Roper 5j4jb

The Roper, Logan and Tierney model of nursing (originally published in 1980, and subsequently revised in 1985, 1990 and the latest edition in 1998) is a model of nursing care based upon activities of living(ALs). It is extremely prevalent in the United Kingdom, particularly in the public sector[citation needed]. The model is named after the authors - Nancy Roper, Winifred W. Logan and Alison J. Tierney.

[edit] Introduction First developed in 1980[1], this model is based upon work by Nancy Roper in 1976. It is the most widely used nursing model in the United Kingdom and is particularly well used by nurses in medical and surgical settings. The model is based loosely upon the activities of daily living (ADLs) that are evolved from the work of Virginia Henderson in 1966. Whereas The latest book edited by these women, in 2001, is the ultimate work made by them. In this book they complete the work they have been made, with an upgrade of the model based on the new needs of the society. Although the model promotes that the assessment be used throughout the patient's care, it has become the norm in UK nursing to use the model only as a checklist on ission rather than as intended (see: modifications) as an approach to the assessment and ongoing care of an individual[citation needed] . It is often used as a way of comparing how a patient's life has changed due to illness or ission to hospital rather than as a way of planning for increased independence and quality of life.

[edit] Activities of living The current model seeks to define 'what living means' (p15)[2], and categorises these discoveries into Activities of Daily Living (ADL), in order to promote maximum independence, through complete assessment leading to interventions that further independence in areas that may prove difficult or impossible for the individual on their own. The model assesses the individual's relative independence and potential for independence in ADLs,(considering their lifespan, development, and the five key factors (see Factors below)) on a continuum ranging from complete dependence to complete independence in order to determine what interventions will lead to increased independence as well as what ongoing is or will be required to compensate for dependency. Its application requires that it be used throughout the engagement with the patient (not only on ission) as an approach to problems and their resolution, and as a tool to determine how the patient can be ed to learn about, cope with, adjust and improve their own health and challenges. The ADLs themselves are frequently misunderstood or are assumed to have limited scope, leading to dissatisfcation with the model, when one fails to recognise that the ADLs are more complex than the title would lead one to believe[citation needed]. For this

reason, it is not recommended in the model that it be used as a checklist, but rather as Roper states "As a cognitive approach to the assessment and care of the patient, not on paper as a list of boxes, but in the nurse's approach to and organisation of her care" [3] and that nurses in clinical practice deepend their knowledge and understanding of the model and its application; it is essential that those using such a widespread tool be competent in its correct application. The ADLS are listed as: • • • • • • • • • • • •

Maintaining a safe environment Communication Breathing Eating and drinking Elimination Washing and dressing Controlling temperature Mobilisation Working and playing Expressing sexuality Sleeping Death and dying

These activities, outlining both the norm for the patient as well as any changes that may have resulted from current changes in condition, are assessed on ission onto a ward or service, and are reviewed as the patient progresses and as the care plan evolves. To provide effective care, all of the patient's needs (which are determined by assessing the patient's specific abilities and preferences relative to each activity, based on the factors listed) must be met as practicably as possible through ing the patient to meet those needs independently or by providing the care directly, most preferably by a combination of the two. By considering changes in the dependence-independence continuum, one can see how the patient is either improving or failing to improve, providing evidence either for or against the current care plan and giving guidance as to the level of care the patient does or may require. This value only results when the assessment is done frequently as changes occur and if it is combined with health improvement and health promotion. It is not effective in a paternalistic environment where all care is provided for an individual even when self care is possible[citation needed].

[edit] Factors influencing activities of living The following factors that affect ALs are identified [2]. Nancy Roper, when interviewed by of the Royal College of Nursing's (RCN) Association of Nursing Students at RCN Congress in 2002 in Harrogate [4] stated that the greatest disappointment she held for the use of the model in the UK was the lack of application of the five factors listed below, citing that these are the factors which make the model holistic, and that failure to

consider these factors means that the resulting assessment is both incomplete and flawed she implored students to the use of the model through promoting an understanding of these factors as an element of the model. These factors do not stand alone; they are used to determine the individiual's relative independence (and requirements to restore independence) for each othe activities of daily living. •

Biological- the impact overall health, of current illness or injury, and the scope of the individual's anatomy and physiology all are considered under this aspect. An example is how having diabetes mellitus causes the person's nutritional activities to differ from those of a person without diabetes.

•

Psychological- the impact of not only emotion, but cognition, spiritual beliefs and the ability to understand. Roper explained this was about "knowing, thinking, hoping, feeling and believing". One example of the application of this factor would be how having paranoid thoughts might influence independence in communication; another example would be how lack of literacy could impact independence in health promotion.

•

Sociocultural- the impact of society and culture experienced by the individual. Expectations and values based on (perceived or actual) social class or status, or related to the individual's perceived or actual health or ability to carry our activities of daily living. Culture within this factor relates to the beliefs, expectations and values held by the individual both for themselves and by others pertaining to their independence in and ability to carry out activities of daily living. One example is when caring for an individual of advanced age and how societies expectations and assumptions about infirmity and cognitive decline, even if not present in the individual, could influence the delivery of care and level of independence permitted by those with suffiecient authority to curtail it.

•

Environmental- Roper stated in the interview above that this consideration made hers the first truly "green" model, as it recommends consideration of not only the impact of the environment on the acitivies of daily living, but also the impact of the individual's ADLs on the environment. One example of the environment impacting ADLs is to consider if damp is present in one's home how that might impact independence in breathing (as damp can be related to breathing impairments); another example, using the "green" application, would be how dressings that are soiled with potentially hazardous fluids should be disposed of after removal.

•

Politicoeconomic - this is the impact of government, politics and the economy on ADL's. Issues such as funding, government policies and programmes, state of war or violent conflict, availability and access to benefits, political reforms and government targets, interest rates and availability of fundings (both pubic and private) all are considered under this factor. One example is how becoming

eligible for housing benefit might impact a person's independence, especially if the current housing is poor or inadequate; another example is how living in a place where violence and conflict are the norm would impact the ability to self care.

[edit] The life span continuum The model also incorporates a life span continuum, where the individual es from fully dependent at birth, to fully independent in the midlife, and returns to fully dependent in their old age/after death. Some researchers argue that the lifespan continuum begins at conception, others that it begins at birth[citation needed].

[edit] Modifications Within short-stay settings such as surgery or in areas where the assessor is uncomfortable with or unsure of the applicability of certain activities of daily living (ADL) it is common for the activities 'sexuality' and 'death' (as well as others) to be disregarded. These modifications depend upon the institution or the nurse and often results from a lack of understanding of the application of, or the factors within, the model. This is unfortunate, because this limits the application of the model and thereby reduces its efficacy[citation needed]. Often clinical settings use a list of the activities of daily living as an assessment document, without any reference to the other elements of the model; Roper heself rejected the use of the list of ADLs as a "checklist" as she stated that it was essential not simply to read the title of the ADL, but to base assessment on knowledge of the scope of the ADL as assessed using the 5 key factors.[3].Roper stated that if nurses themselves were uncomfortable discussing certain factors, they might assume patients also would be and thereby attribute the lack of assessment to the patient's preference, when the patient's opinion was never actually sought.[4] Roper's assertion leads one to believe that rather than delete or disgregard activities of daily living, it can benefit the individual being assessed if the nurse uses the model more thoroughly and assesses the ADL fully, using the 5 factors, irrespective of the area in which the care is being received. Roper stated "The patient is the patient, they are not a different patient because they are in a different clinical area. Their needs are the same- its who will meet those needs that changes".[4] For example, "sexuality" as an activity of daily living refers not only to the act of reproduction, but also to body image, self-esteem and gender-related beliefs, roles, values and practices, all issues which could have a high degreee of relevance for the individual about to undergo surgery. Another example is the ADL "death" which does not only apply strictly to the specific last moments of life, but also to the processes we perceive as leading up to the eventuality of death, such as loss of independence, periods of ill health, fear of failure to recover, fear of the unknown, and as such are all immeasureby relevant to most if not all eposiodes of care.

[edit] See also

• • •

Activities of daily living Nursing Nursing theory

[edit] References 1. ^ Roper N., Logan W.W. & Tierney A.J. (1980). The Elements of Nursing. Churchill Livingstone. ISBN 0-443-01577-5. 2. ^ a b Roper N., Logan W.W. & Tierney A.J. (2000). The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living. Edinburgh: Elsevier Health Sciences. ISBN 0443063737. http://books.google.co.uk/books? id=RJ21IkAZQQ4C. 3. ^ a b Siviter, B. (2008) Student Nurse Handbook: a survivial guide 2nd edition, Edinburgh: Balliere Tindall for Elsevier ISBN 978-0702029462 4. ^ a b c Siviter, Bethann (2002) Personal interview of Nancy Roper at RCN Congress, Association of Nursing Students, reported in Fall 2002 edition "The ANSwer" (RCN) Retrieved from "http://en.wikipedia.org/wiki/Roper-Logan-Tierney_model_of_nursing" ****rationale Over the past 30 years nursing has evolved from a task-oriented to a logical and systematic approach to care, using theories and models to guide practice (Pearson et al, 1996). Models of nursing outline a framework for nursing care that is systematically constructed and of scientific origin (Fawcett, 1995). When used correctly a nursing model should give direction to nurses working in a particular area, as it should help them understand more fully the logic behind their actions. It should also act as a guide in decision-making and so reduce conflict within the team of nurses as a whole. This in turn should lead to continuity and consistency of the nursing care received by patients (Pearson et al, 1996). The aim of this paper is to demonstrate the use of the Roper, Logan and Tierney Activities of Living Model (Roper et al, 1996) for assessing, planning, implementing and evaluating the care of an infant in a neonatal intensive care setting. The Roper, Logan and Tierney model The Roper, Logan, Tierney model (1996) centres on the patient as an individual and his relationship with the five components of the model (Box 1). Although activities of living are the main component of the model, each person carries out all activities of daily living differently. In of the Roper Logan and Tierney model, ‘this individuality can be seen to be a product of the influence on the activities of all the other components and the complete interaction between them’ (Roper et al, 1996). In an effort to promote independence in the activities of living, the model utilises the stages of the nursing process to formulate logical stages for delivery of nursing care

Medical orientation - The Roper, Logan and Tierney model has received substantive criticism for being medically oriented and for its focus on activities of living. Tierney (1998) accepts that the model does little to ‘loosen nursing from the medical model’. However, Tierney (1998) proceeds to suggest that this may well be a particular strength of the model as it allows nursing to work hand in hand with medicine, rather than trying to separate the two. Tierney (1998) describes this as ‘reframing nursing’s relationship with medicine’. Accessibility of theory - Tierney (1998) suggests that the Roper, Logan and Tierney model presents ‘nursing theory’ to practising nurses in a manner that is understandable, clear and simplistic. The model is easy to use and easy to translate into practice. This gives the practitioner a sense of ‘ease’ with nursing theory as opposed to scepticism or rejection, which is common where concepts appear difficult to understand. The continuum scale - The use of a continuum scale within this model has been highlighted as particularly useful in neonatal settings (Molloy, 1996). It can be easily incorporated into the assessment and care planning of infants and clearly identifies to the nurse that the infant’s dependency is due to his or her position within the lifespan, in addition to the current condition that exists. This facilitates an understanding of the baby’s condition further by shifting the emphasis away from ‘ill-health to health’ (Tierney, 1998), emphasising that dependency at this stage is normal and healthy.

Documentation - Documentation is an important consideration in nursing practice today. Record-keeping is an essential function within nursing; however, the documentation aspect of care planning when using the Roper, Logan and Tierney model is a cause of concern to nurses who find this a time-consuming activity (Murphy et al, 2000; Mason, 1999). Mason (1999) explored issues relating to care planning for practising nurses at ward level, and how they use care plans in practice. Mason found that negative attitudes existed towards the use of care plans, including a belief that there was a mismatch between the demands of clinical practice and the need to document care, which often took place retrospectively at the end of a shift - whereas continuous documentation throughout a shift may be more helpful. the use of the care plan is not particularly time-consuming, and the benefits of having a plan of care on instant view that may be used during handover or to inform nursing practice on the next shift, far outweighs any negative effects of time spent documenting. In addition, it is reassuring to have an instrument that allows the detailed documentation of care in a neonatal unit, as documentation from this area is often used in medico-legal situations.

Educational preparation - Educational preparation is an important consideration for the use of nursing models in practice. For practising nurses the implementation of models may represent a significant change in practice. For successful implementation of change and to avoid ‘resistance’ it is important to adopt a ‘bottom-up’ rather than a ‘top-down’ approach (Wedderburn Tate, 1999). This implies that nurses need to be informed and involved at all stages of implementation, which would include education regarding the model of choice. Murphy et al’s (2000) study revealed that nurses did not feel fully prepared to apply the model. The majority of respondents expressed a need for further education on the model. Even though many had received educational preparation, it is described as having occurred ‘long ago’ and thus had been forgotten (Murphy et al, 2000). Fraser (1996) argues that Roper, Logan and Tierney’s activities of living are a physical/physiological method of assessing patients. However Newton (1992) rejects this, reminding us of the five factors influencing the activities of living (Box 1). These prevent the nurse from focusing on ‘the presenting problems’ but allow the patient to be assessed as a whole, incorporating all 12 activities of living. Conclusion Nursing models give a systematic direction to nursing care. The Roper, Logan and Tierney model (1996) is widely used in nursing practice in both the UK and Ireland. The patient is assessed on his or her or her ability to perform the 12 activities of living in relation to his position on the lifespan, and his or her level on the dependence/independence continuum and aims in care are identified. The goals of the care plan are mutually agreed between the nurse and patient and the family. Finally, evaluation of care determines whether or not the goals of care have been achieved, or if they need to be revised. The model provides a systematic and logical means of delivering care, encouraging team participation leading to primary care and continuity of care, abolishing the 1960’s task allocation style of nursing (Roper et al, 1996). In this paper the care of baby David is demonstrated using this model. It was an effective framework in this situation as his care followed a logical approach with due sensitivity. It also allowed for the incorporation of the many medical aspects of baby David’s care within the neonatal unit.

This critique of the model reveals that the Roper, Logan and Tierney model possesses clarity and consistency, provides for a holistic approach to nursing care and recognises nursing as an independent health-care discipline. The model provides a systematic framework for guiding nursing practice and documentation in the neonatal setting, although further testing of this model may be required in practice.

Roper, Logan, and Tierney model (roh-per loh-găn teer-ni) n. a model for nursing that emphasizes the importance of the patient's ability to perform activities of daily living. Individuals are seen as being engaged in various activities of living throughout their lifespan; during their lives they will fluctuate between total independence and total dependence, according to age, circumstance, and health status. Nursing should provide assistance with these activities when needed Prevention of Intra- and Post-Op Complications: •

•

•

•

Protecting the patient from injury intraoperatively involves correct patient identification, correct informed consent, verification of records, knowing the patients allergies, monitoring and modifying the environment as needed, safety measures such as restraints and not leaving a sedated patient, and verification and accessibility of blood. Prevention of Post-Op complications involves monitoring for cardiac problems such as hemorrhage and DVT, monitor respiratory status for pulmonary embolism, aspiration, atelectasis, pneumonia, pneumothorax, monitor for neuro problems such as confusion or stroke, monitor GI for problems such as paralytic ileus, sepsis, or stress ulceration, monitor for wound complications such as infection, bleeding, hernia, or pressure sores. The Post-Op nurse immediately takes the patient to the PACU and has to do continuous assessments to monitor airway patency, breathing, circulation, LOC, the incision, drains, vitals, and comfort. At risk groups during surgery that need to be monitored for complications are people who are malnourished, obese, have chronic diseases, older age, substance abs, and non-compliant patients. A risk assessment can also be done to see how the patient may be for surgery

Nursing Diagnoses Assoc. With Post-Op Care: • • • • • • • • • •

Risk for ineffective airway clearance Acute pain Risk for infection Decreased cardiac output Risk for activity intolerance Impaired skin integrity Ineffective thermoregulation Risk for imbalanced nutrition Risk for constipation Risk for injury

Pre-Op Patient Education:

• • • • •

Assess what the client knows or if there is a knowledge deficit Best time to teach is about a week before the surgery Teach about the procedure, what to expect, what to do the night before, what to expect the day of surgery, what to expect postoperatively Tell them about early ambulation and exercises to do Perform the pre-op checklist, provide pre-op meds, have the patient sign the site, make sure they have informed consent

Assessment of the Post-Op Patient: •

Post-op assessment involves checking the airway, breathing, circulation, LOC, surgical site, drains or tubes, vitals, fluid and electrolytes, comfort, pain, assess for post-op complications, check the wound and the dressings

Pre Operative nursing care Assess patient. The health history and the physical and pelvic examinations are completed and the laboratory tests are performed. Encourage patient to share details of her menstrual history, the date of her last menstrual period, the events leading up to ission and the current degree of vaginal blood loss or discharge. Assess client’s knowledge of her condition and the surgery. Perform skin operation: The lower half of the abdomen and the pubic and perineal area may be shaved and these areas may be cleaned with soap and water. To prevent contamination and injury to the bladder or intestinal tract, the bladder and intestinal tract need to be empty before the patient is taken into the OR. The patient who has previously been prescribed with oral contraceptive drug will have to stop taking the drug 6 weeks prior to operation. Preoperative medications may be istered before surgery to help the patient relax. The patient must be allowed time to talk and ask questions. The nurse must know what information the physician has given the patient about the surgery. Encourage patient to practice foot and leg exercises before operation to

understand how to carry out the exercises while in bed after surgery. Let the patient will wear anti-embolism socks to prevent venous stasis during the operation. Provide education: Loss of fertility if ovaries are to be removed in conjunction with the operation. Discuss surgical menopause. Discuss how sexual intercourse may change.  Client whose ovaries are removed may complain of a decrease in libido.  Tell the client that once healing has occurred, intercourse should be pain free. Let the patient relax on bed until she leaves the ward escorted by her nurse who completes a safe transfer to the operating theater staff. Intra Operative Nursing Care Prepare and assist for anesthesia. Maintain homeostasis and asepsis. Assist the surgeon and the whole team Assist in transferring the patient to the Operating table in a supine position. Ask patient to remove any jewelry or other objects that may interfere with the procedure. Ask patient to remove clothing and be given a gown to wear. Check for patency of the IV system. Monitor client’s HR, BP and breathing and report abnormalities. The skin over the surgical cite will be cleansed with an antiseptic solution Post Op Perform usual post operative assessments. Evaluate psychological manifestations Monitor proximity of the bladder to the reproductive organ. Monitor Foley catheter to prevent susceptibility to UTI and temporary urinary retention Assist GI functions by listening to bowel sounds. Note distention and palpate whether abdomen is soft or firm Assess abdominal incision for bleeding and intactness. Assess vaginal bleeding. There is no distinct diet. Simple, strong, distinct flavors rather than complicated and multi-flavored dishes seem to be preferred with anything with smallerthan-usual

portions. It’s best to avoid gassy foods like beans, broccoli and cabbage and/or foods that typically cause gas for you. Many suggest avoiding extra-spicy foods. that all pos top surgical patients need protein to aid in healing. Include fiber in your post op diet, drink lots of water, and consume caffeinated drinks sparingly. If pain is experienced during sexual intercourse let the patient manipulate the penetration. Avoid heavy lifting for about 6 weeks to prevent straining the abdominal muscles and surgical sites. Avoid activities that increase pelvic congestion such as aerobics activity, horseback riding and prolonged standing. Report any fresh bleeding and any abnormal vaginal discharge to surgeon. Return for follow-up care as requested by the surgeon. Post op pain and discomfort are common, therefore the nurse should assess it’s intensity and ister analgesics as prescribed. If the patient has abdominal distention or flatus, rectal tube and application of heat to the abdomen may be prescribed Encourage patient to nurse or surgeon when bleeding is excessive. Encourage early ambulation o facilitate the return of normal peristalsis Montior and manage potential complications such as:  Hemorrhage: Count perineal pads used, assess the extent of saturation with blood and monitor vital signs. Guidelines for activity restriction are given above to promote healing and prevent post operative bleeding.  Deep Vein Thrombosis: Encourage and assist patient to change position frequently and exercise leg and feet while in bed. Instruct patient to avoid prolonged sitting in the chair with pressure on the knees, sitting cross legs and inactivity.

Maintaining a safe environment: Due to Emily's mild and intermittent confusion, an awareness of potential dangers to her wellbeing is vital. Care was taken that Emily could manage a hot drink and was supervised when mobilising in the early stages of her stay. A falls risk assessment is carried out on all patients within this particular clinical area. Emily was judged to be of a high risk but was later reassessed as medium as her ability to mobilise competently increased. This section however may include other factors, such as aseptic wound care and the istration of medication. Particularly the istration of antibiotics to prevent infection. The observation and prevention of surgical complications such as DVT may also be included in this section. Communicating: A two way process in which the healthcare staff must identify Emily's needs using both verbal and non-verbal cues. Roper, Logan and Tierney place pain in this zone as the patient must express their discomfort. Therefore the alleviation of pain or the introduction of a coping mechanism, is a nursing issue. Emily's pain was well controlled during her stay with no particular complaints being made post-operation, even with an unidentified broken arm. The use of aids such as spectacles and hearing aids are covered by communicating. Emily does use spectacles but her use of them could just as easily be covered by maintaining a safe environment. Breathing: This also includes the cardiovascular system as a whole. Several of Emily's medical conditions are covered by this area, including hypertension, atrial fibrillation, anaemia and diabetes. The necessity of close observation is clearly required in the early stages of care to prevent complications developing. Eating and drinking: Emily had no particular needs in this area with regard to appetite or surprisingly fluid intake. However Emily is a type ii diabetic and therefore the choice of correct menu was required. Her diabetes was remarkably stable post-operation. Eliminating: Emily is occasionally incontinent, sometimes doubly. Prior to her operation Emily did require catheterisation but this was removed on the fourth day post-operation and incontinence pads provided. Emily was by this time mobilising to the toilet with a walking frame and the catheters removal gave Emily greater independence. Personal cleansing and dressing: Due to her advanced age and her injury Emily required assistance. Over a few short days however, she was able to progress to washing her upper body with less help. When assisting a patient with hygiene healthcare staff are in a privileged position of intimacy, raising many issues regarding privacy and dignity. This time also affords an opportunity to inspect the patient's skin integrity. It was whilst assisting Emily with her

morning wash, that a Health Care Assistant first became suspicious of the injury to Emily's right forearm. Controlling body temperature: Emily is capable of expressing her needs with regard to body temperature and generally only required assistance with the choice of appropriate clothing. There is always a risk of potential infection following an operation and monitoring of the patient's temperature is necessary. Emily also received a blood transfusion peri-operatively and therefore required close monitoring at that time. Mobilising: Emily was able to mobilise on the second day post-operation. Her walking distance and independence increased until she was able to walk to the toilet without assistance. Although Emily could not get in or out of bed or raise herself from a sitting position without aid. This increased mobility is desirable, as it will lessen the risk of complications such as thromboembolism episodes and aid the recovery of Emily's pressure areas. Working and playing: Emily's leisure interests centred around reading and watching television. Her family who visited daily, provided books and newspapers as necessary to relieve the boredom of her hospital stay. Expressing sexuality: The use of the word sexuality within this area causes much confusion. In reality this zone includes both sexuality and gender issues relating to hygiene, self-image and self-awareness. The patient's need to express their individual and self perceived needs relating to hair, make up, washing and shaving (facial if male and lower limb if female). Emily does not normally wear make up but she does like to have her hair looking presentable. One Health Care Assistant after bathing Emily, put her hair in curlers. Sleeping: Lack of sleep and sleeping in a strange environment can have detrimental effects upon an individuals mental state. Promoting good quality sleep and rest in hospital is difficult. The wards are always busy and very often noisy. Limiting the number of visitors to each bedside and monitoring noise levels can help. Providing comfortable and the right number of pillows may also help. Unfortunately there are still difficulties and although necessary from a health and safety position, ward night lights do not promote rest. Dying: People die everyday but an individual does not. However, a patient and his or her relatives may have concerns about the possible worsening of an illness. Patients with a terminal illness or the elderly, may "live with the prospect of death" and the nurse should handle these concerns with care. On a practical front the documentation of who to if the need arises should be made. If living alone the patient may have pets that need to be cared for. In dealing with anxiety, the nurse may need to distant friends, a spiritual advisor or even a neighbour. The suitability of the Roper, Logan and Tierney model within orthopaedics

It can be argued that many nursing models are unnecessarily complicated. Yet the RLT nursing model may be regarded by some nurses as being simplistic. This is a mistaken view. The RLT model has depth that will only become apparent with regular use by the practitioner. This is particularly true when exploring the component factors related to dependency. Here it is for the practitioner to use their own judgement, as to when to step back and allow the patient to do more for his or herself. There is no ideal nursing model and in practice, the nurse may subconsciously use a combination of models. Each nurse (in the opinion of the author) may carry their own nursing theory or philosophy, in their head. However, it may not necessarily be the right one. The RLT model has the balance of being relatively easy to allow familiarisation, together with the depth to allow adaptation in variable settings. The model itself is certainly not the worst in existence but it may not necessarily be the best. Taking mobility as the central focus within orthopaedic nursing, can the above model be improved? Balcombe (1994) has attempted to answer this question by placing the patient's desired health state at the centre of nursing care. Giving eleven areas for consideration within the assessment criteria; mental state, diet, self concept, sleep and rest, breathing (and cardiovascular state), home environment, pain, movement (and mobility), behaviour, hygiene and aspirations. Davis (2005a) takes this one step further by adapting the activities of living model (Roper, Logan and Tierney 1990) to orthopaedics. By centralising mobilising the "Davis model" shares some characteristics of the Balcombe model. Incorporated into the Davis model are the activities of living from Roper, Logan and Tierney. Together with the lifespan and the dependence-independence concepts from the same model. The possible advantage of the Davis model is that it recognises the value of other models and builds upon them. Added to the above is a self-empowerment framework, an area representing individualised nursing that includes assessment and finally an "other" category. This area called "factors influencing" is the framework for factors not necessarily covered by the others. An unfortunate disadvantage of the RLT model is the placing of pain under communication. Based on the view that the patient must express and therefore communicate their experience. The question is does pain really fit within communication? The impression given is that the communication area is something of a catch all. Balcombe has the advantage of recognising the importance of pain as a factor in its own right and not merely as a sub-factor. Davis is honest enough to actually have an "other" category.

One possible way of combining all that is best from the above models would be the continued use and development of integrated care pathways. Care pathways are documentation and care planning tools, following agreed guidelines and protocols while based upon evidence based practice (National Electronic Library for Health 2004, Santy 2005b). Care can be documented and any deviations recorded as a variance (Bayliss and Salter 2004). The UK government has identified the use of the integrated care pathway as having significant benefits to patient care (Davis 2005b). However, less than fifty percent of trusts actually use them (House of Commons 2004). Each care pathway should be tailored around the unique needs of each clinical area (Bayliss and Salter 2004). So recognising their inherent speciality. A key feature of the Davis model (in being different from the Balcombe model) is the recognition that orthopaedic nursing is a speciality and therefore deserves a specialised nursing model."'