Doris Corkin and Pauline Cardwell (contribution from Lisa Hughes)
Introduction
As a healthcare professional caring for children, young people and their families we are accountable for our individual practice. Therefore we must strive to deliver high quality care, acknowledging evidence-based practice and recognising finite resources within contemporary healthcare systems. In order to achieve success, care planning and delivery of individualised care must encompass multiprofessional collaboration, involving service users and carers as essential contributors to the overall process.
Within this introductory chapter the children's nurse will be provided with an overview of the nursing process, its components and how these assist in organising and prioritising care delivery to the child and family. Philosophical perspectives of care will also be discussed and how this impacts on care delivery in the clinical setting. In conjunction with these aspects of care planning, several models of nursing will be explored, and their contribution in the planning and delivery of care will be illustrated within the scenarios in the second section of this book.
Nursing process – what is the nursing process?
The nursing process is a logical, structured approach, which promotes the nurse's critical thinking in a dynamic manner. This process is used to identify and deliver individualised family-centred care, supported by nursing models and philosophies. Yura and Walsh (1978) identified this process, consisting of four interrelated stages (see Figure 1.1):
• Assess
• Plan
• Implement
• Evaluate
More recently, Castledine (2011) has acknowledged the evolvement of the nursing process to be a methodical way of thinking that guides care delivery; whilst focusing on the patient the nurse should base best practice on available evidence with artistic interpretation.
More recently, however, this process has sometimes included a fifth stage relating to `nursing diagnosis'. For example, a six-week-old infant has been brought to the hospital with a history of breathlessness and poor colour, especially during feeds, who tires easily and poor weight gain has been noted. Upon examination, heart rate and respiratory rate are both increased and this may lead the nurse to consider a possible cardiac related diagnosis. In utilising the nursing process a problem-solving approach is applied to the management of individualised patient care. The application of the process is continuous and cyclical in nature and commences with the assessment stage.
Assessment
This important stage of the care planning process aims to collect and record information pertaining to the health status of the individual child and its effect on the family unit. This phase of the nursing process should provide a comprehensive insight into the needs of the child and their impact on the integrity of the family. The children's nurse must consider not only the physical needs of the child but address the social, emotional and spiritual needs of the child and entire family. In order to achieve a comprehensive assessment the children's nurse must utilise a range of proficiencies, including theoretical knowledge and interpersonal skills. Matousova-Done and Gates (2006) highlight the need to both observe and listen to the child and family, utilising verbal and non-verbal communication with the use of appropriate questioning skills to ensure an accurate nursing assessment.
A precise and comprehensive assessment is vital to identify the problems which are currently encroaching on the child's health status and ultimately will ensure safe, effective and efficient nursing care for the child. This stage of the process links closely with the discrete fifth stage identified earlier as nursing diagnosis, which is supported by an accurate and comprehensive assessment of the child's health needs. During the assessment stage the children's nurse is also involved in analysing and interpreting the information collected, thus contributing to the formulation of a care plan.
A very good example of assessment is the ABCDE (airway, breathing, circulation, disability, exposure) systematic approach to assessing the acutely ill child, as recommended by Dieckmann et al. (2000) and the Resuscitation Council UK (2005). This approach aims to enable healthcare staff to recognise when they need additional support from the interprofessional team (see Chapter 8). Furthermore, this systematic process helps guide the healthcare professional in planning the frequency of ongoing assessment, especially in the paediatric intensive care setting (see Chapter 16).
Planning
During the essential second stage of the process, a plan of care is developed aimed at addressing the problems identified in the assessment phase. This phase of the process involves cognitive and written elements in identifying goals to meet the child's needs. The children's nurse develops mutually agreed goals which endeavour to address the child's problems through the provision of nursing care. These goals are then further developed within the plan, in a sequence of interventions aimed at resolving, controlling or preventing escalation of the problem. In creating these goals, Wright (2005) proposes they should be SMART: specific, measurable, achievable/agreed, realistic and time-limited. The care plan is developed to guide the nursing interventions in a timely manner to meet the needs of the child and family.
The children's nurse must be able to clearly articulate and document priorities of care, tailored to meeting the individual needs of the child and family, and easily understood by all members of the interdisciplinary team.
Effective communication with the child and family are integral to this stage of the nursing process, as the children's nurse must work collaboratively to ensure the care planis dynamic in meeting the needs of the child and family. In developing the care plan the children's nurse must engage in developing a partnership with the child and family in which they are active partners in the decision-making processes and their involvement in care provision is recognised. This partnership requires empowerment and negotiated involvement of the child and family, which requires skilled children's nurses who are able to ensure children and their families are at the centre of effective care planning (Corlett & Twycross 2006). Having identified, agreed and set short and long-term goals specific to the child's needs, these must be regularly evaluated during implementation to ensure they remain responsive to the individual's requirements.
Implementation
This penultimate stage of the nursing process relates to the delivery of care, which has been planned based on the needs of the child and family. Nursing interventions should aim to achieve the goals identified in the care plan and these should clearly identify the actions to be undertaken by the children's nurse. The children's nurse must possess the knowledge, skills and abilities to deliver the care to the child and assess the appropriateness of planned interventions (Alfaro-LeFevre 2006). Effective communication with the child and family is central to the success of implementing the care plan, which may require adjustment in response to changing needs.
The cooperation and involvement of the child and family is a pre-requisite in this phase of the nursing process. Children and their families must be given choices and involved in decisions regarding nursing interventions, and their participation will personalise their own care implementation. All goals set must be clear and agreed by the child, family and other carers, including health professionals. Identifiable goals should be achievable, within a realistic timeframe for those involved in care delivery, whilst recognising their continued appropriateness for the child.
Evaluation
The fourth and final stage of the nursing process, requires the children's nurse to consider the impact of the preceding three stages on the child's care trajectory. However, it is essential that the children's nurse continually evaluates the child's response to interventions and modifies planned care to meet the individual's needs and their response to previously identified goals. Overall, this evaluation process aims to recognise changes in the child's condition and identify the need for modification. Analysis of the care delivered by the children's nurse requires critical thinking in order to consider its effectiveness and other possible required interventions to meet the changing needs of the child. The frequency of evaluation may vary depending on the acuity of the child's condition.
This evaluative stage of the nursing process links closely with the assessment phase of the cycle, assessing the attainment of previously identified priorities of care and goals (Heath 2005). Documentation and reporting in this phase of the nursing process is critical in accurately measuring and recording the child's response to planned interventions and to support the continuity of care delivery. Furthermore, this assists in information sharing between healthcare professionals and identification of progress towards goal attainment and also the continued relevance of previously identified goals.
Nursing diagnoses
The North American Nursing Diagnosis Association (NANDA International) is the clearing house for nursing diagnosis work both within the United States of America and internationally (Carpenito-Moyet 2010). This association was initially established in 1973, and later recognised worldwide as NANDA-I in 1982 and is committed to developing the nursing contribution to patient care through `nursing diagnoses' which informs the creation of care plans (NANDA International 2008). Those care plans approved by NANDA International are rigorously tested and refined in line with current best practice and evidence-based guidelines in clinical settings. Within the NANDA International system, five levels of nursing diagnoses are identified:
• Actual
• Risk
• Possible
• Syndrome
• Wellness
What is a nursing diagnosis?
This is a professional judgement relating to the health problems of the individual or family, which is used to identify appropriate goals and interventions in nursing plans of care, based on a holistic nursing assessment (see Chapter 34).
Planning of care – what is a care plan?
A care plan is a comprehensive record (handwritten, pre-printed or electronic) of essential information which is created following discussions between the child, family and the children's nurse, detailing priorities of care aimed at meeting the individual's needs. This record consists of a table featuring problem identification, patient goals and nursing intervention, alongside day-to-day living activities affected (see Appendix 1). This is a legal document which is managed and stored in accordance with legislative and professional guidelines, whilst still being accessible to the individual patient and other healthcare professionals with responsibility for care delivery, whether in the hospital or community setting (NMC 2009).
In addition to the framework provided by the nursing process, care plans are normally developed with the support of a nursing model, which assists in managing and enhancing effective, high quality care delivery. The development of nursing models attempts to link nursing theory to clinical practice and indirectly informs the growing body of nursing knowledge. Various models of nursing are available and utilised, for example Roper, Logan and Tierney (1985), Casey (1988; 1995), Mead (McClune & Franklin 1987), Orem (1995) and Neuman's system model (Neuman & Fawcett 2002), as well as chapters within this book that demonstrate the application of these models to clinical practice. These models are flexible structures that can be easily adapted to incorporate elements from other models in order to address individual care needs, encouraging the children's nurse to think creatively about the holistic care of the infant, child or young person and their family.
Increasingly, evidence-based practice is advocated globally as effectively delivering quality care, and thus must be integrated within care plans for the individual (Parsley & Corrigan 1999). The children's nurse must be able to appraise nursing research critically and use this up-to-date knowledge to underpin their clinical judgement and practice, and promote efficiency within healthcare systems. Whilst aiming to provide contemporary high quality care, the children's nurse should reflect upon his/her knowledge and experiential learning, which are key requisites to ensuring best practice as identified in professional regulatory guidelines (NMC 2008).
The nursing care plan is also supportive of engaging and sustaining interdisciplinary collaboration with the child, family and other health professionals involved in their care. Children's nurses do not work in isolation, instead care delivery is organised around a team approach and in collaboration with other members of the multiprofessional team. More recently, integrated care pathways have evolved, supporting the development of a multiprofessional document, to which the nursing care plan is integral. These multiprofessional documents are supported by clinical governance and quality agendas within healthcare organisations in delivering effective outcomes (DH 1998).
Philosophy of care
This aspect of professional practice relates to the expectation of service users and nursing staff in a particular clinical environment of how care and services will be organised and delivered. A philosophy of care helps nurses to define their role and guide practice, within a growing diversity of roles in the clinical environment. Children's nursing, as a distinct field of practice, may relate to a philosophy of care that recognises the individuality of each child and their family, understanding their unique needs in relation to healthcare provision and ensuring their involvement in decisions about their care. The child's needs must be paramount, whether physical, psychological, social, cultural or spiritual, as well as those of their family, and these should be embedded in the philosophy of care within the clinical environment (RCN 2003).
What are nursing models?
Nursing models, which are also known as grand theories, attempt to illustrate the theory of nursing practice and facilitate the children's nurse to organise and deliver care. When applied to practice these models of care influence the performance of the nurse and the experience for the child and family (McGee 1998; Pearson et al. 2005). The construction and application of nursing models support the development of nursing practice, whilst recognising the values, beliefs and culture of the individual and the changing clinical environment.
Since early work by Fawcett in 1984, numerous nursing models identify the four components of a model as:
• The person
• Their environment
• Health
• Nursing
Care is organised and delivered around identified deficits relating to these components. The development of nursing models, aims to enhance the delivery of family-centred care whilst facilitating the experienced children's nurse to practice autonomously. Through engagement with the child and family the children's nurse is able to identify needs and create a plan of care for the individual and their family, when employing the nursing process in conjunction with a model/s of care.
Roper, Logan and Tierney – the 12 activities of living model
This conceptual model of nursing was devised by three United Kingdom-based nurses and is widely recognised both nationally and internationally. The model is practice orientated whilst incorporating a theoretical framework for care delivery. The model relates to the lifespan of the individual, identifying twelve activities of living (see Table 1.1), which are considered in relation to the continuum of dependence to independence throughout life, appreciating aspects of age, environment and circumstances which may impinge on this continuum. Each activity of living is influenced by five identified factors, which are biological, psychological, socio-cultural, environmental and politico-economic (Roper et al. 1985). This model is used in conjunction with the nursing process to identify actual and potential problems for the individual and how nursing care can advance the patient along the dependence to independence continuum. This model of care will be utilised in subsequent chapters such as Chapter 22, illustrating its application in care planning.
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