Advances in the Delivery of Nursing Care--A New Concept

The aim of this set of lectures is to demonstrate how the use of nursing models and the nursing process can shape our practice.

Florence Nightingale (1859) was of the opinion that medicine and nursing should be clearly differentiated from each other but in the 1970s doctors were still being asked to lecture to nurses about nursing, in 2008 veterinary surgeons are still being asked to lecture veterinary nurses about veterinary nursing. Peplau (1987) argued that those who teach control the content of the occupation.

According to the Medical Model the patient is a complex set of anatomical parts and physiological systems (Aggleton & Chalmers, 2000). The medical model emphasises anatomical, physiological and biochemical malfunction as the causes of ill health and by doing so encourages a disease-orientated approach to the patient.

If We Substitute Veterinary for Medical

The veterinary surgeon is likely to have a disease-orientated approach to a patient but we as nurses should have an individualised, holistic, patient orientated approach to care.

How many of us have referred to a patient by its illness--'the dog in kennel 8 with diabetes mellitus'--rather than as an individual? According to Aggleton and Chalmers within human centred nursing it was the disenchantment with the medical model that has been the main reason for the development of nursing theories and models. Other reasons included nurses believing that the medical model was not a focus for our discipline, the advent of university educated nurses and the quest for professional recognition.

What is Meant by a 'Model' Within the Context of Nursing?

'It is a mental or diagrammatic representation of care which is systematically constructed and which assists practitioners in organising their thinking about what they do, and in the transfer of their thinking into practice for the benefit of the client and the profession' (McKenna,1994).

Models of Nursing will enable us to deliver care to our patients using a systematic approach and in doing so will enable the profession to produce a unique body of veterinary nursing knowledge which is evidence based rather than saying 'that's because it's what we've always done'!

However at this stage Nurses may be ill equipped to help the patient as a whole: 'If we are to argue that nursing is a profession in its own right, then we need to be able to work out the boundaries of nursing so that we can recognise our field or practice' (M Walsh, 1997).

The Nursing Process

Care of patients was always planned long before the term 'Nursing Process' was coined; the fundamental difference, however, is that the focus of care has changed from the disease or task to patients. The Nursing Process is divided into 4 stages:

It is a Cyclical Process

Carrying out the nursing process ensures that the nurse considers the whole patient rather than the condition or problem that needs treatment.

Assessment

Assessment must clearly establish the individuality of the patient and it is only once this has been done that effective care can be given. Collect the information needed via your own observations, information from the client and other team members, collect the information systematically and write it down. Review the information that has been collected and in doing so identify the patient's actual and potential nursing problems and identify priorities among problems.

"Each stage of the nursing process is of equal importance. If we skimp on one stage it will be reflected in the quality of the next. This is particularly important for the assessment stage as assessment forms the basis for the remainder of the nursing process." (C.R. Kratz, 1989)

Gathering information about a patient is very important. It sets the scene for any action to be taken.

Wrong information Wrong action
Lack of information Inadequate action

Planning

Planning is carried out to determine a number of things:

 How to solve identified actual problems

 To prevent identified potential problems becoming actual ones

 To alleviate those problems that cannot be solved

 To help the patient/client cope positively with those problems which cannot be solved or alleviated

 To prevent recurrence of a treated problem

 To help the patient to be as comfortable as possible when death is inevitable

Setting Goals

A goal has to be set for each actual and potential problem and a distinction should be made between short term and long term goals. Goals should be stated in terms of outcomes that are able to be observed, measured or tested so that evaluation can then be carried out.

Nursing Plan

A plan is made of all the proposed nursing interventions needed to achieve the goals and the plan should be written in enough detail that any nurse reading it would know what the plan is.

Implementation

Implementing the nursing plan is the 'doing' stage of the nursing process, It is important though, that nurses make it clear what decision making has taken place to justify the nursing intervention.

Evaluation

This is a crucial phase of the nursing process as it is difficult to justify planning and implementing nursing interventions if the outcomes cannot be shown to have benefited either the patient or the client in some way. Evaluation is a difficult thing to do because you are hoping that your evaluation will show that all the nursing goals have been achieved. If this is not the case you need to ask the following questions:

 Has it been partially achieved--is more information needed to decide the next step?

 Is the problem unchanged and should the nursing intervention be changed or stopped?

 Is there a worsening of the problem and should the goal and nursing intervention be reviewed?

 Was the goal inappropriate?

 Does the goal require interventions from other members of the veterinary team?

By asking these questions we are effectively revising the nursing plan to address the issues that have become apparent during the evaluation. Re-evaluation then takes place by assessing the patient and the whole process begins again, thereby offering a systematic approach to nursing care.

However the Nursing Process.............

 Exhorts nurses to assess but does not tell them what to look for.

 Advocates planning but does not say what form the care plan should take.

 Talks of intervention but does not specify what might be appropriate interventions.

 Calls for evaluation without specifying the standards against which comparisons should be made.

This is where nursing models come in! Models tell us what to look out for when carrying out an assessment, how to plan, what kind of interventions are appropriate and so on. Together with the nursing process they provide detailed guidance for the steps that need to be taken when delivering nursing care.

 Models are systematically constructed--they have been developed logically.

 They have scientific foundations--evolving from observations that nurses make.

 They act as guides for nursing practice by suggesting better ways of nursing and caring.

 They identify the values with which nurses should work, which is essential if groups of nurses are going to provide continuity of care.

References

References are available upon request.

1.  Aggleton & Chalmers (2000)

2.  Peplau (1987)

3.  McKenna (1994)

4.  Walsh M. (1997)

5.  Kratz CR. (1989)