Within human nursing, models of nursing care feature heavily, with many texts and research papers devoted to the subject. Pearson et al (2005) suggest an interesting trajectory in their use in practice, with the initial scepticism surrounding their introduction in the 1970s soon giving way to a widespread adoption of them in both practice and education during the 1980s. However, more recently, there have been attempts by the human nursing literature to critically evaluate models of nursing care in the pursuit of ‘new perspectives on their use and implementation in practice, education and research’ (Wimpenny, 2002: 346).
If it is assumed that models of nursing care within veterinary nursing might follow the same trajectory, at what point of this curve are we now on? A review of the literature would suggest a current gathering of momentum for veterinary nursing to ‘use them as a way of taking practice forward’ (Davis, 2007: 104). The Royal College of Veterinary Surgeons (RCVS) Awarding Body's Veterinary Nursing Professional Syllabus (2010a) includes several learning outcomes pertaining to models of nursing and numerous journal articles have extolled their potential benefits (Joiner, 2000Davis, 2006Jeffery, 2006Orpet and Jeffery, 2006Cory 2007).
However, there is much less focus in the veterinary nursing literature on critical analysis, discussion and evaluation of their implementation by veterinary nurses (VNs) in practice. The case study presented in this paper seeks to start to fill this gap in the veterinary nursing body of knowledge through critical reflection of designing and implementing a nursing care plan (NCP), based on a nursing model of care, in a veterinary referral hospital ward setting. The factors influencing the choice of this model will also be considered.
Selecting a model of nursing care
Fundamentally, a nursing model is ‘a collection of ideas, beliefs and values about the nature and purpose of nursing, which influence the way in which nurses work with their patients’ (Davis, 2007: 98). In selecting a model of nursing care, the author felt it was important that the ideas, beliefs and values of the model closely resembled her own view of veterinary nursing. This is termed ‘reality convergence’ and is proposed by Stevens Barnum (1998) as one criterion to use in order to analyze and evaluate potential models for practice. The author selected the Orpet and Jeffery Ability Model (2007) on the basis that it particularly fulfilled this criterion (Orpet and Jeffery, 2007). This model was influenced by the work of prominent theorists Orem and Roper, Logan and Tierney (RLT) and to date is the only one designed specifically for veterinary use.
The author's concept of veterinary nursing is to make animal welfare the first consideration, which is essentially the first guiding principle for VNs (Royal College of Veterinary Surgeons, 2010b). The author felt that considering nursing care through the framework of the Orpet and Jeffery Ability model (2007), which identifies ten ‘abilities’ of animals that are necessary for their physical and mental wellbeing, would ensure that she was keeping animal welfare uppermost in her daily practice.
Designing the NCP
The NCP can be thought of as a written plan of action for patient care, the structure of which is largely provided by the model of nursing on which it is based (Mason, 1999). While Orpet and Jeffery provide templates for a NCP based on their model, it is also stated that adaptations can be made to them for use in practice (Orpet, 2008). Adaptations and inclusions to nursing models, and in particular their resulting NCPs, are encouraged in both the human and veterinary nursing literature. Davis (2007) asserts that models should never be employed in an inflexible manner, but instead must be regularly questioned and assessed. In addition, NCPs may be designed ‘without the constraint of a nursing model as the necessary foundation’ (Mason, 1999: 386), thus leading to a wide range of practice-led formats.
As a result, the author made the decision to make adaptations to the Orpet and Jeffrey Ability Model (2007) NCP templates. Inclusions were driven by one of the model's guiding principles that ‘detail in the care plan is important’ (Orpet and Jeffrey, 2007). In order to clearly describe nursing interventions, for problem prevention as well as problem resolution, an actual and potential problem column was incorporated. Another addition was to have specific sections for each of the ten abilities. The aim of both of these changes was in line with Cory's (2007: 17) attitude that the provision of NCPs should ‘ensure that all patients’ needs are identified and catered for' and so preventing a ‘subtle area of patient care being overlooked in the presence of more obvious or immediate needs’. An element obtained from the RLT Activities of Living Model for Nursing source material (Roper, et al, 1990) — the dependence-independence continuum — was also included alongside each of the abilities. This is a useful way ‘to see both improvements and setbacks easily’ when reviewing a patient's NCPs (Davis (2006: 5). Finally, a prompt regarding pain management was added to the ‘express normal behaviour’ ability. Pain is not explicitly developed as a subject for assessment within RLT's model, meaning it may be overlooked (O'Connor, 1995); as specific reference to it is also absent from the Orpet and Jeffery Ability Model (2007), the author felt VNs might require guidance as to where to include this important consideration.
Case studies: formulation of a care plan for two hospitalized patients
After gaining approval from the hospital's nursing managers, the author formulated a care plan for a canine patient admitted for investigation and treatment of oesophageal hypomotility. As per the Orpet and Jeffery Ability Model's (2007) guidelines, this included an initial patient assessment in conjunction with the owner. An abridged version of this, and the NCP documentation from the second of the 3 days it was implemented, are included here as Figures 1 and 2 respectively.
Following a preliminary reflection on the initial experiences, the author produced a revised template to be used with another case. Among the revisions, is the addition of an extra ‘ability’, described as ‘morbidity/clinical status.’ Inspired by Davis (2006), this originates from RLT's reference to ‘dying’ as an activity of living (Roper, et al, 2000). The author chose to incorporate this, as during the first case study, when new clinical information was gained about the patient, there was nowhere to explicitly document it on the NCP. This was felt to be important and is in keeping with Orpet and Jeffery's (2006) assertion that any nurse picking up an NCP would know what the plan is for a patient.
This revised template was then used by two other nurses to formulate the NCP for a feline patient hospitalized over a 48-hour period in order to receive chemotherapy treatment.
Thematic analysis
Following the case studies, the author reflected on her experience of implementing the care plan, together with the observations of nursing colleagues within the hospital, to undertake a thematic analysis of the resulting issues.
Increased understanding of the individual needs of the patient
There was widespread agreement that use of the NCP was responsible for an increased understanding of the unique needs of the patient, resulting in appropriate individualized nursing interventions being devised. Case studies by Joiner (2000) and Davis (2006) both note a similar outcome as a result of an in-depth patient assessment guided by a model of care. In particular, Joiner (2000) concludes that as a result of an individual patient-based plan, she was able to offer nursing completely tailored to the patient's needs, rather than ‘general procedural nursing.’
This outcome was attributed to the extensive initial patient assessment, carried out in conjunction with the owner, which is an element absent from the hospital's existing practice. This belief is supported by the veterinary nursing literature. Davis (2007) proposes that comprehensive data collection prior to formulating the NCP allows the VN to identify potential and actual problems ‘specific to individual animals’, suggesting ‘a nursing care plan will only be as good as the quality and accuracy of the information that goes into it’.
Another outcome seen in some of the human nursing literature is that nurses generally believed that care plans hindered individualized care by operating as tick lists that discouraged considered assessment (Mason, 1999). Indeed, examination of documentation showed that 20 patients on a general surgical ward all had the same nursing action recorded for a universally identified problem.
However, like Mason (1999), who emphasizes that negative attitudes to care planning were not universal within her study, the author suggests that further research would need to be carried out to as certain whether the positive outcome of the NCPs within her referral hospital could be consistently replicated.
Actual change in practice?
On reflection, the author has found that since the case study, she is considering the ten abilities while nursing all her patients; the model of nursing care not only changed her nursing practice at the time, but it continues to do so, resulting in improved holistic care being delivered to her patients.
These changes could be attributed to a move away from the medical model, essentially a disease-oriented approach, which Orpet and Jeffery (2006) assert is how VNs are often trained. If both the veterinary surgeon and the VN are maintaining a ‘cure focus’ to their work, consideration of the patient as ‘an active subject with specific needs that may not be linked to the disease itself’ may be lacking (Pullen, 2006). Moving away from a disease focus towards a patient focus means that VNs will be adopting a ‘care focus’, improving patient care. It is the author's opinion that adoption of the Orpet and Jeffery Ability Model (2007) achieved this change in focus.
However, during the second case study, the other nurses using the NCP, who were able to complete the documentation at the time, did not action the individualized nursing interventions that they identified as a result of the NCP. This appears to suggest that NCPs do not result in a change in practice. How can these two different outcomes be explained?
First the NCPs were solely instigated for the purpose of this case study. As such, the other nurses completed them only at the author's request, and may have viewed their completion purely as an exercise of interest. The outcome may have been different if the NCPs had been officially implemented.
Second, while the author studied models of nursing care prior to selecting the model of nursing care used to underpin the NCP documentation, the extent of her colleagues' prior knowledge of conceptual models was not ascertained. In human nursing much of the inadequate use of models originates from ‘a lack of educational preparation’(Timmins and O'Shea, 2004: 163), which could have been the case here. This requires further research and discussion in the veterinary nursing context.
Excessive documentation
The most agreed on undesirable result of the NCP implementation was that it produced excessive documentation. Why is quantity of paperwork perceived as such a significant problem?
A possible answer is that it was felt the additional paperwork did not serve an adequate purpose. Timmins and Horan (2007: 33) state that the RLT Activities of Living Model for Nursing, which influenced the Orpet and Jeffery Ability Model (2007), is often criticised as ‘synonymous with excessive documentation’ and ‘little more than a paper exercise.’ Mason (1999) demonstrated that many human nurses believe NCPs are unnecessary, because bedside charts are more useful as important guides to practice. This may account for the attitudes towards the NCP during their implementation within this referral hospital, where the hospitalization sheets, written in enough detail, may already serve the purpose of NCPs (Chandler et al, 2007). A conclusion could be that the excessive documentation is due to the NCP not being sufficiently adapted to enable integration with the hospital's existing paperwork. Indeed, Mason (1999: 386) recommends that NCPs should be ‘tailored to the requirements of the clinical area’, avoiding duplication and collation of unnecessary data.
During this case study, the author was unable to complete the NCP until the end of her shift as due to work demands a choice similar to that reported by Mason (1999) had to be made: either direct patient care was provided or the NCP was written. Mason (1999: 385) argues that this inadequate implementation of NCPs as tools for retrospective reporting in place of planning may be due to ‘their lack of fit with the demands of practice, and not with performance of staff.’ Conflict between the time required for the completion of NCPs and the time required for direct patient care seems to be given little to no consideration in the veterinary nursing literature.
Recommendations for future practice
The prominent human nursing theorist, Tierney (1998), maintains that the question ‘What is nursing?’ can only ever be answered by conceptualization. The veterinary literature is starting to echo this. Chandler et al (2007) contest that up-to-date evidence-based nursing practice should be achieved through the implementation of care plans and that this in turn is one of the first step towards developing ‘a defined professional role for nurses’. Davis (2007
‘Through the use of the nursing process and nursing models, veterinary nurses will be better able to articulate and demonstrate the nature of their role and the unique skills and knowledge they bring to their practice.’
As a result of the thematic analysis, it seems there is tentative support for NCPs producing beneficial changes in practice, although this seems conditional on a comprehensive understanding of the underlying model and not just mechanical completion of imposed documentation. While there is support for this theory in the human literature, it is unclear whether these can be generalized to veterinary practice, so more work in this regard needs to be done.
The issue of excessive documentation seems to be the biggest hurdle to the use of NCPs. A recommendation for future practice is extensive consultation with the whole nursing team and revisions of the NCP until an optimally integrated template is reached. Ultimately, difficulties with perfecting the documentation should not necessarily reflect badly on the underlying nursing model of care, which as is tentatively shown here, does have the potential to provide positive, tangible benefits to practice.
Further to this, it must be remembered that while care plans are undoubtedly fundamental to conceptual model-based practice, they represent only one small facet of the intervention (Timmins and O'Shea, 2004). Imposed use of NCP documentation alone does not guarantee the benefits derived from the universal implementation of a model of nursing care agreed on and explicitly understood by the whole veterinary nursing team. Conversely, it does not seem necessary to use what may have been seen as traditional NCP documentation in order for a nursing model of care to bring about benefits to an individual's daily nursing practice. However, without documenting such practice fully, be that on an NCP, hospitalization sheet or a locally integrated version of the two, it will not be possible to work towards the body of knowledge that is required for a profession to practice from.
Conclusion
While there are some obstacles to the usage of nursing models of care in veterinary practice, overcoming these is likely to deliver many benefits.
So, if the trajectory of models of nursing care in veterinary nursing echo that of models of nursing care in human nursing, at what point of the journey from initial scepticism, to widespread adoption, to the present critical evaluation might we be on? The conclusion from this critical reflection, is that, in a much shorter space of time, veterinary nursing might have already reached the point of its sister profession, in requiring the new perspectives on the use and implementation of nursing models of nursing care in practice, education and research, in order to continue progression of the profession. It is hoped that this case study will encourage others to contribute to these new perspectives through further research and reflection.