The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [34]
9 To be effective, the process must be structured and clearly documented.
(Alfaro-Lefevre 2002, NMC 2008, Teytelman 2000, White 2003)
Structure of assessment
Structuring patient assessment is vital to monitor the success of care and to detect the emergence of new problems. Different conceptual or nursing models, such as that of Roper et al. (2000), provide frameworks for a systematic approach to assessment (such as Roper’s Activities of Daily Living), implying that there is a perceived value in the co-existence of a variety of perspectives. There remains, however, much debate about the effectiveness of such models for assessment in practice, some arguing that individualized care can be compromised by fitting patients into a rigid or complex structure (Kearney 2001, Tierney 1998). Nurses therefore need to take a pragmatic approach and utilize assessment frameworks that are appropriate to their particular area of practice. This is particularly relevant in today’s rapidly changing healthcare climate where nurses are taking on increasingly advanced roles, working across boundaries and setting up new services to meet patients’ needs (DH 2006a).
Nursing models represent a set of concepts and statements integrated into a meaningful conceptual framework (Kozier et al. 2003) representing different theoretical approaches to nursing care.
Nursing models can serve as a guide to the overall approach to care within a given healthcare environment and therefore provide a focus for the clinical judgements and decision-making processes that result from the process of assessment. It has been argued that whilst nursing models have not been widely implemented in clinical practice, nurses do use them as a way to consider the process of nursing (Wimpenny 2001). During any patient assessment, nurses engage in a series of cognitive, behavioural and practical steps but do not always recognize them as discrete decision-making entities (Ford and McCormack 1999). Nursing models give novice practitioners a structure with which to identify these processes and to reflect on their practice in order to develop analytical, problem-solving and judgement skills needed to provide an effective patient assessment.
Nursing models have been developed according to different ways of perceiving the main focus of nursing. These include adaptation models (e.g. Roy 1984), self-care models (e.g. Orem et al. 2001) and activities of daily living models (e.g. Roper et al. 2000). Each model represents a different view of the relationship between four key elements of nursing: health, person, environment and nursing. It is important that the appropriate model is used to ensure the focus of assessment data collected is effective for particular areas of practice (Alfaro-Lefevre 2002, Murphy et al. 2000). Nurses must also be aware of the rationale for implementing a particular model since the choice will determine the nature of patient care in their day-to-day work. The approach should be sensitive enough to discriminate between different clinical needs and flexible enough to be updated on a regular basis (Allen 1998, Smith and Richardson 1996).
In the context of cancer care, the Cancer Action Team (2007) has published guidance for a holistic common assessment of the supportive and palliative care needs of adults with cancer. The content of the assessment is divided into five domains including background information and assessment preferences, physical needs, social and occupational needs, psychological well-being and spiritual well-being. The guidance recommends that a structured assessment should be undertaken at key points throughout the person’s cancer illness trajectory, recognizing the importance of assessment as an ongoing process (Cancer Action Team 2007, NICE 2004).
Incorporating these key dimensions, the framework of choice at the Royal Marsden Hospital is based on Gordon’s Functional Health Patterns (Gordon 1994; see Box 2.2). The framework facilitates an assessment that focuses on