This article is for nurses working with people who have an intellectual disability.
It tells nurses that each person with an intellectual disability should have a care plan.
A care plan tells the nurse how the person with an intellectual disability would like to have their needs met.
The article gives the nurse five (5) ways to plan care with the person with an intellectual disability.
It looks at the good and not-so-good parts of each way.
Registered Intellectual Disability Nurses (RNID’s) are unique, being the only group of professionals who are educated solely to work with people with an intellectual disability (ID) (Northway et al 2006). This specialised education is only available in Ireland and the UK. RNIDs work in a wide range of settings, and have a diversity of roles and skills (one of which is care planning) in addressing the needs of the person with an ID. Good nursing practice dictates that the best available evidence should underpin healthcare decision making. Whether working individually, or as part of a wider interdisciplinary team, all care provided by the nurse should be guided by a care plan. Care planning is an ongoing process of working with the individual, involving assessment, planning, implementation and evaluation of the individual’s needs, culminating in a written care plan that documents the individual’s specific needs and how those are to be addressed. Devising a care plan can be a complex process; therefore using a framework of care for guidance can make care planning more achievable.
As there are multiplicities of frameworks of care available, selecting the most appropriate one for the individual can be an onerous task. This can be further complicated by the variety of practice settings within which intellectual disability nursing takes place, and the current needs of the individual e.g. health, social, educational and/or a combination of needs. RNIDs need to understand the components of the various frameworks, and be able to justify the selection of the most appropriate framework to guide the development of the individuals care plan. The components of a good framework of care should be specific to addressing the person’s individual needs, informed by evidence and seen as a continuous process of discussion, observation, planning, implementation and evaluation. This paper presents a brief overview of the ideology underpinning five such framework approaches that the nurse can draw upon, along with some of the more common advantages and disadvantages associated with each one (Table 1).
The use of the medical model approach can be traced back to Hippocrates, Aristotle and Galen and has guided medicine and nursing across the centuries. Since Nightingale’s era, the nursing profession has adopted an assessment, diagnosis, prescription and treatment model of care (McKenna and Slevin 2008). Unfortunately, this diagnosis-orientated approach does not allow for independent thinking or holistic care within nursing.
This model is connected with scientific rigour and objectivity, and linked with well-established areas of science and medicine (Bickenbach 1993). Using this model, disability can be classified, quantified and measured or rated (Smart 2009). It is also linked with fragmenting the disability community, identifying individuals by their diagnosis e.g. the deaf, the blind. Labelling the person with ID using the biomedical model legitimises disability as the individual is diagnosed as biologically inferior, thereby increasing the chance of stigma and prejudice (Smart 2009). It is linked with routinisation of care (Pearson et al 2005) and should be questioned and challenged for its failure to address the social, physical and human barriers to disability or economic, political or social issues.
The biopsychosocial model of health and illness adopts a holistic view of health. It combines biological, psychological and social factors, acknowledging that all play a significant role in human functioning in the context of disease or illness (Smeltzer 2007). This framework views disability as arising from a combination of factors at the physical, emotional and environmental levels. This approach takes the focus beyond the individual and addresses issues that when combined, affect the ability of the individual to maintain as high a level of health and wellbeing as possible, and to function within society. Recognising that disabilities are often due to illness or injury, it does not dismiss the importance of the impact of biological, emotional and environmental issues on health, well-being, and function in society. The disabling condition, rather than the person and the experience of the person with a disability, is the defining construct of the biopsychosocial model.
In an attempt to move away from the medical model of care, nursing models were developed in the 1960s and are described as frames of reference, providing guidelines which facilitate the nursing process (assessing, planning, implementing and evaluating nursing care) and enhance the quality of care (Fawcett et al 1992). There are numerous models of nursing available, each representing a distinct way of thinking about and guiding nursing practice (Murphy et al 2010).
Roper, Logan and Tierney Model of Nursing
Developed in the 1970s, the Roper, Logan and Tierney model of nursing is based on a model of living which views the person as an active participant in the development of their nursing care. It focuses on identifying the person’s actual and potential problems in 12 activities of living (ALs). It takes into account the biological, psychological, sociocultural, environmental and politico-economic factors that influence the person’s ALs, and the lifespan or stage of development of the person. Also, the inclusion of a dependence/independence continuum acknowledges the person’s changing health status during illness. These four components culminate in the development of an individualised nursing care plan framed by the nursing process (Tierney 1998). This is the most widely used nursing model in ID settings.
Ecology of Health Model
In response to practitioners’ desire for a specialist model of nursing, the ecology of health model was developed in order to specifically address the healthcare needs of the person with intellectual disabilities (Aldridge 2004). The person is seen as having physical and psychological elements that form the self and which exist within a social environment. The person relates to their environment through a process of interaction, thus forming an ecological system. Underpinning this model is the idea that all care plans are person-centred, structured and purposeful. The model allows for contributions from the individual and also reflects what is important to the person in their life, in turn promoting person-centeredness. Its implementation in ID settings, with its holistic approach, deems it influential in ID practice (Barr 2005).
The Social model approach is the antithesis of the medical model; it emerged as a reaction to the dominance of the medical model from the analysis of the experiences of institutionalised disabled persons (Scullion 2010). Within this approach, the emphasis is not on the person’s disability but on the way in which physical, social, and/or cultural environments disadvantage or exclude people with disabilities.
Social Model of Disability
This model developed in the mid-1970s, relating to people with physical and sensory impairments. It differentiates between impairment (i.e. loss of function of the body) and disability (i.e. meaning society attaches to the presence of impairment) (Chappell et al 2001). Disability is viewed as a consequence of society’s lack of awareness and concern about those persons who may require modifications in order to lead full lives. This model sees staff delivering care within the home, with involvement in decision making and care planning by the person and his/her family. The notion of addressing rights and equality is to the forefront of this model, with nursing interventions focused on increasing social inclusion by reducing or eliminating barriers to good health (Northway et al 2006).
Person-centred planning (PCP) is identified as one of the key points for the delivery and development of services for persons with disabilities. Underpinned by core values, and the central tenet being putting the person first (Valuing People 2001, National Disability Authority (NDA) 2005), it acknowledges that care begins with the individual and focuses on what the person and the family think is important for the person, as opposed to what the healthcare professional considers to be necessary for the person (NDA 2005).
Personal Outcomes Measures (POMs)
Quality of Life measures are used to assess the impact of service initiatives on the lives of people with ID and to guide programme delivery (McCormack and Farrell 2009). POM’s place emphasis on quality assurance and quality improvements within services to support person-centred development (Gardner and Carran 2005). The move away from congregated settings towards community settings was the impetus for the development of these measures to assess quality.
Person-centred nursing framework
The person-centred nursing framework (McCormack and McCance 2006) contains four constructs focusing on the professional competence of the nurse, i.e. the nurse’s knowledge, decision making, prioritising and delivery of care. The care environment addresses the context within which care will be delivered. The person-centred process focuses on engaging with the individual, acknowledging their beliefs and values and facilitating shared decision making and the delivery of physical care by a competent nurse. The outcome construct addresses the expected results from the person-centred planning.
An eclectic model of care is one that combines elements from different frameworks that include a reflective, person-centred, evidence-based and outcome-focused approach to care, and above all ensure best practice for the individual. McKenna (2009) suggests that each nursing framework is limited by the vision of its creator and no one framework can deal with all eventualities. Any combination of frameworks may be used with the key aspects of concepts incorporated to achieve a new or differing nursing framework.
Eclectic modelof care
Moulster et al (2012) developed an eclectic model of reflective and evidence-based person-centred care for use with individuals with ID, amalgamating elements from Roper, Logan and Tierney (Roper et al 2000), the Tidal Model (Barker 2001), Orem’s Self Care Model (2001), Ecology of Health Model (Aldridge 2004) and Person-Centred Nursing Model (McCormack and McCance 2006). This model has been shown to improve clinical governance, makes outcomes easier to measure, and the effectiveness and/or ineffectiveness of the outcomes easier to identify.
Frameworks of care in practice guide the assessment, planning, implementation and evaluation of care and support in practice, in turn developing and maintaining consistency in how care is delivered. RNIDs have a duty to underpin their practice with evidence-based frameworks of care. These frameworks all contain concepts capable of being researched and research evidence underpins practice, therefore the adoption of frameworks is an important factor in developing evidence-based effective nursing practice. They are also useful in nurse education as tools to identify what nursing is, who the recipients of care are and what skills and knowledge RNIDs should possess in order to be fit for practice. The provision of high quality, safe nursing care is central to nursing practice – thus, care delivered through a framed knowledge base is more likely to be of a high standard (Cutliffe et al 2010).
What is evident is that no one framework can reflect all of the needs of a person with ID, and therefore diversity in frameworks will allow individual models build upon each other. Individuals’ needs change according to the stage of their lives, or their physical, mental and social health status, and so the nurse must be skilled in selecting the most appropriate framework, most suited to address the person’s current needs. This may involve combining a number of elements from various different frameworks. Cross-modelling can be strengthening and enriching (Walkup 2000), and nurses with increased awareness of a variety of frameworks and their strengths and weaknesses, can make informed judgements on which particular framework suits the individual and the practice setting. Each framework is capable of adaptation; therefore RNIDs need to be cognisant of the potential to refine or modify a chosen framework.
While the authors have provided an overview of various frameworks that can be used with persons with ID, there are numerous others that can be adapted for use in a variety of health and social care settings. For example, Peplau’s model has been used to frame care delivered to children with ID in the community (Doyle and Buckley 2012), and Barkers’ (2001) tidal model has been adopted to support persons with ID who also have mental health difficulties.
This paper has provided an overview of five framework approaches used with persons with ID in planning care. Key advantages and disadvantages of those reviewed have been identified. The decision to use a specific framework approach with persons with ID should be well-informed, and its components should be fit for purpose, meeting the needs of the person with ID. Frameworks of care represent an important and integral part of intellectual disability nursing practice, and are powerful in meeting the needs of the person with ID in the 21st century.
Table 1: Advantages & Disadvantages of Framework Approaches
References available from authors on request