Models of Nursing

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The focus of this assignment is to outline the assessment process within nursing and show its practical use and importance. The assignment is broken down into different elements, including defining what assessment means and its importance within the nursing process leading on to the various sources of information which are used to inform nurses upon their assessments. The STAMP assessment tool will be explored to show how it supports the assessment process in practice. Finally, suggestions will be made as to how nurses develop a positive relationship with patients to assist the assessment process.

The ideas developed throughout the assignment will be backed up using the wealth of literature available. The nursing process was introduced in the United Kingdom by Yura and Walsh in 1967 (White, 2005, p128). This was an attempt to direct traditional nursing away from intuitional and ritual practice. The purpose of developing this process was to develop a method for applying a scientific problem-solving approach to nursing practice (Haberman, 2005). Alfaro-LeFevre, (2006, p4) summarises this process into a systematic six staged sequence. He defines them as follows: – Assess, diagnose, identify, plan, implement and evaluate.

Every phase within this process outlined above have an individual role yet they are all interdependent with one another (Royal College of Nursing (RCN), 2009, section three). Barrett, Wilson and Woodlands, (2009) expand this process further, adding that this is a cyclical, on-going process which continues throughout the nursing process. Benner (1984, pp42-43) expands on the nursing process stating that many different models of nursing have been established to augment this procedural, elemental staged approach giving structure to the care delivery whilst meeting a patients individual needs.

The various different models represent a varied range of values and beliefs that guide the nurse through the problem-solving process. Roper Logan and Tierney (1980) argue that the nursing process on its own is vacuous, unless used within the context of a conceptual framework or nursing model. Assessment is both the initial stage of the nursing process and a continuing element in every other step of this process (Atkinson & Murray, 2000, pp25). In their classic work, Roper, Logan and Tierney (2000, pp. 124) consolidate this point, noting that the word assessment has been adopted as the title of the first phase of the nursing process.

They clarify that this does not mean it is a once only activity, but it includes: gathering information from or about the client, reviewing that collected information, then recognizing the person’s problems and prioritizing from amongst those problems, whilst following the nursing process. This ascertains the care/treatment and services an individual requires throughout the nursing process. Additionally, the word ‘assessment’ in its broad sense can be defined as ‘an activity which includes gathering data, interpreting the significance of the data and deciding on whether there is need for further action,’ (Campbell and Glasper, 1995, p.

127). Linking this definition to the nursing process, it can be interpreted as the manner in which the nurse collects and evaluates data about their client (family, community or individual). Mason and Webb (1997) highlight that the nursing diagnosis and the nursing assessment are very closely related, being that the diagnosis a clinical judgement, which is made as a result of the assessment process. In their findings Barrett, Wilson & Woollands (2009) observe that assessment is not just about recording a list of problems; it is more about identifying what the client can do as well as finding out what the client cannot do.

Field and Smith (2008) support this further, suggesting that assessment should be an individualised person- centred approach taking the whole overall picture into account, covering all aspects of a person’s life such as culture, religion, any illnesses or disabilities etc. This is looking at the patient as a person in their own right, rather than as the condition/disability they may have, subsequently forming an overall objective assessment within the nursing process. The assessment stage within the nursing process can be split up into different levels.

McGee (2009, p174) describes a two level approach; the first-level assessments represent behaviour and this involves gathering data about the behaviour of a person or group. Second-level assessment is the assessing of stimuli by identifying the internal and external stimuli that influence a person’s behaviour. Peplau (1992) suggests that the data collected is often attained through observation and interview which are as a response toward challenges to the internal and external environments. These forms of assessments are continually being assessed and reassessed, and contribute to the overall assessment process.

Atkinson and Murray, (2000, pp25) understand assessment as a method of data collection and condense the assessment process to a simplified equation. They suggest that assessment is equal to the observation of the patient + interview of patient family and other nurses + examination of patient + medical record review; these are all examples of the many different sources of information and evidence that is obtained within the assessment process. Dillon (p. 11, 2003), proposes that all the different sources of data collected can be categorised as subjective and objective.

Subjective data reflects the feelings of the person articulating it and can generally be found in the realm of the individuals’ experiences. The information being portrayed, is typically immeasurable and covert, Atkinson and Murray (2000, pp. 34) highlight that subjective information could infer many different interpretations and is therefore unreliable without support from additional data. Examples of subjective data include memories, thoughts, perceptions, emotions, immediate sensations and states of mind.

Relating this to nursing, an illustration of subjective data would be, the patients’ health history (i. e. from the patients’ point of view) and symptoms (i. e. from the practitioners or patients point of view), (Marilyn et al, p234, 2010). However, this is an important source of primary data, as McCain (1965) cites that secondary sources only clarify and substantiate information obtained from the primary source. Objective data is often referred to as signs; these are measurable and quantifiable pieces of data which are unbiased, factual, and unaffected by personal feelings or understandings.

This form of data comprises of a wide range of sources, included in these are, the physical examination, integral patient care plans, diagnostic studies, and anything that we can touch or observe scientifically in time and space. Nursing care within the multi-disciplinary team makes use of objective evidence, this may be shown by the use of biographical data, height, weight, test results etc. to determine drug calculations, all these resources of information contribute to the overall care delivery of the patient (Marilyn et al, p234, 2010).

Beck and Polit, (p233, 2008) analyse these different sources of data and support it further stating that within a healthcare setting the primary data is regarded as the client/patient which contributes the first-hand information. Primary data represents the most direct link with the situation and is often the most valued source. Secondary sources are used when a patient is incapable of supplying the necessary material due to age seriousness of illness or deterioration of mental status. Both primary and secondary data can be subjective or objective in nature.

Secondary data sources are pieces of information collected from anyone or anything aside from the client, these include family members, friends, other healthcare providers and old medical records e. g. x-rays. Secondary sources are interpretations of an incident by any method of communication other than the client/patient, these sources often clarify or summarise the primary data (Reed, 1992). Assessment takes place across the nursing process in an informal and formal manner. Formalised sources of information such as admissions, handovers and care notes are valuable in their own right.

It is however imperative to gather data from multiple sources in order that the data can be corroborated and verified as accurate. (MacNeela, 2010) Many different assessment tools are used broadly across the healthcare setting, assisting the assessment process. Cowell Gilbride and Simko (1995) describe the purpose of the assessment tool, explaining that the tool can be seen as a device used for facilitating or doing, this can be demonstrated as an instrument or implement to accomplish a purpose.

Tools can be adapted and individualised to give and receive data of interest in a particular situation, they guide and a form access to provide an understanding into the data we are trying to receive from the patient/client. Generally a series of tools are selected to strengthen the validity of data collection and implement essential intervention. A typical example of one of these tools currently used in practice is the STAMP assessment tool (screening tool for assessment of malnutrition in paediatrics).

STAMP was developed and validated at the Royal Manchester Children’s Hospital in a project led by Dr Helen McCarthy in 2008, this was a nurse administered screening tool for assessment of malnourishment in paediatrics for children between two and sixteen years of age (NHS foundation Trust, 2010). STAMP consists of five stages; with steps one to three containing elements that cover the background clinical condition, dietary intake and finally anthropometric data.

This involves the mixture of two questions, which are both forms of subjective data, for the child’s guardians/parents and an assessment of nutritional status – weight and height, drawing on the use of objective data. All these are then scored and combined to give a nutritional risk score at step four. Step five guides through a care plan and the suitable pathways for support. This amalgamation of risk questions and nutritional status produces a result which relates to the child’s chance of becoming malnourished.

(Bhagavatula and Tuthill, 2011) STAMP is an invaluable tool which facilitates the assessment process within paediatric nursing, as evidence mounts that malnutrition poses a risk. According to the RCN (Royal College of Nursing) one in five children admitted to hospital are at risk of malnutrition. Increase in morbidity, extent of hospital stay, mortality, and sequentially the cost of supplying healthcare can all be as a result of malnutrition. Malnutrition can be caused by insufficient nutrition or a disease process, clinical malnutrition negatively affects outcomes and has serious effects on recovery from disease, both chronic and acute.

Consequently the detection of people at risk of malnutrition is a significant part of any strategy for providing optimum patient care (Lennard-Jones, 1992). The STAMP tool is completed by the nurses who have a key role in the nutritional screening of children (Dixon & McCarthy, 2008). Nursing staff are the first to come into contact with children and families within the healthcare setting, it is therefore practical for them to be authorised to screen for nutritional discrepancies and review a pathway accepted locally or regionally and to start the cascade.

Staff may need some training to use this tool so the outcomes are uniform making it dependable and reproducible (Hop et al, 2009). Recent research evaluating this tool has compared the ‘STAMP assessment tool’ to another paediatric nutritional screening tool developed in the Netherlands. STRONG kids (screening tool for risk of impaired nutritional status and growth), assess the nutritional risk of a child by probing four questions, two of these are answered by another health professional and the other two by the child’s primary caregiver.

The data presented from this tool, relays exclusively on the questions answered by the parents and investigators – subjective data, whilst STAMP on the other hand draws on objective and subjective data which support each other. Another drawback of the STRONG kid’s assessment tool is that it’s developed for use by paediatrician and therefore may not be suitable for nursing use (Tuthill and Bhagavatula, 2011). However there are some limitations of STAMP, some of the terminology used are vague; this highlights the need for appropriate training and good communication with regular updates.

The STAMP tool has a tendency to over-diagnose the nutritional threat in hospitalised kids compared to the STRONG tool which delivers a more accurate identification of kids who are at risk of malnutrition. There are on-going studies to determine the ease of use in both nutritional assessment tools, rough estimates suggest that STAMP is clumsier to apply. (Hedges, Ling and Sullivan, 2011) The NMC code (2008) highlights, that all nurses must respect patients in their own rights, prioritising their care whilst maintaining professional boundaries at the same time, this is the basis for creating a therapeutic relationship.

The nurse establishes and maintains this key relationship demonstrating caring behaviours and attitudes. McMohan & Pearson (1992) recognise that therapeutic nursing contributes to the client’s wellbeing and health and is therefore acknowledged for its effects. This relationship is based on respect, trust, professional intimacy and empathy (Practice Standard, 2006). Smith (1992) apprises that therapeutic relationships demand suitable interpersonal relationships with patients, other health care providers and relatives, this creates a good rapport, and reflects nurse’s ability to communicate effectively.

Ley (1988) postulates that interpersonal communication is extremely important to all nurses as patients interact more with them than any other healthcare specialist. Empathy, warmth and genuineness in conjunction with unconditional positive regard will assist successful communication whilst maintaining a person centred attitude. Within communication, the verbal channel is used to express information whilst the non-verbal channel which is used to transmit interpersonal approaches (Trower, Bryant and Argyle 1978).

Practical examples of communication within assessment could be the data collected will act as a basis on which the patient status is evaluated or simply escalation if the patients vital signs are unstable, this would include communication between other healthcare professionals using some objective and subjective data. (Choi et al, 2009). An open communication channel would confirm that the patient will feel secure, with the expectation of being accepted and understood, this involves an amount of mutual trust and intimacy (Timmerman, 1991).

This displays non-judgemental practice and enables the nurse to get a more accurate assessment of anything, like incidents from the patient as they will feel more comfortable to disclose. This may include examples of empathetic communication, this conveys a resonating, validating and understanding with the meaning that the situation holds for the patient. In nursing assessment it is important that the nurse includes an emotional distance to ensure objectivity. (Kunyk & Olsen, 2001) Within the nurse-client relationship trust is crucial as the client is in a vulnerable position.

Bricher (1999) demonstrates how trust is the key cornerstone in developing cooperation especially in paediatric patients and supports the assessment process by allowing the child or parent to confide, so necessary services/support are accessed. Hupcey et al (2001) proposes that trust may be fragile initially and it’s especially important that it is not breeched as it may be difficult to re-establish. Another feature of the therapeutic relationship that the practice standard (2006) cited is professional intimacy.

Kadner (1994) describes intimacy as being the self-disclosure of personal material with the expectancy of encouragement and acceptance. This is integral in the type of services and care that a nurse delivers. It may associate with physical activities, such as bed washing that is performed by the nurse, this creates closeness with the client. Respect is the acknowledgment of the uniqueness, worth and inherent dignity in all people unrelatedly of their personal attributes, description of health problem or socio-economic class.

This allows the nurse to be objective when assessing the patient and not jump to conclusions distorting the information (American nurses association, 2001), (Milton, 2005). In conclusion this assignment has defined what assessment is and how its use within the nursing process. Practical examples of assessment tools were explored, illustrating their benefits and finally shown how the professional nurse-client relationship is formed around assessment process.

In short the main feature of assessment is the meeting between two people – the patient and nurse, to tackle a specific health problem with the intention of determining what further action should be taken. Consequently assessment lays the basis for therapeutic decision making and action within a professional relationship. (Peplau, 1952) Alfaro-LeFevre, R. (2006) Applying Nursing Process: A Tool for Critical Thinking (6thed). London, Lippincott Williams & Wilkins. American nurses association. (2001) Code of ethics for nurses with interpretive statements. Washington, DC. Atkinson, L. , D.

& Murray, M. , E. (2000) Understanding the nursing process in a changing environment (6thed). USA, Mcgraw Hill, pp25. Barrett, D. , Wilson, B. & Woollands, A. (2009) Care Planning: a guide for Nurses. UK, Pearson. Beck, C. , T. & Polit, D. , F. (2008) Nursing research: generating and assessing evidence for nursing process (8thed). Philadelphia, US, Lippincot, Williams and Wilkins, p233. Benner, P. (1984) From novice to expert. Menlo Park, California. , Addison-Wesley. Bhagavatula, M. & Tuthill, D. (2011) The role of a hospital nutritional support team, paediatrics. Child and Health, 21:9, pp.

389-392 Bricher, G. (1999) Pediatric nurses, children and development of trust, Journel of Clinical Nursing, (8), p. 451-458, Blackwell science ltd. Campbell, S. & Glasper, A. (1995) Whaley and Wong children’s nursing. St Louise, Mosbey press, p. 127. Choi, J. , Dykes, C. P. , Esumi, K. , Goldberg, H. S. ,Goldsmith, D. M. & Kim, H. (2008) The adequacy of INCP version 1. 0 as a representational model for electronic nursing assessment documentation. Journal of the American medical Informatics Association, 16(2), pp. 238-246. Cowell, C. , Gilbride, J. , A. & Simko, M. , D.

(1995) Nutrition assessment: a comprehensive guide for planning intervention (2nd ed). USA, Aspen publishers, pp55. Dillon, P. , M. (2003) Nursing Health Assessment: A Critical Thinking, Case Studies Approach, Davis Company, p. 11. Dixon, M. & McCarthy, H. (2008) Time to STAMP out under nutrition in children. Complete nutrition, 8 (3), pp. 41-43. Field, L. & Smith, B. (2008) Nursing Care; an essential guide. UK, Pearson. Habermann, M. (2005) The nursing process-a global concept. lr, uys. Hedges, V. , Ling, R. ,E. , Sullivan, P. ,B. (2011) Nutritional Risk in hospitalised children; an assessment of two instruments.

Department of paediatrics children hospital, European society for clinical nutrition and metabolism, University of oxford, Elsevior ltd. Hop, W. C. , Hulst, J. M. , Joosten, K. F. & Zwart, H. (2009) Dutch national survey to test the STRONG (kids) nutritional risk screening tool in hospilized children. Clinical Nutrition, 29(1), pp. 106-111. Hupcey, J. E. , Penrod, J. , Morse, J. , M. & Mitcham, C. (2001) An exploration and advancement of the concept of trust. Journel of advance nursing, 36(2), pp. 282-293. Kadner, K, (1994) Therapeutic Intimacy in Nursing. Journel of Advance Nursing, 19, pp. 215-218.

Kunyk, D. & Olsen, J. , K. (2001) Clarification of the Conceptualisation of Empathy. Journel of advance nursing, 35(3), pp. 317-325. Lennard-Jones, J. , E. (1992) A positive approach to nutrition as treatment. Kings fund report, London, kings fund centre. Ley, P. (1988) Communicating with patients: improving communication, satisfaction and compliance. Chapman and hall London. MacNeela, P. , Scott, A. , Treacy, P. & Hyde, A. (2010) In the know: cognitive and social factors in mental health nursing assessment. Journal of Clinical Nursing, 19, pp. 1298–1306. Marilyn, E. , Marlaine, C. , Parker. & Smith. (2010)

Nursing Theories & Nursing Practice. F A Davis Company. Mason, G. & Webb, C. (1997) Researching children’s nurses clinical judgements about assessment data. Clinical effectiveness in nursing, 1, pp. 47-55. McCain, R. , F. (1965) Nursing by assessment not intuition. American journal of nursing, 65 (4). McGee, P. (2009) Advanced Practice in Nursing and Other Health Professions. (online). Wiley. Available from: http://lib. myilibrary. com? ID=218892 17/10/2011, 07:30. McMohan, R. & Pearson, A. (eds). (1992) Taking up the challenge: for the future for therapeutic nursing. In nursing as theory,London, Chapman & Hall.

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