In recent years, veterinary nurses (VNs) have been experiencing the immigration of new terminology relating to a range of concepts, theories and models, many of which have been imported from the human nursing professions (Joiner, 2000; Davis, 2006; Orpet and Jeffery, 2006). The terms medical model, holistic nursing, nursing models, nursing process and care planning are not entirely new to veterinary nursing, with articles appearing in the popular veterinary nursing press on these concepts as long ago as 2000 (Joiner, 2000), but they present the veterinary profession with an often bewildering set of unfamiliar and as yet, often unproven ‘rules’ which it is proposed should be followed (Orpet and Jeffery, 2006; Jeffery 2006; Cory, 2007; Orpet, 2011; Royal College of Veterinary Surgeons (RCVS), 2011).
The introduction of many of these models and terms into the RCVS National Vocational Qualification (NVQ) Veterinary Nursing syllabus in 2006 also guaranteed these concepts a place in the vocabulary of all newly qualified VNs. Despite this, however, the experience of the authors leads them to believe that the application and adoption of nursing models and care plans by VNs into clinical practice is not particularly widespread, and even for those VNs who have ‘grown up’ with these concepts, there appears some uncertainty about both their benefits and suitability for useful application in the clinical setting. What the authors therefore assert is occurring is described by Pearson et al (2005: 7) as the ‘theory–practice divide’; the use of concepts such as models and care plans may be taught, expounded and advocated by academics, but their uptake and use in clinical practice is minimal. While there is little published material to support these claims, the authors, having collated the views and experiences of 56 Registered VNs (RVNs) from 3 years of a module of the Royal Veterinary College (RVC) Graduate Diploma in Professional and Clinical Veterinary Nursing (GD-PCVN) titled Applied Clinical Nursing, propose that this theory–practice divide is apparent and that RVNs, for various reasons, are reluctant to incorporate care planning into their daily clinical practice. Further analysis of the experiences of these RVNs will be discussed in part two of this article series.
In parallel to these assertions though, the presence of published reports from RVNs who have applied a nursing model and care planning to their practice must be acknowledged. Lock (2011), Wager (2011) and Brown (2012) unanimously conclude that there are ways to incorporate these immigrated concepts into veterinary practice in such a way that develops a new way of both thinking about and carrying out veterinary nursing, which in turn helps to provide a better level of patient care. All three of these RVNs have achieved this by utilising the Orpet and Jeffery Ability Model (OJAM) (Orpet and Jeffery, 2007), with the observed outcomes including a more holistic, patient-focused approach to nursing and an increased understanding of the needs of individual patients (Lock, 2011; Wager, 2011; Brown 2012). Interestingly, the OJAM (2007), which to date is the only model of care specifically designed for veterinary use, has yet to be included in any published veterinary nursing awarding body syllabus.
Part one of this article therefore aims to summarise the OJAM (2007) with the hope of bringing both student and qualified VNs alike a new, and largely practical, perspective to the concept of care planning, with the intention of closing the theory–practice divide. It will also highlight how this model may be used by VNs to adopt a more ‘veterinary nursing approach’ to their work, rather than following the instruction and orders of the veterinary surgeon (VS) alone. In order to demonstrate the differences between these approaches, the methods taken by the VN who follows a more patient-focused, ‘nursing process’ approach to the delivery of care will be compared and contrasted with that of the VN who adopts a more ‘traditional’ viewpoint, which may also be referred to as adhering to the medical model.
The medical model or veterinary nursing model?
The medical model derived from the human medical practice focuses on the illness or malfunction of a particular part or system of the body (Faulkner, 1985). The treatment thus focuses on just that part of the body or disorder. Jeffery (2006) identifies that VSs, by following a disease-orientated approach to the diagnosis and treatment of their patients, are following a medical model approach. In the same way that human nurses have been accused of following this approach (Faulkner, 1985), some VNs are also suggesting that VNs have, by default, adopted the medical model approach to the nursing care of their patients (Jeffery 2006; Orpet and Jeffery, 2006; Pullen, 2006; Brown, 2012).
Terminology — do we nurse patients or cases?
As an aside, before progressing to examine the differing nursing actions that may result from applying the OJAM (2007) versus the medical model approach, it is worth asking: to what extent does terminology alone affect behaviour and attitudes?
In other fields, it is widely recognised that there is an interlinked relationship between the development of a theory or concept, which then leads to development of a set of terminology, which in turn further influences the way people behave (Ferraro et al, 2005). It has been established that the medical model approaches patient treatment by identifying the underlying disease (Shah and Mountain, 2007) and so it is not surprising that the terms used by most doctors and VSs when referring to their patients turns them from sentient beings to something altogether more inanimate sounding. For example, instructions along the lines of ‘Bring the cruciate dog to surgery’, ‘Can you get a blood glucose from the diabetic cat in cage 3?’ are familiar in clinical practice. This is a perhaps a good illustration of the interlinked relationship between a theory, concept or model, creating its own set of terminology, which then perpetuates a certain type of thinking, attitude and behaviour.
Following this through then, as previously suggested by Welsh and Orpet (2011) it would seem pertinent to presume that one way for VNs to promote a more patient-focused, holistic approach to their practice, might be to consider moving away from using the term ‘case’ when referring to the animals under their care, and instead use the term ‘patient’.
Orpet and Jeffery Ability Model 2007
In the mid 2000s, VNs Hilary Orpet and Andrea Jeffery started to disseminate their proposal that it was time for VNs to begin to adopt a more patientfocused, systematic approach to their patient care using models and knowledge base extrapolated from human nursing practice (Jeffery, 2006; Orpet and Jeffery, 2006). Shortly afterwards, at the annual British Small Animal Veterinary Association (BSAVA) Congress in 2007, they proposed a novel veterinary-specific framework, influenced and adapted from the work of human nursing theorists to help VNs identify and provide the most appropriate nursing care for each patient's individual needs. Thus, the OJAM (2007) was born. The fundamental goals of the OJAM coincided with changes to animal welfare legislation with the introduction of the Animal Welfare Act 2006, which made owners and those temporarily responsible for an animal legally responsible to ensure that ‘five needs’ of welfare for animals under their care were met.
As illustrated in Figure 1, the OJAM (2007) framework requires the VN to consider ten patient ‘abilities’ on which to base their patient assessment, and the planning, implementation and evaluation of their nursing care. The ultimate aim is to address any inabilities before they become more problematic for the patient and to help minimise the risk of any potential problems becoming actual problems through lack of action on the VN's behalf. An example of this process in action is shown in Box 1.
| Frankie is a 16 year old, female DSH admitted following investigation of weight loss |
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| VN observes Frankie and identifies that she's not eating. VN offers Frankie her favourite food, having established this information by speaking to Frankie's owner. |
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| Based on results from blood tests and VN’s observations of clinical signs and behaviour, Frankie showing early signs of dehydration (VN becomes concerned that Frankie at risk of dehydration) |
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| VN and VS collaborate to discuss feeding and hydration plan for Frankie which incorporates information provided about Frankie's normal feeding and drinking habits |
Orpet (2011) advises that the success of the OJAM (2007) is also aided by incorporating and following the key stages of the nursing process:
Students on the RVC GDPCVN have also experienced positive outcomes by incorporating the OJAM (2007) into these stages; this will be discussed further in part two of this article.
Assessment
In the assessment of the patient, the VN can gain information directly from observation of the patient, speaking to the admitting VS or VN, colleagues including student VNs and Animal Nursing Assistants and crucially, the patient's owner.
As part of the veterinary team, VNs in practice are, of course, already regularly gaining information about their patients in order to assess them. For example, it is routine to obtain a baseline temperature, pulse and respiration rate (TPR) of patients, as it is fully appreciated that it is important to assess these in order to monitor any deviations from normal values. Yet do VNs gain enough information about the other abilities of patients in order to establish their distinctly individual ‘normal’ baselines, for example in relation to eating preferences and behaviour? As asserted by Orpet (2011), obtaining this information could make a significant difference to the approach to nursing care; this is illustrated by the example in Box 2.
As it is frequently the VS who admits the patient, traditionally much of what is known by the VN about the patient on admission will be disease focused. An additional and supporting admitting consultation from the VN, is therefore likely to be necessary in order to obtain the type of information identified in the above example as necessary to help inform the type of nursing care required, while also ensuring that each of the ten abilities is covered. When it is not possible or perhaps appropriate to have this opportunity for a VN-led admission process, alternatives to face-to-face meetings with the owner include, but are not limited to, telephoning the client at a later stage and independently completed client questionnaires. An example of the latter is shown in Figure 2. This type of questionnaire can be easily independently completed by the client and then placed directly with the patient's notes or on their kennel. This allows information about all of the patient's normal abilities to be gained and then shared, without adding to the nursing team's workload.
At whatever point and in whichever format a VN-led client interview is carried out, it is wise and polite to let the owner know exactly why additional questions are being asked. The following suggested introduction to any such interview process has been adapted from Murray and Atkinson (1994: 21) and Orpet and Welsh (2011: 21):
‘Mrs Kerr, I'm Jo, the veterinary nurse who is responsible for planning the nursing care that Frankie will receive while he is hospitalised with us. I would like to ask you some questions about Frankie's normal routine to help me work with you to begin to plan Frankie's care and make her as comfortable as we can during her stay with us’.
As established above, the interview process needs to cover each of the ten abilities in order to systematically gain all of the necessary information for nursing the patient holistically. For each ability, questions should be asked in such a way that answers to the following, again adapted from Murray and Atkinson (1994) and Orpet and Welsh (2011), will be obtained:
While considering both the initial and on-going assessment of the patient, it should be noted that the client interview process is utilised in addition to and not to the exclusion of the VN’s other established patient assessment skills, such as physical examination and continued patient observation.
Veterinary nursing diagnosis
It is well understood that a clinical diagnosis is not within the legal or professional remit of anyone other than a VS. However, a VN needs to be able to make judgements about a patient's nursing needs based on the information gained during the assessment of the patient. This includes identifying and naming actual problems with the patient's abilities and can include any potential problems that the patient is at risk of. The aim is not to get a clinical diagnosis but to identify problems with any of the ten abilities to help alleviate them. Examples of nursing diagnoses for a patient are shown in Box 3.
Planning
The planning phase is about setting goals for the patient and working out how these goals will be met with nursing care and actions, known as ‘nursing interventions’. It is during this stage that the care plan is developed for the patient.
From the information gleaned from the assessment phase, a number of actual and possibly also some potential, veterinary nursing problems will have been identified. With these veterinary nursing diagnoses, a decision can be made on the goals for the patient and the subsequent nursing care and action required. This phase therefore allows the VN to set and identify the nursing interventions required and also prioritise the order in which they should be carried out.
In the medical model, the choice of intervention usually involves focusing on the particular dysfunctional body system or part; the physiological problems, and administering some kind of medication to help resolve the problem. The focus of intervention in the OJAM (2007) however, is more likely to focus on other factors in addition to the physiological ones, to include consideration of all of the abilities of the patient as detailed by the model in Figure 1, ensuring that no aspects of care are missed.
When setting both goals and nursing interventions, it is important to consider:
Implementation
Veterinary nursing interventions need to be written in such a way that enables anyone involved in the veterinary care to understand and carry out what needs to be done. This means specifying exactly what is to be done, how often it is to be done, how much should be done and in what order in relation to other veterinary and veterinary nursing activities. For example, writing something along the lines of ‘feed little and ofte?’ is vague and open to interpretation depending on who is reading it. A more appropriate way would be to specify what to feed, how much and how often. That way, any member of the nursing team can follow the instruction and later measure to what extent any of the goals have been met.
An example of what part of a patient's care plan might look like is shown in Box 4. Consider how detailed these instructions are compared with a standard hospitalisation chart and how the veterinary nursing interventions relate to Frankie's idiosyncrasies as established at the assessment phase.
| Problem (nursing diagnosis) | Short-term goal | Nursing intervention | Reassess/evaluation | Review time/date |
|---|---|---|---|---|
| Imbalanced nutrition: less than body requirements | Achieve voluntary intake of food | Mix Hill's Science Plan Dry with smoked salmon and offer 25 g of this mixture. Ensure that a plastic bowl is used | Frankie ate 20 g of this mixture directly from the bowl, after some fuss and encouragement | Repeat at 16:00 |
While it may be assumed that all experienced VNs would approach a particular patient with particular problems such as Frankie in a very similar ways without such detailed planning, it is clearly documented in the literature (Lock, 2011; Wager, 2011; Brown, 2012) and, as will be demonstrated in part two of this article, in the experiences of GDPCVN students, that having a systematic approach to planning patient care has many benefits to patients.
Evaluation
Evaluation of the nursing care is an essential part of the process and is required not only to ascertain the extent to which the interventions and treatment is doing what it sets out to achieve, but also to provide data and information to build up an evidence base for nursing practice. To evaluate effectively, the VN needs to assess the patient again, which the authors propose is already likely to be an unconscious integral part of their practice; experienced VNs tend to make on-going judgements about the type and effectiveness of the care they are administering as they complete their work.
Use of the OJAM (2007) however ensures a systematic and holistic approach to this continuous evaluation. The VN will reassess each of the patient's abilities now, compared to what he or she could or could not do before and in this way a judgement can be made as to whether the patient is responding to the nursing care better or worse than expected.
Conclusion
It is hoped that this overview of the OJAM (2007) demonstrates how use of this veterinary nursing model of care can improve and develop veterinary nursing practice. Advocates of the use of this model believe that it is more likely to foster a systematic approach to the nursing of patients rather than relying on the intuition of an individual VN (Lock, 2011; Wager, 2011; Brown, 2012). Furthermore, in addition to helping VNs to consistently deliver a high standard of appropriate nursing care to patients, the authors propose that adoption of the OJAM (2007) in clinical practice can assist VNs in developing their profession by providing a basis for the theoretical and clinical development of their subject. Potentially, this is the ultimate resolution of the theory–practice divide — a position where practice informs theory — which the veterinary nursing profession should be striving for. Part two of this article will therefore seek to contribute to this objective by examining the outcomes observed from GDPCVN students applying the OJAM (2007) in clinical practice.