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).
Mary O’Connor, RN, RM.
Neonatal Nurse, Neonatal Intensive Care, Coombe Women’s Hospital, Dublin
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. This model was chosen because it is the most widely used in both the UK and Ireland. Although frequently used by nurses, the usefulness of models of nursing has been questioned (Bellman, 1996; Robb, 1997; Tierney, 1998). However, despite reservations, the Roper, Logan and Tierney model (1996) has been suggested as suitable for use in intensive care settings (Robb, 1997; Sutcliffe, 1994). Indeed, Molloy (1996) advocates the use of this model in a neonatal setting. This model has received widespread interest on both sides of the Atlantic (Tierney, 1998). Although its direct impact may be difficult to measure, it is widely taught in preparatory nurse education programmes in the UK, and where models are used in practice it is described as ‘one of the most popular’ (Tierney, 1998). Despite the acclaimed popularity of models and the suggestion that the use of models is one of the hallmarks of success in nursing practice (Fawcett and Carino, 1989), for many nurses models of nursing are viewed as ‘distant and elitist’ and are not always ‘valued by practitioners or managers’ (Bellman, 1996). It is hoped that exploration and discussion of this model will encourage practitioners to adopt a similar approach to neonatal nursing care delivery.
A search of the electronic database Cinahl was performed using the key words ‘nursing models’, ‘nursing theory’, ‘conceptual framework’, ‘Roper Logan Tierney’, and ‘neonatal nursing,’ revealing 17 citations. All of these citations referred to the period 1982 to 1995; there were no citations after this period. The majority of this literature referred to theoretical or theory-based papers and there were some isolated studies. One paper examined the use of the Roper, Logan and Tierney model (1996) in a neonatal setting (Molloy, 1996).
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 terms 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 (Box 2).
The following section of this paper outlines the use of the Roper, Logan and Tierney (1996) model in a clinical setting. A case study is presented in Box 3. A care plan is used to provide a structured plan of action for David, the compilation of which is guided by the model of choice (Mason, 1999), which in this case is the Roper, Logan and Tierney model of nursing.
The processing of Baby David’s care using the Roper, Logan and Tierney model provides an invaluable contribution to nursing this infant. This contribution may be considered under the following headings:
- Medical orientation
- Accessibility of theory
- The continuum scale
- Educational preparation.
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’.
In the case of David, and possibly in neonatal units in general, the facility for the model to include quite medically oriented data in both the assessment and the care plan is a distinct advantage. The neonatal unit and infants therein often require a ‘medical’ approach to care, as much of the intervention is concerned with the administration of medications, other medical interventions and life-sustaining technologies such as ventilatory therapy.
Baby David required many medical interventions, including mechanical ventilation, blood gaseous analysis, suctioning, blood pressure monitoring, administration of intravenous dopamine, incubation and intravenous fluids, all of which are interventions that, although medical, have evolved to become integral to the role of the nurse in critical care. Many of these therapies, although guided and prescribed by physicians, are managed exclusively by neonatal nurses.
Benner (1984) outlines the development and expansion of the role of critical care nurses into the medical domain. Nurses are involved in continuous monitoring and treatment of patients who are critically ill. They guide the delivery of ventilatory and cardiovascular support in intensive care settings as well as other treatments that may have been ordered by the physician. Benner (1984) highlights the fact that the nursing role in critical care has also expanded greatly through unplanned practices and interventions delegated by physicians. An example of this is that nurses have become experts in titrating and weaning patients from vasopressors such as dopamine. Clearly, the ability of this model to incorporate the medical aspects of care, but yet provide a distinct individualised holistic approach, is a distinct advantage that moves away from ‘checklist’ and routine approaches to care.
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.
In neonatal ICUs, 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).
The usefulness of nursing models
The usefulness of nursing models in practice has generated much debate in the nursing literature (Murphy et al, 2000). The Roper, Logan and Tierney (1996) model in particular appears to have generated debate regarding its usefulness beyond the general nursing field (Murphy et al, 2000). Nursing models are continually being challenged and evaluated.
Evaluation of nursing models attempts to establish their relevance and value to nursing practice and to the patient (Aggleton and Chambers, 2000). Cormack and Reynolds (1992) furnish the nurse (the model user) with the criteria for evaluating the clinical usefulness of models used by nurses. In this way they empower the nurse to make his or her own informed judgement of the suitability of a particular model to his or her field of nursing.
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. This is demonstrated clearly in Baby David’s assessment. His nurse could easily become preoccupied with his ventilation, thermoregulation and normotension, and overlook his parents’ and his own psychological needs, which are fundamental at this time.
Marks-Maran and Rose (1997) report that some authors believe that the physical assessment predominates over the psychological in the model. However, it could be argued that this is a reflection on those using the model rather than the model itself.
Understanding nursing models
There is evidence that nurses find nursing models difficult to understand, leading to lack of use (Cormack and Reynolds, 1992). Conversely, Girot (1990), has accused Roper, Logan and Tierney of simplicity. This simplicity has contributed to the popularity of the model. It is widely used in the UK and Europe, has recently been included in American texts and is translated into eight other languages (Tierney, 1998), emphasising its cultural and geographical portability. Although the model has been used in practice for 20 years Fraser (1990) was unable to find research to support the model’s validity. A lack of ‘testing’ is another criticism of the model by Fraser. Cormack and Reynolds (1992) suggest that a model should be valid, reliable and well tested. Tierney (1998) acknowledges this fact, but asserts that the model has ‘research-generating potential’. In addition, Tierney also questions whether models ‘can, and should, be tested’ (Tierney, 1998).
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.
The authors acknowledge the negative attitudes that exist in some areas with regard to the use of models. However, it is suggested that the Roper, Logan and Tierney model (1996) serves as a useful adjunct to care delivery in the neonatal unit. Recommendations for practice include the incorporation of this model for use in neonatal units, with appropriate education for nursing staff involved. It is also recommended that the usefulness of the model be examined through research or audit means, and that the model is adapted locally to suit particular needs.
- The patient’s name has been changed.
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