An Exploration of a Needs Orientated
Approach to Care Planning
The aim of this assignment is to explore a needs orientated approach to care, and use a model of nursing – Roper, Logan and Tierney (RLT) model – to formulate a care plan. The RLT model of nursing is based on 12 activities of daily living and it provides a framework for nurses to plan and deliver appropriate nursing care. By using the activities of daily living when gathering information about a patient a nurse can begin a problem solving approach to care planning, however, as suggested by Barrett et al (2009), the nursing model not only provides questions to ask during the assessment of a patient, but they offer beliefs and values and instructions to what is important and relevant during the process of care planning. “The nursing process is the tool or methodology of professional nursing that assists nurses in arriving at decisions and helps them predict and evaluate consequences.” George (2002).
The RLT model was created in 1980 for educational purposes – students and teachers – and was the first UK model to be used in a variety of settings; it is now used in many parts of the world and has been translated into 8 other languages, it is also popular with UK nurses and is one of the most commonly used within the UK according to Tierney, (1998). Barrett, et al suggests it is popular in the UK as it is written by British nurses and is easily understood. RLT’s model of nursing follows the process of assessment, planning, implementation and evaluation, this is also known as APIE which enables the nurse to carry out a care plan which provides complete holistic care. RLT’s model focuses on individuality, dependence-independence continuum, progression along a life span continuum and influencing factors. Barrett (2009) have also introduced ASPIRE which includes assessment, systematic nursing diagnosis, implementation, recheck and evaluate. A care plan is included as an appendix (1) to provide an example of RLT and APIE, this will be used to make comparisons with other models and to identify weaknesses or strengths of the care plan.
“Assessment is a systematic, deliberate and interactive process that underpins every aspect of nursing care”. (Heaven & Maguire 1996). It is the collection of information and data about the health status, past and present, of the patient. It is used to make nursing diagnosis, therefore if inaccurate assessing takes place it may lead to inappropriate nursing diagnoses. One of the main aims of assessment is to identify what the current health problem/experience means to the patient, this can then lead to a diagnosis, based on information collected, on the cause of pain/problem. RLT use the word assessing as it promotes the idea of ongoing assessing whereas assessment implies that it is used once to gain information about the patient. The first assessment carried out by the nurse will provide a baseline against further information gathered, the information can then be reviewed by the nurse whose time is spent observing and talking to the patient. This not only provides the opportunity for collecting data but establishes and builds a relationship with the patient, although some patients may not be willing to disclose problems and will wait until the relationship has built gradually, and not all nurses may be able to build up relationships with all patients, as Hastings et al (2006) agree it is unlikely that you will be able to establish and maintain easy relationships with all your patients, the patients may not want to follow our suggestions and choose not to interact fully with the nurse. RLT use 12 activities of daily living to provide the framework for their assessment (appendix 1), this is to establish what the patient can and cannot do. The activities take into account physical, psychological and sociological perspectives.
Each of the activities are discussed with the nurse asking questions such as : What could you normally do? What can you do now? If there is a change and what is causing the change? Do you have any help? How do you cope now and in the past? Pearson, Vaughan, & Fitzgerald (1997) go on to say the activities of living are used at the assessment stage so that the nurse can ascertain the level of independence a patient has, which will ensure promotion of independence according to that individual’s daily routine. Although RLT express that each of the 12 activities of daily living should be considered RLT (2008) state that that it is not necessary to use all 12, whilst McSherry (2007) suggests that if an effective assessment is not completed, patient needs may be omitted from a care plan. Lack of time on a busy ward may see the assessment rushed and not all 12 activities considered. The 12 activities of daily living provide the nurse with a holistic and problem solving approach to care planning and also give structure to student nurses and newly qualified nurses to help reflect on their practice when providing an effective patient assessment. The assessment contains objective and subjective data such as the patient’s experiences, the knowledge of abilities and disabilities and understanding of their illness. The activities of living are meant to represent the common elements of everyday living that ensure our survival and quality of life. Barrett et al (2009) suggests that the 12 activities of daily living are all interrelated to each other that should not be considered as separate entities. When the information from the patient has been gathered by the nurse for the activities of living, the nurse can then ensure the patient can perform their usual activities they can do themselves whilst providing help with those that cannot be performed independently. RLT’s model of nursing promotes the position a patient is within the dependence – independence continuum RLT (2000) which is closely interlinked with the 12 activities of daily living.
A person’s position of the life span is relative not only to current circumstance but also to the dependence – independence continuum, a newborn baby is dependent on others to live, but as it grows older the child grows less dependent thus ,moving along the continuum for the 12 activities of daily living. Alexander et al (2006) states that no single measure reflects the capacity for independent function in the activities of living, since it can be argued that few, if any, people are truly self-sufficient, and RLT (1983) agrees with this by suggesting that if a person is born with the potential for complete independence circumstances, such as environment could delay or prevent it. However it is necessary to acknowledge that people biologically move along the stages of the continuum dependent upon their age according to Barrett et al (2009). In appendix 1 Mabel Dunn’s assessment, 11 out of the 12 activities of daily living have been completed. I have not been able to gain previous information regarding Mabel’s personal cleansing and dressing. This information is important as individuals have different cleansing requirements, some patients will consent to having a wash everyday as this is what is normal for them. However some patients do not carry out daily washing at home and can therefore feel pressurised by the nursing staff, become abusive or feel as though they are being looked down upon because of their personal routines and habits, patients should receive the level of assistance that they require to meet their individual personal hygiene needs DH(2001), which will vary between individuals and cultures. This information could be gathered when reassessing Mabel so that her own individual views are taken into account and a more holistic care plan could be made for Mabel. The assessment contains quantative and qualitative data and includes some of the coping strategies that Mabel had used so that she was able to cope better with mobilising and sleeping. The activities have all come under separate headings but a more holistic approach may have been formed if they were more closely interlinked such as maintaining a safe environment links closely with breathing and mobilising, as some of the environmental factors have an impact on breathing and mobilising. The assessment does contain information regarding Mabel’s husband smoking and that they live in a industrial zone of a city which could lead to Mabel feeling stressed and Long (2003) states “the environment may trigger a stress response, but the environment may in turn be modified by the individual to either increase or decrease stress.” Therefore in the next stage of planning, which the 12 activities of daily living enable the plan to be formulated, the factors of the environment and Mabel’s husband smoking should be addressed. Barrett et al (2009) have put forward a stage between assessment and planning which is called systematic nursing diagnosis. They believe that this step will offer the healthcare professional direction and time to reflect on the patients problems. Barrett et al (2009) believe systematic nursing diagnosis is often confused with medical diagnosis, but is the stage where information from the assessment is gathered to identify the patients nursing needs.
Planning is the next stage of the APIE process. The object of planning is to make an individualised care plan which is not only evidenced based, but also identifies a goal and explains how this is going to be carried out and who will implement the plan. It is created from the ongoing assessment of the 12 activities of daily living that has been previously carried out, although Ford & Walsh (1994) argue that whilst the information from the assessment process is valuable, they believe that very little of the information is put into documentation. As this plan needs to be individualised to the patient to provide a holistic problem solving approach, they should be involved as much as possible and present when goal setting.
A good relationship between the patient and the nurse should be established so that the patient will feel at ease disclosing information which can sometimes be personal to them although Chalmers (1988) suggests that individuality can be taken too far. Pearson & Vaughan (1990) state the overriding goal is for the patient to agree to the way in which goals are achieved and the schedule for achieving them in as full a way as possible. The aim of the care plan is to enable the patient to reach desired outcomes. Barrett et al (2009) suggest the word PRODUCT to use to help remember what needs to be included and to write goals that are P – patient centred, R – recordable, O – observable, D – directive, U – understandable and clear, C – credible, T – time related. Hogston and Marjoram (2006) also use the word MACROS, which stands for measurable, achievable, client centred, realistic, outcome written and short. This criteria helps the nurse when setting goals. The plan should include goals, some of which are short term and some long term. All of the goals should be achievable, measurable and set within a time scale which is realistic to the patient, if the goals planned were not achievable and/or the time scale unrealistic the patient may become disheartened, depressed non compliant and feel useless, whereas if the goal is realistic they will be reached more easily encouraging the patient to progress and improve self esteem as suggested by Orem (1980) self care encourages positive self esteem. A written plan is the most effective way of keeping all individuals and the patient informed of their goals and outcomes it must therefore be legible and easily understood by the patient as well as the nurse and any other healthcare professional that it may include such as occupational therapists, it should not include jargon or abbreviations which could be misinterpreted and have undesirable consequences. Whilst the plan is being carried out it is important to assess the patient on an ongoing basis Dougherty & Lister (2008) this is important as the patient may develop new problems and the care given may need to be altered. The code of Professional Conduct (NMC, 2002) advises that “good note-taking is a vital tool of communication between nurses.
It states that nurses ‘must ensure that the health care record for the patient or client is an accurate account of treatment, care planning and delivery. It should be written with the involvement of the patient or client wherever practicable and completed as soon as possible after an event has occurred. It should provide clear evidence of the care planned, the decisions made, the care delivered and the information shared.” An example of a goal can be seen in the care plan included for Mabel Dunn. It includes short term goals with a date for these goals to be reached so that Mabel feels she is improving thus improving confidence, self esteem and general well being. The long term goals which are also dated include interventions from not only nursing care but other health professionals such as dietician, physiotherapist and occupational therapists. The NMC (2007) state “care will be responsive to patient needs, following patient pathways and dependant on multidisciplinary team working and education.” On reflection there could have been more goals in the plan itself to include Mabel’s husbands smoking, it could involve Charlie being made aware of the facts regarding passive smoking and the harm smoking can have on individuals, and perhaps see if Charlie would like help to cut down or stop smoking. In which case others members of the team – smoking cessation – could arrange information and tools which could help Charlie thus improving Mabel’s health. However these goals must be measurable and achievable, Charlie could be given all information regarding smoking and may not want to engage in other services. “It is vital that people are encouraged to stop smoking, not just to reduce the costs associated with treating ill health, but also for individual health gains.” Long (2003).
Implementation is the part of the care plan which is “doing”, the nurse or other health care professional will follow the care plan and carry out the goals set in the nursing intervention. The nursing interventions state what is to be done and who will carry the duties out, including members from the multi disciplinary team. Whilst carrying out the care planned, it is important to carry on assessing the patient to determine if the patient has developed any new problems that require attention and also assess their response to care given. This will enable the nurse to determine if any changes to the care plan are required and if so whether action taken is to be carried out immediately or can be done at a later date. If any referrals are required they should be clearly documented so that it can be easily read by all members of the health care team. White (2003) believes that the use of clinical documentation in nurse hand over will help to ensure that the care plans are up to date and relevant. This is important when “handing over” patients during shift changes, information should not only be legible and up to date but should also be recorded as soon as possible as the NMC (2004) state “if it is not recorded, it has not been done” which could have legal implications, as health care professionals we are personally accountable for our actions as the NMC (2002) clearly state “As a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions.”
The goals that are to be carried out are not only done by health care professionals but are done by the patient and their families and care must be taken to remember to keep the goals individualised to the patient taking into account their cultural and spiritual beliefs as recognised in M Leininger’s theory (1991) which aimed to support and inform nurses about the importance of using cultural information. By using evidenced based care it ensures that the treatment or care given is the most appropriate and up to date for the patient as the NMC (2008) state “Nurses have a responsibility to deliver care based on current evidenced based practice”. By using evidenced based practice it ensures that high quality care is given to the patient. Evidenced based practice was introduced by the Department of Health through government policy in 1997 and whilst research is one of the best sources Pearson et al (2007) believes there is a lack of evidence available to support decisions made in practice. By implementing Mabel’s goals when using her inhaler and being shown the correct techniques, which is evidenced based, this would increase her movement along the dependence-independence continuum and also impact on other goals that have been set. Barrett et al (2009) introduced the process of recheck before evaluation. They believe that if the patient has not been rechecked and their progress evaluated, it would not be possible to see if the care given was successful. Rechecking means collecting all of the information needed to gauge if the care given was appropriate and successful.
Evaluation is the final stage of APIE, the objective of which is to find out if the goals and nursing interventions set have been, or are being met and to determine if the patient has progressed along the dependence – independence continuum. Although it does not always end the process as evaluation can lead to re-assessment of the plan. The skills needed for evaluation are those skills used when carrying out the assessment of the patient, these skills enable the nurse to critically analyse the patient’s health, to make sure that they are stable and to see if they are improving or if they have deteriorated, and to determine whether the goals have been met. This enables the nurse to make changes to the care plan and by including the patient in the evaluation stage it will help when making decisions on the care to be given. If the goals are not being achieved it could mean the goals need adapting, or the goal could be inappropriate to the patient needs, or the problem has become worse and the nursing interventions needs review. The goals may also require input from other members of the multi disciplinary team to help in the rehabilitation and progress of the patient. RLT (2000) suggest that the evaluating stage has caused considerable difficulties for nurses as evaluation can be difficult and complex. The evaluation of the short term goals should take place within the time frames specified in the nursing interventions, “you should determine the patient’s progress toward achieving the goal within the time frame and revise the care plan if needed.” Hoffman, (2007). Therefore, if one or more of the short term goals we not being met then the care plan would have to be modified, the patient reassessed and nursing interventions changed according to the patient’s new baseline.
The long term goals would also have to be reassessed, thought would need to be given the goals to make sure they are still valid, achievable, measurable and agreeable to the patient. If any of the goals and nursing interventions need to be changed it must be 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” Barrett et al (2009) believe communication must also be considered when evaluating care as the patient is more knowledgeable about themselves, how they are feeling and managing, Fallowfield and Jenkins (1999) suggest effective communication with patients can help to improve trust, support and establish a plan for treatment. Wilkinson, (2001) mentions two evaluation steps, structure and process evaluation. The structure evaluation relates to appropriate equipment needed to carry out the plan and time restrictions upon the nursing staff, whereas process evaluation focuses on the activities of the nurse. Barrett et al (2009) suggest two types of evaluation formative and summative. Formative evaluation involves discussion between the nurse and patient and uses the patient’s baseline to judge whether the patient has progressed and if the care has been effective and set within reasonable time limits. Summative evaluation is finding information on how efficiently the process worked and if the outcomes were reached therefore providing a holistic, patient centred care plan. When evaluating the care plan for Mabel Dunn, the nurse will assess whether Mabel has achieved her outcomes to the time limits set, if not Mabel would be reassessed. For example, if Mabel was unable to mobilise from the bed to the chair in the time frame specified in the plan, it would have to be amended to a realistic time frame agreeable to Mabel. In changing the short term goal the long term goal may also have to be amended, however, the nursing intervention of referral to physiotherapy would still remain. On reflection Charlie’s smoking habits could have been addressed in the goals and intervention, as these have an effect directly on Mabel’s health.
In conclusion assessments using the RLT model of nursing consider the patient’s individuality and provide a complete holistic approach to care planning, one of the strengths of the model is that it is easily understood and incorporates physical, social and psychological components. It includes the progression of the patient on the dependence – independence continuum and their position on the lifespan. The model encompasses activities of daily living, “the objective of these is to preserve as far as possible the patient’s usual habits and routines associated with each activity of living.” RLT (1983) they include three components of nursing, preventing, comforting and dependence. The assessment stage allows a relationship to build with the nurse and the patient, building up trust which will then enable the nurse to deliver individualised care in the implementation stage. Barrett et al (2009) also suggest there are limitations of the RLT model in that it is oversimplified and Reed & Robins (1991) suggest assessment may be used as 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) claims the model is over physically and physiologically orientated, whereas Chavasse (1987) encourage a task orientated approach to care, but Newton (1991) agrees that RLT’s model of nursing helps to identify factors that influence activities of living. One of the keys for this model of nursing is communication, it is paramount at every stage. In assessment by questioning and listening to the patient, at the planning stage making an agreement with the nurse and the patient to make sure the plan is individualised, at implementation explaining to the patient what treatment will be carried out and by whom, and then at the evaluation as the patient will be able to tell the health care professional if the goals and interventions have been met and if they both the patient and the nurse feel they have progressed along the dependence – independence continuum. As the NMC code (2008) states “you must listen to the people in your care and respond to their concerns and preferences.”
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