The objective of this assignment is to examine a needs-oriented approach to care and utilize the Roper, Logan and Tierney (RLT) model of nursing for developing a care plan. The RLT model incorporates 12 activities of daily living and provides a structure for nurses to effectively plan and administer suitable care. By incorporating these activities, nurses can view care planning as a problem-solving procedure. Barrett et al (2009) propose that the nursing model not only guides patient assessment but also encompasses beliefs, values, and directions that are significant and applicable during the care planning process. According to George (2002), the nursing process serves as an instrument that assists nurses in making decisions while aiding them in predicting and evaluating outcomes.
The RLT model was created in 1980 for educational purposes, specifically for students and teachers. It was the first UK model to be used in multiple settings and has gained popularity worldwide, being translated into 8 other languages. It is especially popular among UK nurses and is one of the most frequently used models in the country, according to Tierney (1998). Barrett et al suggests that its popularity in the UK is due to it being written by British nurses and its easy comprehension.
The RLT model follows the APIE process, which stands for assessment, planning, implementation, and evaluation. This process allows nurses to provide comprehensive holistic care through a well-developed care plan. The model also emphasizes individuality, the dependence-independence continuum, progression along a life span continuum, and influencing factors. Barrett (2009) has further introduced ASPIRE, which includes assessment, systematic nursing diagnosis, implementation, recheck, and evaluate.
To provide an example of RLT and APIE, a care plan is included as an appendix (1). This care plan serves as a reference to compare with other models and identify strengths or weaknesses.
According to Heaven & Maguire (1996), assessment in nursing care is a systematic, deliberate, and interactive process that is essential for every aspect of patient care. It involves collecting information and data about the patient’s past and present health status. The purpose of assessment is to make nursing diagnoses, so if inaccurate assessing occurs, it may result in inappropriate diagnoses. One of the primary goals of assessment is to understand what the current health problem or experience means to the patient. This understanding can then lead to a diagnosis based on the collected information about the cause of pain or problem. RLT uses the term “assessing” to emphasize that it is an ongoing process, whereas “assessment” suggests that it is performed once to gather patient information.
The nurse’s initial assessment serves as a starting point for gathering further information, which can be reviewed by the nurse. During this time, the nurse will spend observing and talking to the patient. This process not only allows for data collection but also establishes and develops a relationship with the patient. However, some patients may not be open to sharing their problems until a relationship has gradually formed. Additionally, not all nurses are able to establish strong relationships with all patients. As Hastings et al (2006) acknowledge, it is unlikely that every nurse can easily establish and maintain relationships with all patients. Some patients may choose not to follow the suggestions given by the nurse and may not fully engage in interactions with them. RLT utilizes 12 activities of daily living as a framework for their assessment (see appendix 1) to determine the patient’s capabilities and limitations. These activities incorporate physical, psychological, and sociological perspectives.
The nurse asks questions about each activity to determine the patient’s abilities, limitations, and support. The activities of living are used in the assessment stage to determine the level of independence and promote independence according to the patient’s routine. It is not necessary to use all 12 activities, but failing to do so may result in important patient needs being omitted from a care plan. Lack of time on a busy ward can lead to rushed assessments that do not consider all 12 activities.
The 12 activities of daily living provide nurses with a comprehensive and analytical approach to care planning. They also serve as a framework for student and newly qualified nurses to evaluate their practice during thorough patient assessments. These assessments involve gathering both objective and subjective information, including the patient’s personal experiences, understanding of abilities and limitations, and knowledge of their illness. The activities of daily living encompass fundamental aspects necessary for survival and overall well-being. According to Barrett et al (2009), these activities are interconnected and should not be seen as separate entities.
The nurse collects patient information and assists with both independent and dependent activities of daily living, following RLT’s nursing model (2000) that emphasizes the patient’s position on the dependence-independence continuum.
The position of a person in the lifespan is determined by their current circumstances and level of dependence on others. A newborn baby, for instance, relies entirely on others for survival. As a child grows older, they become less dependent and can engage in more daily activities. According to Alexander et al (2006), there is no single measure that fully captures an individual’s ability to function independently in daily activities. The authors argue that very few people are truly self-sufficient. Additionally, RLT (1983) supports this idea by suggesting that even if someone has the potential for complete independence from birth, external factors like their environment may hinder or prevent it.
It is important to recognize that people’s movement along the continuum is dependent on their age, as stated by Barrett et al (2009). In Mabel Dunn’s assessment (see appendix 1), 11 out of the 12 activities of daily living have been completed. Unfortunately, I do not have information about Mabel’s personal cleansing and dressing. This information is crucial because different individuals have different cleansing requirements. While some patients may consent to daily washing as their norm, others may not perform daily washing at home. Consequently, they may feel pressured by nursing staff or experience feelings of abuse or being looked down upon due to their personal routines and habits. It is important for patients to receive the appropriate assistance to meet their individual personal hygiene needs (DH, 2001), which will vary among individuals and cultures.
By reassessing Mabel, her individual views can be taken into account and a more comprehensive care plan can be developed. The assessment includes both quantitative and qualitative data, as well as the coping strategies that Mabel employed to improve her ability to mobilize and sleep. While the activities are discussed separately, connecting them in a more holistic manner would have resulted in a more comprehensive approach. For example, maintaining a safe environment is closely related to breathing and mobilizing, as environmental factors can impact these aspects. The assessment also mentions that Mabel’s husband smokes and they live in an industrial area, which may contribute to Mabel’s stress levels. According to Long (2003), the individual’s modification of the environment could either increase or decrease their stress response.
Therefore, in the next stage of planning, the plan can be formulated by considering the 12 activities of daily living and addressing the factors of the environment and Mabel’s husband smoking. According to Barrett et al (2009), there is a step called systematic nursing diagnosis between assessment and planning. This step provides healthcare professionals with direction and time to reflect on the patient’s problems. Although often confused with medical diagnosis, Barrett et al (2009) explains that systematic nursing diagnosis is where information from the assessment is gathered to identify the patient’s nursing needs.
The next stage of the APIE process is planning. The objective of planning is to create a personalized care plan that is evidence-based and includes the goal, implementation details, and responsible parties. This plan is derived from the ongoing assessment of the 12 activities of daily living conducted previously. According to Ford & Walsh (1994), although the assessment process provides valuable information, there is limited documentation. To adopt a holistic problem-solving approach, it is crucial to customize the plan for each individual patient and involve them as much as possible in setting goals.
The establishment of a strong patient-nurse relationship is vital, as it allows the patient to comfortably share personal information, according to Chalmers (1988). Pearson & Vaughan (1990) stress the importance of the patient’s agreement with and adherence to the goals and schedule for achieving them. The care plan aims to assist the patient in attaining desired outcomes. Barrett et al (2009) suggest using the PRODUCT acronym – which stands for patient centred, recordable, observable, directive, understandable and clear, credible, and time related – when setting goals. Hogston and Marjoram (2006) also provide nurses with their own criteria for goal setting: MACROS – measurable, achievable, client centred, realistic outcome written, and short.
The plan should include attainable and measurable goals, both short-term and long-term, set within a realistic time frame for the patient. If the goals cannot be achieved or if the time frame is unrealistic, it can result in feelings of disheartenment, depression, non-compliance, and worthlessness in the patient. However, establishing achievable goals can make them easier to reach and motivate the patient to progress and boost their self-esteem. According to Orem (1980), self-care plays a role in promoting positive self-esteem. Having a written plan is the most effective way of informing all individuals involved, including the patient themselves as well as nurses and other healthcare professionals like occupational therapists about their goals and outcomes. The plan must be legible and easily understandable by everyone involved to avoid confusion or misinterpretation that could lead to undesirable consequences.
According to Dougherty & Lister (2008), while executing the plan, it is crucial to continuously evaluate the patient. This is necessary because the patient might encounter new issues and the provided care may require modification. The NMC’s Code of Professional Conduct (2002) suggests that effective note-taking plays a significant role in communication among nurses.
According to the text, nurses have a responsibility to ensure that the health care record accurately reflects the treatment, care planning, and delivery provided to the patient or client. The record should involve the patient or client as much as possible and be completed promptly after an event occurs. Its purpose is to provide clear evidence of the planned care, decisions made, care delivered, and information shared.
An example of a goal is demonstrated in Mabel Dunn’s care plan. The plan includes short-term goals with corresponding dates, allowing Mabel to track her progress and enhance her confidence, self-esteem, and overall well-being. Long-term goals are also included in the plan and specify interventions not only from nursing care but also from other health professionals such as a dietitian, physiotherapist, and occupational therapist.
The NMC (2007) emphasizes that care should be responsive to patient needs, follow patient pathways, and depend on multidisciplinary team working and education. Upon reflection, the plan could have included additional goals, such as addressing Mabel’s husband’s smoking habits. It would be beneficial for Charlie to be informed about the risks of passive smoking and the potential harm it can cause to individuals. Additionally, efforts could be made to assist Charlie in reducing or quitting smoking, if desired. In this case, the smoking cessation team could provide information and resources to support Charlie’s journey and ultimately improve Mabel’s health. However, these goals should be measurable and attainable, as it is possible that Charlie may choose not to utilize other services even after receiving all the necessary information about smoking. “It is imperative to encourage people to quit smoking not only to reduce the costs associated with treating illness but also for their own health benefits” (Long, 2003).
The implementation phase of the care plan involves following the plan and achieving the goals set by the nurse or healthcare professional. This includes carrying out specified interventions and assigning responsibilities to members of the multidisciplinary team. The nurse must continue assessing the patient during this phase to identify new issues that may need attention and evaluate their response to the care provided. Based on these assessments, adjustments to the care plan can be made, either immediately or at a later time.
The use of clinical documentation in nurse handover is crucial for maintaining current and relevant care plans. It is vital to clearly record any referrals so that all healthcare team members can easily access the information. According to White (2003), this helps ensure that patient information remains legible and up to date during shift changes. The NMC (2004) emphasizes the importance of promptly recording information, as failing to do so may result in legal consequences. As healthcare professionals, we are personally responsible for our actions and omissions, as stated by the NMC (2002). Justifying our decisions in practice is essential.
The goals should be met by healthcare professionals, as well as the patient, their families, and their care providers. It is important to tailor the objectives based on the patient’s cultural and spiritual beliefs, which is emphasized in M. Leininger’s theory (1991) that aims to educate nurses about the significance of cultural information. By utilizing evidence-based care, it ensures that the treatment or care given is the most suitable and up-to-date for the patient, as stated by the NMC (2008): “Nurses have a responsibility to deliver care based on current evidence-based practice.”
The Department of Health introduced evidenced based practice through government policy in 1997 to ensure high quality care is provided to patients. However, Pearson et al (2007) argues that there is a lack of evidence available to support decisions made in practice, even though research is considered one of the best sources. To address this issue, implementing evidence-based techniques, such as Mabel’s goals when using her inhaler and being shown the correct techniques, can increase her movement along the dependence-independence continuum and impact other set goals. Barrett et al (2009) introduced the recheck before evaluation process, emphasizing the importance of rechecking and evaluating a patient’s progress to determine if the care provided was successful. Rechecking involves collecting all necessary information to assess the appropriateness and effectiveness of the care given.
Evaluation is the final step of APIE. Its purpose is to determine if the goals and nursing interventions have been achieved and if the patient has progressed along the dependence – independence continuum. While evaluation may not always conclude the process, as it may lead to reassessment of the plan, it plays a crucial role in analyzing the patient’s health, stability, improvement or deterioration. Additionally, it helps determine if the goals have been met, allowing the nurse to make necessary changes to the care plan. Involving the patient in the evaluation stage aids in decision-making regarding their care.
If the goals are not being achieved, it could indicate the need for adjustments to the goals, or that the goals are not appropriate for the patient’s needs, or that the problem has worsened and requires a review of nursing interventions. The involvement of other members of the multidisciplinary team may also be necessary to support the patient’s rehabilitation and progress. According to RLT (2000), nurses face challenges in the evaluation stage as it can be complex and difficult. The evaluation of short-term goals should occur within the specified time frames in the nursing interventions. As Hoffman (2007) states, “you should determine the patient’s progress toward achieving the goal within the time frame and revise the care plan if needed.” Hence, if one or more short-term goals are not being met, the care plan must be modified, the patient reassessed, and nursing interventions adjusted based on the patient’s new baseline.
The long-term goals would need to be reassessed, ensuring that they are still valid, achievable, measurable, and agreeable to the patient. Any necessary changes to the goals and nursing interventions must be accurately documented, as stated by NMC (2008), “You must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been.” Communication is also emphasized as an important aspect in evaluating care by Barrett et al (2009), as patients possess more knowledge about themselves, their feelings, and self-management. Fallowfield and Jenkins (1999) suggest that effective communication with patients can enhance trust, support, and establish a treatment plan. Wilkinson (2001) discusses two steps of evaluation: structure evaluation and process evaluation. Structure evaluation pertains to the appropriate equipment required for implementing the plan and time constraints on the nursing staff, while process evaluation focuses on the nurse’s activities.
Barrett et al (2009) propose two types of evaluation: formative and summative. Formative evaluation involves discussions between the nurse and patient to assess progress and effectiveness of care within set time limits. Summative evaluation focuses on assessing the efficiency of the process and whether desired outcomes were achieved. When evaluating Mabel Dunn’s care plan, the nurse will review if she has met her goals within the specified time frame. If not, reassessment is necessary. Modifying short term goals may also require changes in long term goals, but the referral to physiotherapy intervention will remain. Reflecting on Charlie’s smoking habits, addressing these would directly impact Mabel’s health and should have been included in the goals and interventions.
Overall, the RLT model of nursing incorporates the patient’s individuality and offers a comprehensive holistic approach to care planning. It is easily comprehensible and encompasses physical, social, and psychological elements. The model takes into account the patient’s progression on the dependence-independence continuum and their position on the lifespan. It includes activities of daily living with the aim of preserving the patient’s usual habits and routines associated with each activity. According to RLT (1983), the model comprises three core nursing components: preventing, comforting, and dependence. During the assessment stage, a relationship is established between the nurse and the patient, fostering trust that is vital for delivering individualized care during the implementation stage. Although the RLT model has its strengths, Barrett et al (2009) argue that it is oversimplified, while Reed & Robins (1991) suggest that assessment may be reduced to a checklist.
If the practitioner does not understand all of the activities of daily living, information gathered could be misinterpreted making the goals and plan inadequate. Fraser (1996) argues that the model is focused too much on physical and physiological aspects, while Chavasse (1987) advocates for a task-oriented approach to care. However, Newton (1991) agrees that RLT’s nursing model helps identify factors influencing daily activities. Communication is essential at every stage of this nursing model. During assessment, it involves questioning and listening to the patient. In the planning stage, it requires reaching an agreement with the nurse and patient to ensure individualized care. During implementation, it entails explaining the treatment to the patient, including who will administer it. Lastly, in evaluation, the patient can provide feedback on whether goals and interventions were met, and both the patient and nurse can assess progress along the dependence-independence continuum. According to the NMC code (2008), it is crucial to listen to and address the concerns and preferences of those under your care.
