Chapter 1
An introduction to nursing theory
By the end of this chapter you will be able to
1.Define care planning and nursing care plans.
2.List the advantages of planning care and using nursing care plans in relation to patient care and professionalism in veterinary nursing.
3.Define nursing models of care.
4.Discuss the differences between the traditional medical model of care and holistic care.
5.Consider the factors that have influenced the use of nursing care plans in veterinary practice.
It would be easy to dismiss veterinary nursing care plans as a recent fad or fashion. It would be easy to disregard the care plan written by an enthusiastic nursing student as little more than a useful educational tool. However, care plans are not new and rather than being reserved for education, a well-written care plan can have benefits for patients, for their owners, and for the veterinary team who care for them.
Care planning and the care plan
The terms care planning and care plan do not mean the same thing. Care planning is the process of recognising a patientâs actual and potential problems and selecting interventions to assist in addressing those problems. This is what all nurses have been doing since nursing began, albeit implicitly. It is what many nurses do subconsciously when they meet and greet their patients. Care plans are the written record of that care planning process and can be used as a tool in a number of situations to facilitate the care of patients. Essentially, care planning is the thinking, the preparation, and the care plans are the resulting record of that action, or proposed action.
In 1860, when Florence Nightingale [1] was carving out the foundation of the nursing profession, she allocated a section in her book to âpetty managementâ. She went on to explain that âall the results of good nursing, may be utterly negativised by one defect: petty management, or in other words, by not knowing how to manage that what you do when you are there, shall be done when you are not thereâ. Essentially, she was saying that good care may be compromised if there is no plan in place to continue that care once a nurse goes off duty. She goes on to explain that fresh air to the patient is just as important at Tuesday at 10 oâclock when the nurse must be absent, as it is at 10 oâclock on Monday when the nurse is with the patient. For todayâs nurse, the tasks have changed, but the principle remains. Nursing care requires careful planning to ensure continuity and quality of care.
The medical model of nursing
Researching the way nurses traditionally ran hospital wards reveals evidence that care was very much focused on the tasks that needed doing rather than on the patients and their needs.
In 1973, a research project called, âA study into nursing careâ, was commissioned by the Department of Health and Social Security [2] and administered by the Royal College of Nursing. The main objective was to develop techniques of measuring the effectiveness of nursing care in general hospitals, and it consisted of twelve individual studies. As part of this project Sylvia Lelan conducted a study into nursing communication which revealed some interesting details on the way nursing care was planned and delivered at that time. She explained that there were generally two methods of planning the nursing work on the ward, and both involved making lists. One method assigned individual nurses to specific roles for that shift. For example, Nurse S would be responsible for bed-making, Nurse T was directed to carry out bed baths, and Nurse U was directed to administer medicines or four hourly observations. The second method of care planning used a notebook to list patients who had specific care needs in common. For example, a dressing book that listed Mrs F, Mr G and Mr O as in need of wound care on a particular day, or bath books that listed the patients in need of support with personal hygiene. It is clear that nurses were very much focused on tasks. This way of working is what is referred to as the medical model of nursing.
This is a model in which a person is always considered as a complex set of anatomical parts and physiological systems. Any symptoms that may be exhibited will be due to a disruption in that anatomy or physiology. The treatment of the patient is directed entirely by the disease with which they suffer and consequently, nursing under the medical model encourages nurses to carry out tasks solely on the instruction of the physician. The care was always centred on the disease or malfunction rather than on the patient. Just like the example of Florence Nightingale, this demonstrates that nursing care has always been planned, albeit in a different way.
With this brief reflection on a small part of nursing history, it would be easy to assume that nursing in the 1970s was bad and nursing today is good. This is not the case; such conclusions cannot and should not be made in such a simplistic manner. First, it is very difficult to compare the healthcare service of then with now, as resources, patient needs, and staff training are all significantly different. Second, to dismiss the care provided before current times as inferior is short-sighted. As an interesting example, in 1960 Isabel Menzies [3] published her seminal work discussing, amongst many things, the emotional impact of nursing. Within her work she defended the medical model of nursing. She maintained that breaking the work of a ward down into lists of tasks protected the staff from anxiety as personal relationships were not established with patients and decision making was avoided. This is certainly an interesting point of view in todayâs working environment, where mental health problems are experienced by many healthcare professionals. The key point is that a comparison of nursing across the years is too complex an issue for the pages of this text. Any such discussion must be contextualised to take into account the significant changes in nursing specifically and the health service generally.
Defining nursing
During the 1950s and 1960s there was a new emphasis on developing the knowledge base of human-centred nursing. This led to the specific consideration and development of the role of the nurse, of models of nursing, and of care planning. Starting in the 1950s, Hildegard Peplau, a mental health nurse, started to promote professional standards in nursing and introduced the idea of advanced nursing practice. She proposed, amongst others, theories around the nurse-patient relationship and stressed the importance of the nurseâs ability to understand their own behaviours in order to help others.
In 1955 Virginia Henderson [4] developed one of the most widely used definitions of nursing. It was a definition that was adopted by the International Council of Nurses in 1960 and is still widely used to identify the role of the nurse today. Her description of the âunique function of the nurseâ follows:
To assist the individual, sick, or well in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. In addition, she [the nurse] helps the patient to carry out the therapeutic plan as initiated by the physicianâ and âshe also, as a member of a team helps others as they in turn help her to plan and carry out the total programme whether it be for the improvement of health or recovery from illness or support in death. (p. 22)
In 1966 Virginia Henderson went on to publish her book, The Nature of Nursing: A Definition and Its Implication for Practice, Research and Education. In it, she introduced her philosophy of nursing, describing how people have biological, psychological, social, and spiritual components. It was a philosophy of that moved the profession away from simply carrying out tasks as instructed by the doctor. She envisioned the practice of nursing as independent from the practice of doctors, emphasising the unique role of the nurse. She supported empathy with patients and believed nurses really needed to get to know their patients to understand their needs. It was the foundation of caring for people as individuals, concentrating on their specific needs. It was the beginning of the development of holistic care. Holistic care may be defined as âa system of comprehensive or total patient care that considers the physical, social, economic, spiritual and emotional needs of the patient, his or her response to illness, and the effect of the illness on the ability to meet self-care needsâ [5].
In practice â Basic holistic care
In veterinary nursing, a holistic approach may be illustrated in a basic change from referring to âthe blocked bladder in kennel fiveâ to the use of the petâs name and subsequent consideration of that animal as a whole.
So, the âblocked bladder in kennel fiveâ becomes Bam-Bam, the 4-year-old domestic short hair with urethral obstruction, who has a penchant for escaping from the kennel whenever possible and is owned by Mr Smith, who is deaf and needs more support with communication. Each of these aspects are relevant to a nurse approaching the patient and the owner.
As part of her work in 1973, Sylvia Lelan [2] supported the philosophy of holistic care, discussing the idea that planning and implementing individual care might provide nurses with increased professional satisfaction since their work would be less fragmented. She also raised the point that in working within the medical model, patients may have been receiving treatments they did not need.
The holistic care model is supported by more recent definitions of nursing, such as the one published by the Royal College of Nursing in 2014 [6], which states that nursing is
The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems and to achieve the best possible quality of life, whatever their disease or disability, until death.
Training the first veterinary nurses
In contrast to the human-centred nurses who were developing theories and philosophies of nursing, veterinary nursing as a role with specific knowledge and training was only just starting. Throughout the 1950s, proposals to formalise the training for veterinary nurses in practice were being debated, with many being opposed to such a scheme. In listing the wide range of tasks that the new animal nurses might carry out, which included laboratory work, radiography, handling and restraint, and the sterilisation of instruments, one vet wrote to the Veterinary Record to register his opinion. He concluded his objection with, âthey will know so little about so much that they will be of very little use at allâ [7]. Other concerns voiced were based on fears that trained animal nurses would replace younger, inexperienced graduate vets, robbing them of their employment.
In contrast, supporters of the scheme believed that having a trained animal nurse would provide valuable and much needed assistance to the veterinary surgeon, freeing them up from menial tasks such as preparation of surgical instruments and administration of medication. So, while human-centred nursing pioneers were putting the patient very firmly at the centre of nursing care, veterinary nursing was being considered very much as a task-based role, falling straight into the medical model.
While the first veterinary nurses ...
