4000 word written assignment that explores an individualized approach to care planning. You are exploring the process of care planning not the care in your reflective paragraph.
Select an individualized approach to care planning. Identify its key elements. Discuss how using the problem solving approach to care and appropriate framework can identify and meet the biopsychosocial needs of an individual. Discuss the strengths and limitations of the individualized approach and underpinning framework. Utilize examples from one of your formative care plans to highlight and support your discussions.
The primary aim of this assignment is to explore the individualised approach to acre planning that provides a basis for needs-oriented assessment alongside a nursing model and process to create an outline for patient-based activities. The paper will utilise Roper, Logan and Tierney (RLT) nursing model to evaluate the most critical factors in relevant to designing individualised care framework. According to Barrett, Wilson and Woollands (2014), a nursing model helps in identifying primary nursing activities across the various fields in nursing to ensure that individualised care plan improves patients’ outcome. A detailed analysis and discussion will be presented in the paper to illustrate the strengths and limitations of the model in providing a specialised treatment plan for patients. Besides, the paper will incorporate the APIE nursing process where APIE refers to Assess, Plan, Implement and Evaluate (APIE) (Yura & Walsh, 1988). A nursing process is a systematic approach that focuses on an individual patient to ensure that his/her holistic needs and experiences are considered when designing individualised care plans. The holistic needs of the patients may involve investigation into factors such as social, cultural, psychological and environmental factors that may affect patients’ outcomes. Barrett, Wilson and Woollands (2014) emphasise that a nursing process is a problem-solving framework used to plan and administer nursing care to patients and their families. When both the nursing model and process are used collaboratively, service providers would be able to treat patients holistically instead of focusing on the specific diagnosis. As such, this paper will consider a fictitious patient James Connery who had been previously diagnosed with myocardial infarction and will be referred to severally within the assignment.
The primary focus of care planning as a highly skilled process is to ensure that patients get the best possible care services. The nursing and midwifery councils mandate that specialists such as graduate nurses under supervision, registered nurses and therapists should provide best care services. Report by Departmental of Health (2015) indicates that personalised care planning services address individual needs while putting into consideration their health, ethnic, cultural, personal, economic, mental health, educational and social backgrounds as well as circumstances associated with the patients experiences with the hope of reinstating the patient to original state of health enjoyed before the illness. As such, care planning enables service providers to establish other causative agents that are not associated with the symptoms of the condition but contributes to the deteriorating health of the patient hence affecting his wellbeing. Care planning is essential as it documents all the material information regarding the medical interventions that were provided by the nurses for future references thus making data and patient management a critical aspect of the practicum experiences. Care planning is vital as it enables care providers to access patient information concerning current problems, the medications and how the challenges affect their twelve activities of living. Taking care of patients is a legal, professional and ethical obligation of any nurse (Dimond 2011, p.88).
Although there exist several nursing models and processes, the choice of an appropriate model and process depends on the individual needs of the patient. For instance, the unique needs of James who suffers from myocardial infarction would be different from individual suffering from diabetes or other chronic health conditions (Krumholz et al. 1998). Despite the proposition by Barret et al. (2014) on the use of fifth and sixth stages such as precise nursing diagnosis and recheck, the care plan for James is based entirely on the four steps which are to plan, assess, implement and evaluate (Holland, Jenkins, Solomon and Whittam 2008). Many hospitals use predetermined care plans that are commercially made and may not contain all the elements that are relevant to specific patient needs. Therefore, it is essential that the nursing process be logically used, as it will enable the nurse to reduce omissions or common mistakes that are not easily identified in the nursing process. Roper, Logan and Tierney propose a nursing model entailing five interlinked concepts that need consideration when planning and implementing care such as activities of living, lifespan, dependence/independence continuum, factors that impact activities of living and individuality in living (Koutoukidis, Stainton and Hughson, J. (2012). The biographical data was collected from the patient’s life experiences, demographic data and attitudinal background. The information is essential in identifying individual personality and past behaviour that would be essential in forecasting future behavioural patterns (Roper, Logan and Tierney 2000). According to Roper et al. (2000), individualised strategy to care provision is achievable by using the nursing model with nursing processes (Yura and Walsh 1988). The process begins by identification and collection of biographical and health information such as name, age, address, date of birth and medical history to obtain necessary data for continuous patient evaluation. Barrett, Wilson and Woollands (2014) confirm that acquiring primary data about a patient is vital in identifying the possible indicators that could have a substantial impact on the nursing intervention adopted. However, Caulfield (2011) indicates that there could be problems and inaccuracies in gathering essential information regarding patients. Promisingly, a holistic approach to care planning where family members are involved is critical for limiting the biases.
The most fundamental nursing skill for nurses and medical practitioners is assessment. It is essential in obtaining basic information concerning patient’s medication history and personal details that are used by nurses to meet their needs (Barrett, Wilson and Woollands 2014, p.128). Assessment is very significant in care planning as t provides an extensive basis for designing individualised care plans. The assessment process begins by identifying and collecting patient’s details and holistic needs such as psychological, physiological, social, economic, environmental and spiritual needs that are essential in designing and delivering individualised nursing care needs (Roper, Logan and Tierney 2008). Whilst using the 12 activities of living for assessment, it is critical for service providers to ask straightforward questions through a general conversation to obtain patient-specific information. During this process, nurses should not jump into conclusion or ask leading questions as this may compromise the quality and reliability of the information received from the patient. Assessment is the foundation upon which the planning, implementation and evaluation of individualised care services are based. Any misconception and misinformation at this stage may compromise the advanced stages of care delivery.
Therefore, nurses may obtain and validate information from the patient, family members and friends for consistency and accuracy (objective and subjective data).
Caulfield (2011) emphasises that care providers should gather information relating to physical activity. For instance, the nurse should identify the actions that the patient can perform with or without support. However, acquiring basic information regarding physical activity requires the nurse to be close to the patient and build effective communication framework that thrives on trust. Besides, comprehensive information about the patient would entail how the patient was before the illness and his/her psychological, physiological and cognitive state after the disease. In addition, the care providers should acknowledge the achievements of the patient in trying to recover from the illness. A comprehensive analysis of the facts would provide nurses with a broader understanding of the perceptible, actual, existing and potential implications that may occur during the individualised care planning process.
Moreover, Caulfield (2011) suggest that the assessment information obtained by the nurses should be classified according to the threat it has on the patient. The most life-threatening conditions should be given priority. Upon complete assessment, information is obtained; the data can be used to assess the patient’s ability to perform the 12 daily activities of daily living hence facilitating holistic, comprehensive and individualistic care services. Although Roper et al. (2000) provides that activities of daily living have relevance in life, Murphy et al. (2000) argue that the increasing prominence of activities of daily living (ALs) may create confusion and shift attention away from the patient. The most critical aspect of the gathered information may be necessary for determining different needs and priorities by patients; there is a need for professional judgement to determine the most appropriate care plan (Dimond 2011, p.100). By the end of the assessment phase, the nurse should be able to identify precisely the problems that the patient has. In addition, instrumental activities of daily leaving such as companionship and mental support, transportation and shopping, preparation of meals, managing household activities, managing communication and finances and communication are higher level and complex activities that determine the patient’s level of independence alongside the 12 daily activities.
The service providers should assess the dependence/independence continuum alongside lifespan because they are closely linked to the activities of daily living. The assessment will provide information on whether the individual is entirely independent, entirely dependent or partially independent/dependent (Roper, Logan and Tierney 2000). The level of dependence/independence enables the nurse to determine whether the patient needs additional support or not. The nature of activity and tasks that a patient may perform is also dependent on the age. James is a senior who has the potential to actively engage in daily activities with proper assistance that facilitates independence. For instance, there are some daily living activities like dressing and cooking that age may limit an individual from performing due to muscle deterioration and other chronic medical conditions such as polymyalgia rheumatica.
Furthermore, biological, politico-economic, sociocultural, psychological and environmental factors that determine an individual’s ability to perform tasks should be considered during the process of assessment (Barrett, Wilson and Woollands 2014, p.150). These factors have a significant influence on the environment where a patient is placed as these dynamics determine the level of a patient’s independence/dependence continuum, lifespan and individuality (Barrett, Wilson and Woollands 2014, p.180). The process enables the nurse to identify the potential risks that may emerge and the severity of the problems (Barret et al. 2012). Trueland (2014) advocates for sharing of information with patients regarding the issues identified with the intention of promoting the independence continuum.
Considering the case of James who suffers from myocardial infarction, the assessment fails to identify the exact position of James on the dependency/independency continuum before his diagnosis. Although James accepts that he experiences exertion when performing do it yourself (DIY) activities and its contributory role in suffering myocardial infarction, it is complicated for the nurse to determine the basis for the care plan and the ultimate goal of care planning. In addition, the available objective data was instrumental in designing a practical approach to individualised care planning because the material facts were collected accurately. Besides, the use of systematic diagnosis would have facilitated a comprehensive approach towards medical diagnosis and holistic needs of the patient including the spiritual and biopsychological needs (Roper, Logan and Tierney 2000). The diagnosis would also enable the nurse in collaboration with the patient to know the level of the patient concerning his performance of the 12 daily living activities.
Planning is the second stage of the nursing process in which the acquired assessment information regarding the patient is used to plan the care services for the patient. At this stage, the care providers, the patients and the representative of the patient discuss the achievable goals regarding the patient. The step involves the identification of a suitable nursing plan that suits the already identified patient needs. According to the National Institute for Health and Care Excellence (NICE 2014), planning stage requires a multifaceted and collaborative approach with the primary objective of making better the health behaviour by providing motivational and supportive interventions that improve the quality of life and wellbeing. The application of both the nursing model (Roper et al. 2000) and nursing processes (Yura and Walsh 1988; Koutoukidis, Stainton and Hughson 2012) in planning individualised care plan provides a conceptual framework used to detect and prevent potential problems from occurring. Yura and Walsh (1988) emphasise that identifying potential problems will not only allow the nurse to teach the patient on the future risks associated with the condition but also explicate the ability to protect the patient from the perils. The most appropriate plan should identify the anticipated problems before they occur and prevent the reoccurrence of the issues that had already been treated. Caulfield (2011) indicate that the use of evidence-based intervention is the best approach to alleviating the problem as it allows the nurse to formulate specific goals that would help in the realisation of positive patient outcomes.
Prevention of relapses is a significant concern for nurses and medical practitioners as it may have adverse impacts on the recovery process. For instance, despite James having a heart attack, he routinely smokes hence increasing the risks associated with other lung infections. Therefore, an effective care plan should incorporate remedial programs that would enable James to stop smoking and make sure that he does not suffer any relapse. Thus, Barrett, Wilson and Woollands (2014) propose that individualised care plan incorporates not only practical patient and nurse relationship, but also a working partnership that reinforces trust and builds patient’s confidence on the nurse. The success of this intervention depends on the effective use of evidence-based practices and meeting the individual needs of the patients to help them improve on areas that require further development (Lövestam et al. 2015). Besides, patients may take a proactive role in planning their recovery process by setting realistic and achievable goals, which in turn facilitates informed decision making.
Trueland (2014) highlights that patients will always feel empowered if they can identify and achieve specific goals. Helping patients’ setup goals is a comprehensive but essential process that is guided by the acronym SMART that describes goals that should be specific, measurable, achievable, realistic and time-bound. The patient formulated goals should be achieved within a given timeframe to enable the nurse to determine if the patient is making positive progress. There should be clarity in the goals set by ensuring that they are address specific needs of the patient, designed a person-centred approach to care planning which is meant to meet specific requirements by patients.
Yura and Walsh (1988) confirm that goals set should be measurable and time-bound hence enabling the nurses to evaluate the patients’ outcome. Besides, Yura and Walsh (1988) observed that making the goals realistic and achievable increases the chances of patient success thereby eliminating disappointments resulting from unaccomplished tasks. Subsequently, to improve the patient’s outcome, it is vital for the care providers to determine the situation of the patient on the dependency/independency continuum before the actual goals are formulated. The evaluation of the independency and dependency continuum allows the care provider to construct personalised goals that either promote independence based on the independency score and dependence based on the dependency placement (Coulter et al. 2015). If high dependency is identified, the required support will be provided by the nurses to prevent disappointment and boost self-efficacy and efficiency of the patient. For instance, a patient with post-traumatic stress disorder may develop cognitive incapacitation that may hinder the patient from performing daily living activities such as basic hygiene requirement and become unable to improve their current state of dependence.
Yura and Walsh (1988) highlight that the goals set should be for short-term and long-term. The short-term goals could take minutes, hours or days while long-term goals could take weeks, months, a year or years to achieve depending on the nature of the illness. Setting short-term goals would enable the nurse to monitor and evaluate the progress of the patient and make adjustments where necessary to ensure that the patient is making positive progress that would help in the realisation of long-term goals. The accomplishment of the short-term goals would build the confidence of the patient in meeting long-term goals. Besides, the goals should be patient-centred and reflect the responses to be observed on the patient rather than nurse oriented with several activities to be performed by the nurse. However, Niven and Scott (2003) opposed the RLT model by explaining that the model deviates from patient centred approach as it provides a checklist of expected outcomes, which does not take care of the psychological needs of the patient.
Based on the first item in appendix 1 in the planning stage, James mobilisation does not indicate complimentary goals because he does not acknowledge the possibility of pressure ulcers occurring. Although the identification of actual problems is evident, James fails to identify potential challenges relating to his health. As a result, his health is likely to worsen because not all the information relating to the potential risks are not recognised and analysed to devise an action plan to mitigate the risks if they occur. Consequently, James will gradually lose his independence and become highly dependent on support. However, if James loses independence, the nurse is professionally and ethically obligated to exercise beneficence and protect the patient from injuries by demonstrating a high sense of accountability (Dimond 2011, p.150).). Besides, it is important to understand that failure to recognise pressure ulcers at an earlier stage increases the burden of the condition on the government costing it over £2.1 billion, accounting for 4% of the National Health Services (NHS) expenditure (Dealey, Posnett and Walker 2012, pp. 261-265). A comparison between the current burden and incidence of the condition with data collected ten years ago by Bennett, Dealey and Posnett (2004) indicate that the cost of treating pressure ulcers is rapidly increasing and needs critical examination.
Moreover, the target set concerning James social relationship in the fourth item in appendix 1 is short-term thereby failing to meet the necessary condition for SMART and PRODUCT goals. The acronym PRODUCT stands for Patient centred Recordable, Observable and Measurable, directive, understandable and clear and time-bound. The short-term purpose of evaluating social connections is unrealistic, cannot be measured and recorded. It is difficult to approximate and allocate the time that James will spend interacting with others alongside the outcome of such contacts. Caulfield (2011) emphasise that individuality and preferences of the patient need great attention for accountability. The nurses should uphold the dignity of the patient, respect his opinions and support his wellbeing throughout by setting realistic goals regarding his mobility explaining to him the importance of gaining self-understanding about his condition.
Roper et al. (2000) describe this phase as the doing stage where the plan that had been designed in the previous stage is executed. The interventions are multidisciplinary as it involves both the nursing team and medical practitioners to help patients’ go through the problems identified. It is paramount that nurses recognise the individuality, personal preferences and uniqueness of each patient’s needs (Hughes, Lloyd and Clark 2008). The short-term and long-term goals identified in the planning stage become actionable through medical and nursing interventions. Yura and Walsh (1988) refer to implementation as the actual dispensation of the actual care services. The implementation involves personnel such as doctors, nurses, clinicians, physiotherapists and dieticians to help the patient return to the previous state of health enjoyed before the illness or admission in a care facility. The care plan is specific as it is centred on the biopsychosocial aspects of the patient and how it affects the patient’s ability to perform daily activities of living (Barrett, Wilson and Woollands 2014).
The implementation phase relies on the patient’s placement on the dependency/independency scale hence it is essential that the patient is correctly placed on this scale at the assessment and planning stages for the effectiveness of the care services (Murphy et al. 2000). The care providers should ascertain the ability of the patient to perform specific tasks and identify the activities that the patient call confidently complete to facilitate the evaluation of the effectiveness of the care provided. Individualised care evaluate how the patient performed tasks before the illness and how s/he handles them currently. Yura and Walsh (1988) highlight that care services should be delivered on an evidence-based basis to assess the possibility of the patient regaining the lost competencies. Yura and Walsh (1998) father indicate that the provision of care services should be instinctive and based on nursing interventions instead of implementation where the nurse offer minimal management (Roper et al. 2000). Furthermore, the RLT model may be used for educational purposes to assist practising students evaluate the effectiveness of their services while giving direction on specific procedures to be followed when designing the individualised patient care program. Besides, Yura and Walsh (1988) underscore that there is need to interrogate the competency level of the nurse to ensure that the care providers have sufficient knowledge to support the patient and intervene effectively (Barret et al. 2014).
The formative evaluation of the patient begins at this stage as the nurse, and the patient begins to discuss matters relating to the illness, collect and examine data and determine the possibility of success in meeting the set goals. The discussion and evaluation at this stage are crucial because it enables the care provider to assess whether the aims will be achieved within the given timeframe and make the necessary adjustment to increase the chances of success. Concerning the evolution of nursing from four steps APIE to six-step ASPIRE, Yura and Walsh (1988) insist that the planning process should be comprehensive, succinct and offer an accurate guideline on improving patient’s outcome. Barret et al. (2014) observed that different people develop the nursing interventions implemented by care providers thereby creating the need for the nurse to have sufficient knowledge to help the patient realise the intervention goals.
Additionally, the success of care planning depends on the competency of the nurse to perform her/his duties effectively. Therefore, there is need to continually evaluate the skills and knowledge of the nurse enhance the safety of the patient and the effectiveness evidence-based practice (Aarons, Hurlburt and Horwitz 2011). Nursing intervention at the implementation stages aims to restore the patient’s independence in performing the daily activities of living. The implementation of the care plan is a comprehensive process, and without routine monitoring and thoughtful planning, the patient may have an adverse outcome. Patient’s success at the implementation stage should entail both physiological and psychosocial needs. The nurses should possess adequate skills and competency that would enable them to devise the required clinical intervention and meets the individual requirements of the patient.
Concerning James’ inability to understand his myocardial infarction condition or how to take good care of himself (Appendix 1 (No. 1)), the care plan focuses on helping James gain meaningful information about his condition and its effects on his daily living activities. James has to accept the information given and use the information to manage his health. The data will help James to work towards the realisation of independence in performing tasks while upholding the most suitable living standards and enhance his level of self-control. Roper, Logan and Tierney (2000) insist that long-term instructional modules will help the patients comprehend their conditions and realise a better quality of life through positive behavioural changes.
Evaluation is the fourth stage of the nursing care plan and is essential in determining the effectiveness of the care plan administered on the patients. At this stage, the care plan has been given can be assessed to determine whether the care plan worked or did not work in helping the patient improve his/her condition. Although summative evaluation comes at the last stage of the care plan, formative evaluation is done from the beginning to determine the success of each stage before the overall assessment of the whole system (Hughes, Lloyd and Clark 2008). As such, evaluation is a continuous process that helps the care providers identify specific patient needs, ability to perform tasks and improvements needed. The summative assessment examines the holistic process of the care plan to assess if the patients felt the care services provided helped improve their condition and whether the goals were achievable during the planning process and determine the effectiveness of the treatment. According to Yura and Walsh (1988), summative evaluation ensures that the original care plan was appropriate, realistic and complete thereby taking care of the needs of the patient. Further studies by Barret et al. (2014) indicate that evaluation is not adequate to determine the effectiveness of the assessment, planning and implementation of the care plan and therefore, proposes an advanced level called recheck. They recommend that recheck would enable the care providers to review the condition of the patient to create a succinct evaluation process.
Nonetheless, Barrett, Wilson and Woollands (2014) indicate that it is essential for nurses to observe, measure and interpret the available information to determine the extent to which the set objectives have been met and the existing gap that requires further development. The individualised approach enables the patient to play an active role in the recovery process with the primary goal of gaining independence in performing daily living activities (Roper, Logan and Tierney 2000). Regarding James who is a fictitious character, it is not possible to evaluate his care plan because he is non-existent. However, the second part of Appendix 1 indicates the appropriate approach for elimination although James does not have previous experiences with the condition. The use of recheck between implementation and evaluation of the care plan provides useful information relevant to the progress of the patient.
The use of RLT model with Yura and Walsh’s (1998) process as a conceptual framework, individualised care plan could be developed to help James recover from his condition. The model and process provide useful information regarding the strengths and weaknesses of the patient by focusing on the patients’ biopsychosocial needs. However, there were some complexities in devising appropriate care plan for James due to uncertainties in the RLT nursing model. Despite the challenges, the nursing process has presented the importance of individualised care planning when helping patients with chronic conditions recover from their illnesses. The model and process have proved invaluable in developing a personalised care plan for patients because it enables the nurse and the patient to know what is to be done, why, where and when it is done hence promoting holistic recovery process.
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