related to biological needs, holistic needs must be considered, i. e. psychological state and cultural/social standing (Aggleton and Chalmers 2000). The opportunity to initiate an effective nurse-patient relationship should be taken at this stage (Holland, Jenkins, Solomon and Whittam 2003).
Mcsherry (2006) explained how physical, biological, spiritual and psychological factors need to be considered when assessing patients, to provide individuals with holistic care. The nursing profession has been criticised for concentrating on biological aspects of a problem and not embracing a holistic care approach. Jones (1998) expresses that the nursing profession can overlook the ‘whole’ person, ignoring their individual needs. Hancock (2000) agrees with Jones, taking this critique further, asking whether nursing theories and models are holistic.
The RLT model stresses the importance of a holistic approach to assessing patients, highlighting the necessity of the nurse gathering two types of information from and about a patient, in order to perform a more detailed and holistic assessment (Roper, Logan and Tierney 2001). According to Roper et al (2001) the information gathered should be numeric where possible and personal to each patient, this is known as objective information (quantitative) and subjective information (qualitative).
It is also at the assessment stage that nurses seek to ascertain what a patient can and cannot carry out independently within each of the activities of living (AL). These are 12 headings, consisting of different behaviours which an individual participates in. Influencing factors such as environmental, socio-cultural, politico-economic, physical and psychological factors should be accounted for. These 12 activities of living (see appendix 2) provide the framework for assessing (Pearson, Vaughn and Fitzgerald 2005).
These AL should all be considered by the nurse in order to assess each patient’s individual holistic requirements. Patients past and present routines and any problems related to ALs and any issues in coping with these must be established when assessing. Each AL is inter-related and this should be considered to gain a holistic assessment of the patient’s individual needs (Roper et al 2001). However, the AL have been criticised for not encompassing the detailed character of life, they do not cover categories of living such as “pain” (Barret et al 2009).
Barret et al (2009) also express concerns of the possibility that AL’s are being used as a “checklist” rather than an assessment tool and interpreted incorrectly. Parker (1997) contends that if used correctly the RLT model and AL’s are highly effective; stating it is straightforward and easy to comprehend meaning there is little room for mistakes to be made. Parker (1997) also expresses how well the model works in-conjunction with medical models. Roper et al (2001) explain how there are factors which influence an individual’s ability to carry out the activities of living.
The affect these influencing factors have on each individual is unique and the influencing factors are grouped into five categories within the RLT model; biological, socio-cultural, psychological, environmental, politico-economic. These factors can act alone or as a combination, and each AL is affected by these factors (Alexander, Fawcett and Runciman 2004). By considering this range of factors and their relationship, a deeper understanding for causes of difficulties experienced by individuals, can be gained during assessing (Alexander et al 2004).
When completing the care plan for Annie Laine and looking at the AL ‘Mobility’ it was clear that Annie had mobility problems. This seemed to be due to the wounds on her legs and the resulting oedema. When assessing Annie, I found myself concentrating on the physical and medical problems she was experiencing. The nurse must have knowledge of all five possible influencing factors and the evidence that underpins these, when assessing. Pearson et al (2005) explain how high-quality nursing requires the best available evidence to underpin practice.
Therefore, a good understanding of the anatomy and physiology of the human body will enable the nurse to provide the patient with an explanation of biological and physical factors that are influencing their AL. Kenworthy et al (2002) propose that providing patients with precise information and accurate explanations reduces feelings of anxiety, easing psychological stress and contributes towards a quick recovery. Reflecting on this assessment, although the physical influencing factor contributed towards Annie’s reluctant mobility, it was not the sole reason for Annie’s poor mobility.
The main contributor towards this was a psychological influencing factor. Previously when Annie walked to the toilet she had a fall (unconditioned stimulus), causing the wound on her leg. This made her feel vulnerable and frightened (response), leading to Annie associating mobility (conditioned stimulus) with being frightened and vulnerable (classical Conditioning) (Watson and Rayner 1920, cited in Rungapadiachy, 1999). This reflection has made me realise that when using the AL’s to assess a patients care needs, all elements of the RLT model must be considered.
A Holistic approach to care needs to be utilised for every individual, as it is not always the physical illness or biological reasons that are the influencing factors. Although I did not pay particular attention to Annie’s psychological influencing factors, by explaining the biological factors to Annie, it may have reduced her psychological and emotional stress (Kenworthy et al 2002). This demonstrates that when the RLT model of nursing is applied correctly, the results for assessing patient’s needs can be highly effective. On the other hand, it also demonstrates how ineffective the RLT model can be when not applied correctly.
Walsh (1998) critiqued the RLT model because of this potential limitation, he expressed his concerns that some practitioners may use the RLT model and AL as a checklist and only consider physical and biological factors, not looking at the situation holistically, viewing the patient as a ‘condition’ rather than as an individual. When the RLT model is used as a ‘checklist’ other important factors may be missed such as psychological influencing factors, which can hinder patient recovery, as demonstrated by the care plan for Annie (See Appendix 1).
The second stage of the nursing process to be explored is planning. Rosdahl and Kowalski (2008) explain, planning is the development of goals to prevent, reduce or eliminate actual/potential problems and to identify nursing interventions to assist patients in meeting these goals. They express, by setting priorities, identifying expected outcomes, and selecting interventions, a plan of nursing care can be derived. Potter and Perry (2004) express the usefulness of Maslow’s hierarchy of needs, in selecting priorities meaning basic physiological requirements take priority over self-esteem requirements.
Roper et al (2001) have explained that planning involves determining the strategies or course of actions to be taken before the implementation of nursing care. It aids with multi-disciplinary team (MDT) work and communication between health professionals (Roper et al 2008). Setting goals and prescribing care are interconnected aspects of planning and will therefore be considered concurrently. It is important that the patient and their family are involved, wherever possible in the planning and goal setting process.
Quan (2009) explains health professionals must realize, the goals set within a plan of care are not nursing goals, they are patient goals, which is why involving the patient in the planning process is vital. The goals set should have the following characteristics; they should be specific to the patient, measurable, achievable, realistic and time orientated (SMART) (Rosdahl and Kowalski 2008). Roper et al (2001) stress, goals set must be achievable within an individual’s limits, and mutually agreed between the nurse and the patient, meaning each goal must meet individual needs of the patient.
If goals are unachievable it may dishearten an individual. Barret et al (2009) also highlight the importance of measurable goals, as this can determine the effectiveness and accuracy of the evaluation. They believe that recording patient baselines for each goal set, enables the practitioner to gage how the patient has moved along the dependence-independence continuum. Barret et al (2009) describe long term and short term goals, elaborating on this; they explain that short-term achievable goals promote motivation and self-esteem, so are likely to aid recovery more than long-term goals.
This can be related to operant conditioning; if a patient is able to achieve goals set, they will experience a feeling of fulfilment (positive reinforcement) meaning they will be more likely to strive to reach future goals (Skinner, 1938 Cited in Eysenck and Flanagan, 2002). Another important factor to consider when setting goals and prescribing care is staff and resources. Roper et al (2001) explain if this is not considered goals and cares set, may be unachievable within the set time frame, leaving the patient with a feeling of failure.
Goals should always be stated clearly and accurately and need to be observable, measurable and able to be tested, in order for future evaluation. It is also necessary, to document the time and date the goal is set, and times and dates for evaluating the goals, enabling the nurse to determine the progression/regression the patient has made on the independence/dependence continuum (Roper et al 2001). Clear documentation of dates and times on care plans, enhances communication between members of the MDT involved in an individual’s care, which in turn can promote a quicker recovery and efficient care for the patient. The Nursing and
Midwifery Council (NMC) (2009) state that, good and accurate record keeping promotes communication and the sharing of information amongst members of the multi-professional health care team, promoting the continuity of care. A vital link for all MDT professionals is a well structured care plan. Once goals are set and agreed with the patient, care needs to be prescribed based on the most recent and reliable evidence and must be documented clearly (Barrett et al 2009). This way prescribed care is consistent and all members of the MDT are working to achieve the goals outlined for the individual, following the prescribed care documented.
Barrett et al (2009) describe how prescribed care should be in the form of activities the nurse, patient, their family and member of the MDT can carry out in order to achieve the set goals. However, it has been argued in the past that although the patient may be involved in the goal setting process, there is a possibility that they are not empowered to cooperate with the prescribing care process, this may mean the nurse faces a non-compliant patient hindering their recovery, and lowering staff and patient morale (Littlejohn 2002).
After assessing Annie, a set of goals were developed. When setting these goals it was important to ensure the SMART tool was utilised, for the goals to be specific to Annie, measurable and achievable within a realistic time frame. Annie was able to provide sufficient information with regards to her lifestyle and how it has changed since her fall. This made it much less challenging to set measurable and achievable goals, as baselines could be recorded, meaning progression/regression along the dependence-independence continuum could be measured effectively.
The goals provided a direction for Annie and the nursing staff to follow in order for Annie to recover. From these goals the care and interventions were prescribed. On reflection, the goals set for Annie and the care prescribed were measurable, achievable and relevant to Annie’s recovery. However the goals were mostly focused on biophysical aspects of Annie’s health and wellbeing, as in the assessing phase. Annie’s holistic, biopsychosocial needs seemed to be disregarded. When setting goals it is vital that all identified problems are assessed with all influencing factors considered (Roper et al 2008).
Waldrop and Doughty (2000 cited in Baillie 2005) highlight the common occurrence of psychosocial and sociocultural factors being ignored during the care planning stage of the nursing process, they stress how these influencing factors are equally as important as biological factors in improving a patient’s condition. A problem addressed within the care plan, was the smell from Annie’s wound on her leg (See appendix 1). Although a goal was set to stop the smell, the psychosocial factors of this problem were not directly addressed.
The smell was embarrassing Annie, making her reluctant to socialise, alongside the fear of falling again, Annie may become socially excluded. At 72 years old, she has expressed the feeling of depression, feeling this is “the beginning of the end”. From a functionalist perspective, this could be described as “disengagement”, she feels she is less independent, due to failing health, and is withdrawing herself from society (Cuming and Henry 1961). This reflection shows that the health professional may not consider all factors influencing a patient’s condition and this is a possible limitation of the planning phase.
Clearly, all factors of the RLT model must be addressed during assessment, in order for a truly holistic care plan to be devised. The goals set for Annie were mostly short term goals. This was a positive aspect of the care plan, as I found them to be achievable and realistic for both the nurse and Annie, encouraging her recovery. When planning care for Annie, I did not involve any MDT’s. This may be due to my lack of experience in planning care. On reflection I feel that by involving MDT members such as occupational therapists, to provide mobility aids for Annie, she may have had a more effective and enhanced recovery.
The next stage is implementing care. It involves the execution of the care plan devised during the planning phase of the nursing process. In the implementation phase the nurse and members of the MDT put the care plan into action (Daniels 2004). Frisch and Kelly (2002), explain, nursing is a dynamic practice and all nurses must continually include new assessment information into the implementation of the care plan. Therefore nurses must use a wide range of evidence based knowledge, careful planning, critical thinking, analysis and judgement (Daniels 2004).
Roper et al (2001) stress the importance of evidence based knowledge in nursing practice, to enable a practitioner to give rationale explanations regarding the decisions made, allowing them to be a safe and ethical practitioner and provide patients with the best possible care. When implementing care, both experiential knowledge and external evidence should be used together (Sackett, Rosenberg, Gray, Richardson 1996). Hall (2005) refers to experiential knowledge and theoretical evidence/knowledge, as ‘fundamental knowledge types’.
Claiming it is in the patient’s best interests to utilise both types of knowledge alongside one another to promote effective care. However, criticisms have been made about the gap between these knowledge bases, claiming some nurses are not able to apply theoretical knowledge with experiential knowledge, leaving a theory-practice gap (Hall, 2005). If practical cares are not supported with current evidence, it can lead to poor care of patients and delayed recovery, the NMC (2008) stress the importance of using current evidence alongside practical and experiential knowledge.
When implementing care, assistance from MDT members, may be necessary. By involving MDT members and ensuring they are aware of the cares and interventions they need to provide, the patients public health needs can also be more easily met. Roper et al (2002) support the involvement of MDT members, in providing patient care and meeting public health needs, and suggest a separate sheet is used entitled ‘nursing notes’ to document patient information, which will help the nurse evaluate care.
This stage of the process continually interlinks with the assessment and planning stages, to reflect the changing needs of the individual patient. When implementing care for Annie, I felt my lack of experience and knowledge prevented me from providing extensive varieties of care, and incorporating this in the care plan. This meant I was potentially unable to carry out the process safely or effectively due to my inexperience. The importance of having a registered and competent nurse/practitioner, with up to date knowledge to plan, prescribe and implement care has been highlighted by Barret et al (2009).
They state a registered nurse is answerable to the NMC who expect high levels of competency (NMC 2009). Bond and French (2009) also suggest that evidence based knowledge teamed with effective implementation strategies cause’s improvements in care and positive changes in practice. Reflecting on Annie’s care plan, involving MDT members, would have aided her recovery, i. e. occupational therapist may have provided mobility aids for Annie. Care was prescribed to tackle Annie’s poor diet, and meet her public health need.
Recently the ‘Change4Life’ initiative has been published, to meet public health needs (Department of Health 2010). Annie may have benefited from these services. On reflection involving an MDT member i. e. dietician and introducing Annie to the change for life scheme, her poor diet may have been more easily tackled and cares more effectively implemented. Evaluation is the final stage of the process. Roper et al (2001) stress the importance of evaluation in recognising if patients have benefited from nursing interventions provided and explain how this is an ongoing process.
Quan (2009) explains how evaluation encompasses the analysis of interventions that have failed to benefit the patient, identifying needs for adjustments and change. Evaluation is not the end of the process and it can lead to assessment all over again. This stage requires the input of all health and social professionals involved in a patient’s care, and the participation of the patient (Quan 2009). Evaluation exists in 2 forms, formative evaluation and summative evaluation. A patient’s behaviour and ability to carry out AL needs to be considered when undertaking a formative evaluation.
Original goals set, are used to assess the progress/regress the patient has made along the dependence-independence continuum (Barret et al, 2009). Martin (2002) explains how the formative approach evaluates the need for further application of clinical care. This evaluation encourages the nurse to reassess and set new goals to be achieved, constantly updating care, making it appropriate for the individual. The progression made along the dependence-independence continuum must be assessed and evaluated for every goal set.
Recognise whether goals have fulfilled a patients potential, when they are achieved within the given time frame, is also important (Aggleton and Chalmers 2000). Formative evaluation measures the effectiveness of goals set. However Barret et al (2009) stress how goals are not measurable if baselines for the patient are not initially recorded, criticising the accuracy of this evaluation. If goals are not measurable, the evaluation stage of the process is difficult to complete, meaning a patient’s progression/regression may not be correctly interpreted.
Summative evaluation takes place after nursing intervention has ended (Aggleton and Chalmers 2000). It questions how successful the RLT model was in delivering care to patients. Summative evaluation determines whether the problems identified were dealt with effectively (Barret et al 2009). This type of evaluation, is only reliable when a model has been implemented over a period of time for numerous individuals, and helps to establish whether the model is appropriate for a particular clinical area, (McAlpine 2002).
In turn it can contribute towards the quality of care a patient receives. Although, summative evaluation is not ideal for communicating complex information regarding the effectiveness of a model (McAlpine, 2002). On reflection evaluating Annie’s care plan, was difficult, although formative evaluation was made easier because baselines had been recorded and Annie could be involved in the evaluation process. I felt that time scales given to complete goals, were not based on specific evidence and therefore not accurate, although they were agreed with Annie.
It is possible that with practice and experience I will feel more confident in proposing realistic timescales to complete goals. Summative evaluation on the other hand proved to be more difficult and less valid as the care plan for Annie was the only care plan to draw upon. Although the RLT model was effective in fulfilling Annie’s needs. Reflecting on the evaluation process it is apparent that the nurse is highly responsible for how care is implemented and evaluated, meaning the process is only as good as the nurse responsible.
This should be considered when evaluating as it means part of the evaluation becomes subjective, because it relies on professional perceptions, when determining the usefulness of the goals and care set and the RLT model. In order to provide a reliable summative evaluation, it would need to be based on more than one care plan for numerous patients. In conclusion, although it is not perfect the RLT model combined with the nursing process (APIE) provides nurses with a good base and direction. Proving one cannot be used effectively without the other, as one directs care and the other provides the delivery of care.
If the model is applied effectively a holistic and individualised approach to care is devised, ensuring influencing factors are not overlooked. Unqualified members of staff and student nurses may make this mistake, justifying the importance for a qualified practitioner to complete the care planning process. I feel this was clearly demonstrated in my care plan for Annie, as I failed to acknowledge the psychological influences on Annie’s reluctant mobility. However, setting baselines was an aspect of importance that was positively demonstrated in Annie’s care plan.
The nurse must also appreciate their own limitations when providing care and understand the importance of MDT members in caring for patients and meeting public health needs. Reflecting on this care planning, RLTs model and the nursing process are of equal importance to one another, and although critics have argued that this approach is over simplified, it is clear that if the approach is implemented correctly it provides a very effective way of assessing, planning, implementing and evaluating care.
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