Salvage (2006) reports the RLT model is based on what is considered as twelve activities of living. The model determines that physical/biological, psychological, sociocultural, environmental and politicoeconomical factors all influence the way in which an individual performs these activities of living (Salvage, 2006). Healy and Timmins (2003) further add that activities of living are one of five main components that are all interconnected. Progression along the lifespan, the dependence/independence continuum, factors influencing the activities of living and the individuality in living completing the final four components. They state the model is one that “focuses on the patient as an individual engaged in living throughout a lifespan and moving from dependence to independence according to age, circumstances and environment” (Healy & Timmins, 2003, p. 792). Healy and Timmins (2003) identify the model is used to identify a patients abilities in each of the twelve activities of living and use this data as a guide to develop an individualised care plan.
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Meleis (2012) defines Orem’s framework as one that identifies patient’s needs and the resulting nursing intervention necessary to enhance self-care. Johnson and Webber (2010) explain Orem’s Model has three interrelated concepts – theory of self-care, theory of self-care deficit and theory of nursing systems. According to Orem, people require assistance when their ability to meet their own self-care needs becomes compromised (Horan, 2004). Orem identifies three categories of self-care common to all people, believing when an individual is unable to meet these needs a self-care deficit occurs (Berman et al, 2012; Fitzpatrick & Whall, 2005). Orem’s model assesses a patient’s self-care ability to determine the deficit in meeting their own care. Once the deficit is established, one of five methods can be implemented to meet the patient’s self-care needs. Depending on the patient’s abilities to perform their own self-care, one of three nursing systems is utilized to meet the needs of the patient (Berman et al, 2012).
Nurses have a responsibility to consider legal and ethical issues that need to be employed when performing health assessments. Legal issues, according to Berman et al (2012) include consent, confidentiality, duty of care and negligence whilst ethical issues include non-maleficence, beneficence, respect for autonomy and justice. Otherwise known as the “four principles of bioethics” (Atkins, Britton & de Lacey, 2011, p. 88). The Australian Nursing and Midwifery Council [ANMC] have developed codes and guidelines that are a minimum standard of practice that a nurse is expected to maintain. When performing health assessments nurses must perform within their scope of practice which is based on “education, knowledge, competency, extent of experience and lawful authority” (ANMC, 2008).
Atkins, Britton and de Lacey (2011) identify the position of power a nurse holds over a patient because of their inability to meet certain self-care needs and their reliance on the assistance of a nurse. They describe the relationship that exists between nurse and patient as a “fiduciary relationship” (Atkins, Britton & de Lacey, 2011, p. 82). Central to this relationship is cooperation with the patient, with him/her an active member of the decision making process (Atkins, Britton & de Lacey, 2011). It is recognised that the nurse has technical knowledge and expert advice however lacks sufficient knowledge and authority over a patient’s life. Therefore the nurse lacks the expertise to make significant decisions without the patient’s consent. A patient must consent to any health assessment being performed, however, the nurse first must provide sufficient and relevant information about the assessment being undertaken.
Any framework implemented in the nursing environment will always come with strengths and limitations. Whilst not practising the Self-Care Model as Orem packaged it, Johnson and Webber (2010) state nurses have embraced the logic of self-care as therapeutic. This has resulted in them focusing their care focused towards helping patients meet their self-care needs rather than performing these for them. This promotes patient independence and maximizes nursing resource. Nurses have integrated principles of the model into diverse practice settings including different cultures and the world.
Horan (2004) presented the use of Orem’s model in the field of intellectual disability and initially believed the model was too complex for successful application in this arena. His view changed when he saw the benefit the model provided to cater for individuals, with total care for one patient or just education and support for another. Meleis (2012) highlights the versality of the model with its use in preoperative and postoperative care, psychiatric, palliative and HIV patient care, ranging from geriatric patients to adolescents and children. Fitzpatrick and Whall (2005) identify the model is relevant, noting its implementation in many health care institutions. Ths suggesting the model is flexible and adaptable to form an individual care plan that will meet an array of patient needs. Orem’s model provides a framework for intervention and in her own words states “self-care deficit theory of nursing will fit into any nursing situation because it is a general theory, that is, an explanation of what is common to all nursing situations, not just an explanation of an individual situation” (Meleis, 2012, p. 208).
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Irrespective of these strengths, Johnson and Webber (2010) believe Orem’s model is detailed and burdened with complicated language. Meleis (2012) supports their idea, suggesting the model is ambiguous, lacks clarity and can result in misinterpretation. Fitzpatrick and Whall (2005) state the theory can be viewed as culturally biased due to the fact it relies on principles such as autonomy, self-determinism and self-reliance. Principles that are not adopted in all cultures.
Orem’s model addresses how nursing actions function to enhance health therefore being a valuable tool in the lives of those whose ability to self-care is thwarted. However, Fitzpatrick and Whall (2005) argue it may not make the same impact in health prevention care and promoting health. They claim its focus on self-care deficits resulting from health problems excludes a health promotion focus. Meleis (2012) supports this claim concluding that as nursing shifts to more community focus, the model will need to be supplemented with focus on health prevention and promotion care. Johnson and Webber (2010) identify that nursing would benefit from principles from a range of frameworks to enhance holistic assessment rather than limiting its practice to the boundaries of one single framework.
This essay has discussed RLT Model of Nursing and Orem’s Self-Care Model as health care frameworks that can be used when collecting heath assessment data. It outlined legal and ethical issues underpinning the nurse-patient relationship and how these must direct any interaction with the patient when conducting health assessment. Finally, it brought attention to the strengths and weaknesses when using Orem’s Self-Care Model, evidence showing whilst there are limitations to the model, there are attributes that make it valuable. Whilst the clarity of the model seemed questionable due to language used, the ability the model has to cater for patients with varying capacities proved it flexible and adaptable, encouraging and promoting patient independence.
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