VII. Conceptual Approaches to Care

INTRODUCTION

            The term ‘nursing model’ was probably introduced to you in your basic education, and used for assignment work. Nursing models are supposed to be used in practice but in reality they are generally not used well, and appear to serve more as checklists for care plans rather than to inform the direction of nursing care. You may now be questioning the value of models of nursing, if they are simply used as a theoretical exercise in nurse education and a checklist in routine practice, but nursing models can, properly used, facilitate thinking about care and the philosophy that underpins it.

            Most nurses have used one or more nursing models. You are likely to be familiar with the Activities of Living model (Roper, Logan and Tierney 1980, 2000) and the Self Care model (Orem 1971, 1991). There are many models that can inform nursing and health practice. Models are not simple; they have been very rigorously contemplated by experts and each one serves as a representation of nursing. An interesting point about nursing models is the way in which they vary quite considerably, so that the purpose and intention of one, and the way in which it informs nursing, is quite different from these aspects in another model, and each is helpful to different branches of nursing.This will be discussed as the chapter develops.

PHILOSOPHIES OF CARE

           It is unlikely that anyone has a blank sheet, mentally, when approaching patient care, and this indicates that professionals take a considered approach in this matter. There are several labels for these general approaches. One approach to nursing is known as task-orientated – referring to the clinical task being carried out in isolation from any other aspects that influence the patient’s condition. Thus the nurse dresses the wound and does not consider other factors that could influence the healing of the wound or the patient’s comfort. Most nurses have heard the term biomedical model, which refers to treating the medical condition of the patient in isolation from the patient as a person. For instance, the patient’s heart condition would be treated but their excess weight and sedentary lifestyle, and the anxiety they might have about their health, would be ignored. Pearson et al. (1996) consider that many nurses still use the biomedical model as the basis for their practice.

            A term that is often used in relation to a general philosophy of care is holistic. The holistic approach takes into account a range of physiological and personal considerations for each individual and also places them in the context of contemporary society and of current health care provision. Holism is concerned with balance, i.e. with balancing the physical, psychosocial, and economic relationships of the person, with the environment in which they live (Aggleton and Chalmers 2000). Some branches of nursing, for example the nursing of those with learning disabilities, are more likely to take a holistic approach, as clients are not perceived in terms of a medical condition.

          The underlying philosophy of our approach to nursing very much reflects our individuality. ‘Philosophy’ refers to the beliefs and values that shape the way each of us thinks and acts. You will certainly have heard the word used in the context of philosophy to life. Some common sayings exemplify such philosophies: Live now pay later; A short life but a good one; You reap what you sow. These sayings demonstrate our use of the term philosophy in this context: how our beliefs and values shape thinking and influence actions. It is to be expected that life experiences, education, professional  socialisation  and professional experience will shape a nurse’s philosophy of care. Thus our underlying philosophy of care says something about us as individuals with unique personal experience.

CONCEPTUAL MODELS

           Nurse theorists have examined the concept of nursing and have illustrated their ideas through nursing models. The full term is ‘conceptual model’, differentiating this kind of model from the sort that are exact miniatures of real objects – model cars, boats, buildings, for example. Each of these can be perfectly recreated as a working model. Is it possible to build such a model of nursing? The answer is, of course, No; and the reason for this is that nursing is a concept. A concept is a collection of images and ideas that help to classify things and it is not possible to build anything material from images and ideas. The notion of a concept can be explained through something that is familiar, for example the concept of spring. There are certain aspects that embody spring: lambs, daffodils, buds on trees, sunshine and warmer days. Put all these together and a set of images that creates a picture of the season of spring comes to mind. Nursing is a concept that is built around a set of images.

          Your concept may involve images about caring, knowledge about health and illness, prevention of ill  health, rehabilitation and enabling people to help themselves, partnerships with patients and other health workers, the list goes on. When nursing is viewed in this way it is easy to determine why models of nursing are conceptual. It would be impossible to build such a set of images into a visible working model.

       It is possible to see that models may differ quite considerably because nurses think differently and hold divergent views about the concept. The difference in views will also reflect the varied concepts that are embodied in the different specialities of nursing. Take, for example, the conceptual difference between mental health and acute nursing. The concepts that make up the two roles will vary because the nature of nursing is different in each role; mental health nursing treating psychological disorders and imbalances while acute nursing is concerned with physical illness or disability. As conceptual models are developed for the nursing role it is logical that they will differ in accordance with the differences between branches of nursing.

         Fawcett (1984) identified some common ground by analysing four key concepts that are embodied in all nursing models. These are: (1) the person or individual; (2) the environment in which nursing takes place; (3) health; and (4) nursing itself. Whatever other concepts make up a particular model, these four are found in all. Nurse theorists have attempted to build conceptual models that illustrate ‘systematically constructed, scientifically based, and logically related sets of concepts which identify the essential components of nursing practice’ (Riehl and Roy 1980: p. 6).

Building Nursing Models

         Models must be put down in writing/text to enable them to be shared and used by other nurses. It is in this state that you have probably encountered nursing models. You might imagine how difficult it is to represent a complex set of concepts in writing. All models require to be portrayed through the written word and with the use of diagrams.

        Before any model can be effectively used it must be interpreted and understood. It may take time to work through some of the terminology, but this is necessary if the is model to be used as intended. You can see that Orem’s model (1980) is based on the ability of people to care for themselves. The model represents a balance between what people need to be able to do, which Orem refers to as ‘universal self care needs’ and a person’s ability to perform their care, which Orem refers to as ‘self care’. The model also lists areas where, for various reasons, an individual may require nursing intervention and suggests, under methods of helping, the form that such intervention might take.

       The model proposed by Orem has several components that relate to self care, starting with the premise that individuals wish to be independent and listing areas where people normally meet their own self care needs. There are health-related reasons that interfere with people’s ability to be independent and to care for themselves. The model looks at general reasons why a person may need help and makes suggestions about ways in which a nurse may support a patient in their striving for self care. The overall philosophy is to support self care and independence, and this sets the tone of this particular model and the direction that nursing care will take.

       Representing this conceptual model is not easy and Orem supports the concepts embodied in the model with detailed explanatory text. To use any model well, the whole model should be applied, with all concepts captured, in its application to patient care. Nurses tend to take what they consider to be the useful ideas from models and apply them in isolation. A prime example of this is the use of the Activities of Living model (Roper, Logan and Tierney, 1980, 2000), where the list of daily living activities is used as a checklist against which care plans are developed. This action ignores the essence of the model.

       You should now have an understanding of the nature and purpose of a nursing model. One or more models should be used by a care team to guide the process of care, and the model(s) must be supported by all members. The team leader has responsibility to ensure that all team members are sufficiently knowledgeable to be able to use the chosen model(s) competently to follow through the planned programme of care. Effective caring using a nursing model is a team effort.

Models with Differing Philosophies

         You may not feel that a Self Care model is suitable for the patient that you have in mind or for your branch of nursing. There are other options to explore, some similar to the ideas expressed in Orem’s model, others very different. A similar model was developed by Roper, Logan and Tierney (1980, 2000), informed by earlier work from Henderson, who offered a definition of nursing based on 14 activities of daily living (Henderson 1966). The Activities of Living model is well known and much used in the British Isles. It approaches nursing care by considering the activities of living that are common to all people, and how these can be influenced by a range of factors, the origins of which might be physical, psychological, social, cultural, environmental, political or economic. Other aspects that come into the model are the age of the person and the degree to which they are able to lead an independent life. The model focuses strongly on the many factors that influence activities of daily living and requires nurses to take these into consideration in making judgements about nursing care.

          Self care and activities of living tend to be concerned with planning nursing care in order to meet physical health deficits, which is why these two models are widely used to nurse patients with acute and chronic illnesses. They are equally suitable for wider use. Aggleton and Chalmers (2000) illustrate this point by applying the Activities of Living model to bereavement.

        Other models take a very different philosophical approach. Roy (1976) proposed a model based on adaptation. It works from the premise that each person is constantly adapting to an ever-changing environment. Roy suggests that an altered state of health requires a person to adapt to cope with changed circumstances. She sees the role of the nurse as one of facilitating adaptation in the patient by adopting a systematic series of actions, directed towards the goals of adaptation. The role of the nurse in this model is to facilitate the patient to adapt to their altered health circumstances and through adaptation learn to cope with the change. This explanation is much over-simplified but it indicates yet another conceptual approach.

        Neuman’s Systems model (Neuman 1989) takes a very different conceptual approach, based on wellness. It is concerned with the patient’s response to stressors in the environment. Each person develops a range of responses to cope with normal circumstances, with some people appearing to cope better than others with everyday life. There are, however, situations that occur in the lives of all people that deviate from normal and produce stressors that are very difficult to cope with. Neuman defines stressors as inert forces that have the ability to impact on the patient’s steady state (Neuman 1989: pp. 12, 24). Some situations may be positive and enabling whilst others may be detrimental. This model views the nurse’s role as intervening to enable the patient to maintain an optimal state of wellness. There may be opportunities in primary care practice to capitalise on facilitation and enable the patient to manage stressors that face them in order to attain an optimum state of health. Such a model may be well suited for use in school nursing, health visiting and occupational therapy.

     In Peplau’s Interpersonal Relations model (Peplau 1988) the key components are the interpersonal process, nurse, patient and anxiety. Peplau considers that people are motivated towards self-maintenance, reproduction and growth by biological, psychological and social qualities. The model views the interpersonal relationship between nurse and patient as the focal point of interface that will produce benefits for the patient’s health. There are elements of adaptation and coping in this model with the main thrust of nursing intervention coming through the nurse–patient relationship as a therapeutic interpersonal process. A model such as this, based on interpersonal relationships, may be well suited to mental health and learning disability nursing.

        The conceptual models that have been mentioned in this chapter serve to illustrate the wide and varying approaches that contribute to the development of models of nursing. The differing approaches afford choice in decisions that are taken about delivery of care, and consideration should be given by the care team to the most suitable choice of model for the patient. The models are complex and to use any one effectively it will be necessary to refer to texts where the model under consideration is fully examined. It will also be necessary to make sure that others involved in the care know and understand the model in all its aspects.

THE NURSING PROCESS: A MEANS OF IMPLEMENTING NURSING MODELS

          The vehicle for implementing a nursing model is the nursing process, a functional approach to the organisation of nursing care. Yura and Walsh (1967) identified a number of stages in nursing care with which all nurses have some familiarity: assess, plan, implement, evaluate. The four stages of the process are used in conjunction with a nursing model and its philosophy. Using Orem’s model as an example, the four stages of the nursing process could be applied as follows.

The assessment stage of the nursing process would take into consideration:

• the philosophy that people are normally self caring

• the ability of people to care for themselves, using universal self-care needs to guide the assessment

• recognition of the reasons an individual may require nursing intervention

• recognition of the way in which lifestyle and the patient’s environment influence the situation.

The care plan would detail:

• the actions that need to be taken to meet identified needs in relation to the patient’s normal lifestyle and wishes

• interventions that could be used to achieve self care, whether they are the responsibility of the nurse, the patient or others

• the type of intervention needed: for example, teaching how to carry out care, or giving care, and providing aids to living that enable the patient to regain independence

• ways in which the planned actions would be evaluated.

The planned care would then be given (implemented), bearing in mind that:

• planned care is given according to good practice;

• current knowledge that is evidence-based underpins the care

• lifestyle and the environment are accommodated in the provision of care

• care given is evaluated against changes in the patient’s physical, psychological and socio- economic condition.

Evaluation of care takes place to determine its effectiveness. This is:

• carried out as an ongoing practice at each visit

• includes, at regular predetermined intervals, an objective review of the care with reference to changes in condition, treatment effectiveness,

introduction of new treatments

• leads to an adjustment of the care plan, if necessary, updating it in accordance with the evidence of the review.

     Thus the nursing process, systematically applying a model, connects theory to what is done on a practical level; and the nursing process and model(s) of care offer a care team a more supportive structure than can be provided by a task-oriented approach to nursing. They enable systematic, logical organisation of care to be developed around a philosophical focus.

     Though we are here referring to ‘nursing process’, in fact the four-stage process outlined above can be applied to any situation that requires organizing. It is a tool that can be just as useful for organizing a charity walk or planning a teaching session.

       Through the use of models of nursing and the nursing process there is good support on which to base nursing and health care practice, in a well  planned manner. All nurses must be thoroughly conversant with models and process, but although these provide a philosophy of care and give structure to care, what else is needed to provide sound practice? Evidence from patient surveys suggests that patients would want competent and caring practitioners (Carey and Posovac 1982) and the next part of this chapter is concerned with competent practice.

EVIDENCE-BASED PRACTICE (EBP)

          You are taught in formal and informal situations. You read professional journals, books, literature from medical suppliers and drug companies. You observe those who you work with, some of whom you admire as role models. As you progress through your career you gain from experience. Many things that you have done have worked well and the patient has had positive outcomes from your care. These positive outcomes are sources of learning: you learned from something that went well. Learning can also take place following a poor experience. If something did not work well or went wrong a great deal can be gained from reflecting on the event, identifying what went wrong and considering measures that could be taken to improve the situation.

Objectivity in Nursing Practice

         Learning takes place in a variety of ways and everyday work provides a mixture of objective and subjective learning experiences. Information that is evidence-based has been based on research studies, and this is objective knowledge, gained from systematically established evidence. Subjective knowledge is gathered from observations made in practice, from conversations with colleagues and sometimes from teaching sessions. The problem with knowledge gained in this way is that it may not be reliable, and could even be unsound and dangerous. It is important that care is planned on the basis of objective evidence, and this means that knowledge that is gained subjectively must be checked to see that it supported by evidence.

     EBP, a key concept in modern health care, is one element of clinical governance (DOH 1999), a framework for the continual improvement of services and quality in the NHS, the purpose of which is to ensure that clinical decisions are based on the most up-to-date evidence and that clear national standards are set to reduce local variations in access to and outcomes of health care. Clinical governance has the following key elements:

• To set national standards for health services through development of national service frameworks and the National Institute for Clinical Excellence (NICE).

• To provide mechanisms for assessing local delivery of high-quality services, reinforced by a new statutory duty to quality.

• To provide support for life-long learning.

• To develop effective systems for monitoring the delivery of quality standards in the form of the Commission for Health Improvement, the NHS Performance Framework and surveys of patient/user experience (DOH 1999).

All health professionals are accountable for their individual practice and are responsible for making sure that their knowledge and skills are current. This implies that any care given is based on the most up-to-date knowledge available.

         EBP forms an essential element in the quality of health care and is directly related to clinical care in that clinically effective practice is based on national standards, frameworks and research.

A Systematic Approach to Acquiring Evidence

        Systematic acquisition of evidence provides the information from which standards and protocols for care are developed. Standards and protocols related to the provision of care are written by employers to guide the process of care. Health trusts use national guidelines based on the work of the National Institute for Clinical Excellence (NICE) and evidence from research as the basis for protocols. Each employee has a duty to keep up-to-date with, and refer to, guidelines that are supplied by their employer to inform their specific area of care, and to work to protocols.

       Research is the means of gathering evidence, and thus the source of guidelines and protocols. Nurses should have a working knowledge of the research process to enable them to appraise and understand the evidence that is presented as the basis for care, and be able to make a judgement on validity.

        McInness et al. (2001) suggest that evidence is not easily integrated into practice. The reasons that they offer for this are that research literature can be poorly organised and not easy to read, making it particularly hard for busy practitioners to access. The same authors also acknowledge the poor quality of some research. These comments make it clear that evidence is not always easy to access/understand, neither is it always sound. Health professionals must be able to interpret the information that is given to them to enable them to question evidence when it is unclear or unconvincing. The application of EBP lies with each health professional who must exercise judgement about the applicability of knowledge, whether it is evidence-based or subjective. Senior members of the team should have sufficient knowledge to support less experienced nurses, but all registered nurses should have a working knowledge that equips them to question the soundness of practice.

     A part of professional life must be the acquisition of knowledge that informs patient/client care. Access to information through electronic journals and websites makes information readily accessible. Most health trusts have access points for internet searches and this makes it so much easier for nurses to keep informed and current in their practice.

Evidence-based care or patient preference?

       There may be some instances where a treatment or practice, even though based on evidence, may not be appropriate for a patient. Thought and consideration are required to be given by practitioners at each care intervention. This makes the argument for evidence-based practice turn on itself. You may reasonably ask why objective evidence cannot be applied in all cases when it is likely to be effective. The response to this rests in the nature of health care practice, which is described by McCormack et al. (2002) as practice that takes place in a variety of settings, communities and cultures. To add to this complexity, there are other relevant influences, for example psychosocial and economic factors. Taking all these factors into account it is reasonable to assume that thought needs to be given to the application of practice. While practice should be based on evidence, it is also important to establish that the patient is suited to this care, and willing to accept the proposed treatment.

Informed decisions and patient choice

       One example of advocated treatment being found unacceptable to the patient, would arise in the case of a family who do not wish to have their child vaccinated with the triple measles, mumps and rubella (MMR) vaccine. The family might hold strong views about the safety of triple vaccine. Here the parents’ wishes might conflict with those of professionals, who have convincing reasons why children should be protected from childhood infections. There are no easy answers to this type of problem, and decisions taken must be carefully considered in the light of evidence that is presented from a range of sources. The patients’, or in this case the parents’, wishes are vital. When decisions about care are to be made the nurse’s role is to provide information that can enable the patient to make an informed decision, but in the end the choice rests with the patient.

     Planning decisions about care are normally considered by the care team, and a long-term treatment plan, though initially developed by one nurse, would not rest with a single individual. The plan would be discussed by the team to ensure that it was suitable and allow all team members to understand the goals and process of care. Daily evaluation of circumstances would, however, rest with an individual and would rely on informed decision making.

      Professional practice relies on nurses being competent in a range of specified outcomes (UKCC 2001), successful achievement of which equips nurses to practice. Practice requires that decisions are made, and that implies that each professional should be knowledgeable in their subject area and have the ability to translate their knowledge to support practice. Knowledge in itself has only limited value if it is used without due consideration of the effect that it might have on a situation. Thus a key aspect of professional practice is the ability to interpret and apply knowledge in widely varying circumstances. It is around the varying circumstances that decisions must be made that assure that care is appropriate and each nurse is accountable for the decisions that they make about patient care (NMC 2002).

LEARNING THROUGH REFLECTION

       Many of the issues raised in this chapter illustrate the complexity of nursing practice and demonstrate how thinking skills and decision making are essential to good practice. Not only is nursing practice complex it is also dynamic, and changes with developments in health policy and scientific knowledge. For nurses this means that every patient contact is unique and that over a period of time a great deal of experience is generated from nursing practice. Nursing practice, taken in its widest sense, means working with other health and social care practitioners to provide the assessment, organisation and management of holistic care for patients.

     Reflection is a great way to learn. It enables nurses to capitalise on what they do well and see how to improve the aspects of care that did not go so well. Taylor (2000) stresses this by stating how the unconsidered life is transformed, through the process of reflection, into one that is consciously aware, self-potentiating and purposeful. All recently qualified nurses will have been taught to use reflection as a method of learning, for just as EBP is a key concept in current nursing practice, so is reflection. Reflection has particular value to learning in nursing because of the richness of experience in practice and the direct observation that nurses are able to make about how the care that they and the health care team give affects patients.

Reflection and practice

       Reflection can and should take place during the process of practice. Schon (1983) refers to this as ‘reflection in action’. It also takes place after the event, which Schon refers to as ‘reflection on action’. Sometimes reflection is private, at other times it is shared with colleagues or may even form part of a team meeting.

       The exercise that you have undertaken is an illustration of reflecting on practice, learning from it and using the learning to inform and develop future practice. This is why reflection is so beneficial in nursing. In part it is explained because of the uniqueness of each situation demands new thinking and reasoning and this accumulates over time as experience increases.

      Reflecting on action is a deliberate event. It can be a very effective learning experience for the individual nurse or for the team. Each nurse should regularly take time to reflect on their practice, considering their knowledge and skills, the evidence base from which care is given and the many influences that impinge on care.

     Group reflection probably occurs informally in many teams at hand-over meetings when care is discussed. Reflection by the team in a more formal sense provides opportunity for review of patient care on a planned and regular basis. Like the individual nurse, the care team considers their knowledge and skills, the evidence base from which care is given, the influences on care, that are raised in models of nursing, and take a general reflective view of the care provided for each patient. Group thinking can be productive, with each member contributing an individual perspective, and everyone learning from the others in the group. Shaw (1981) suggests that groups make better- quality decisions than individuals, which has particular significance when so much is at stake for patients. However, some caution needs to be exercised when a group reflects, on account of a phenomenon known as groupthink, whereby pressures for conformity and for keeping within the boundaries of accepted practice stifle creative thinking (Robbins 1986).

     Learning often occurs when something happens that is disappointing or does not turn out the right way. It is this type of experience that most frequently makes people think about what they have or have not done and how it could have been more effectively achieved. It is not enough only to reflect and recognise where things went wrong: that is evaluation of the incident. Reflection is more than evaluation – it involves new learning. For learning to occur it is first necessary to identify what, in the case of a negative experience, went wrong. It is then essential to take the necessary steps to remedy the deficit and put it right. It may be as simple as recognising that work has been done without sufficient thought and that corners have been cut. In this instance the practitioner knows what should be done but has failed to do it correctly. The learning will be in the nature of accepting that however great the pressures, sufficient time must be given to each patient and procedure. It may, however, be that new learning needs to take place, perhaps a new skill needs to be learned, maybe from a colleague who has the necessary expertise. Sometimes knowledge is out of date and must be updated by reading or by attending study days. Very often in primary care nurses come across health problems that are new to them and they have to find the information that is needed to enable them to provide effective care. As you can see, learning involves taking some action. The purpose of reflective practice is to actively enable learning so that it becomes integral to routine practice. If a nurse constantly reflects on practice, learns from it and changes practice in response to learning, practice will not become static and out of date.

Aids to reflection

A number of frameworks have been designed to help the process of reflection. Many nurses are introduced to reflection by using the staged process advocated by Gibbs (1988). Gibbs’s model offers a cycle to guide nurses through the reflective process:

• describe what happened

• explore the thoughts and feelings that occurred as part of the experience

• evaluate what was good and bad about the experience

• analyse the experience in order to better understand it

• consider what else could have been done, and finally

• make an action plan to determine how the situation would be handled should it occur again.

       This cycle of steps gives an easy-to-follow process, guiding the nurse through reflection. There are other frameworks that facilitate the reflective process, for example Burnard (1991), Boud, Keogh and Walker (1985) and Goodman (1984). Goodman’s approach focuses on levels of reflection, suggesting three levels of increasing complexity. The first level consists of a simple approach that involves considering how the job was done with regard to technical efficiency and effectiveness, and in terms of accountability. The second level takes a wider view, looking at the implications and consequences of the nurse’s actions and beliefs, which includes the underlying rationale for practice. The third, most complex, level draws on all the considerations in levels one and two, and adds ethical and political considerations and developments.

       There are distinct differences between the approaches that are taken by Gibbs and Goodman. Gibbs offers a framework to facilitate structured thinking while Goodman pushes the boundaries of thinking to levels of considerable complexity. Examination of different approaches helps nurses to choose the one most suited to the situation. As with models of nursing the most suitable approach to reflection may vary with differing experiences and so it is beneficial to have a range of approaches to draw upon.

CONCLUSION

        This chapter has covered some of the key factors that influence and inform professional practice in nursing. This should create awareness of sources of nursing knowledge and reinforce earlier learning that introduced the nature and purpose of nursing models. There is no doubt that practice is complex and nurses can only truly attempt to meet the needs of patients if they are able to understand and manage complexity. The value of models of nursing is that, in representing the complex nature of practice, they act as prompts. Because each model is presented in diagrammatic form it enables the same detailed process of assessment, planning, implementation and evaluation to take place for every patient. Professional skill comes into play as infinitely variable information is analysed and interpreted into personal and individual plans of care that take account of very differing needs. The skill of the nurse is needed to manage patient information and translate it, with the patient’s collaboration, into meaningful and appropriate delivery of care. Nurses must therefore be knowledgeable and skilful. The dynamic nature of health care means that new knowledge is constantly emerging, and health practitioners are obliged to keep up to date with the latest developments.

         Knowledge and the validity of information are requirements for planning effective, economic care. Quality in care is high on the government agenda for improving the National Health Service (DOH 2000). Receiving care that is based on objective information is an essential part of provision; application of care without thought or consideration of the individuality of people would go against the ethos of professional practice (Norman and Cowley 1999). Norman and Cowley state that knowledge based on evidence is valuable and should underpin protocols and guidelines. Information that is collated and current greatly assists practitioners. Blind acceptance of evidence is not, however, consistent with professional practice, one criterion of which is autonomy. Reflective practitioners who are constantly learning on the job are fundamental to the profession – nurses who can plan appropriate care on an individual basis, with the patient, and are able to be justify their decisions.

 

 

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