The aim of this assignment is to explore the four stages of APIE, explaining their importance in nursing, as well as identifying possible problems within the stages, in relation to the videos of Joe. These issues will then be anaylsed using theory, to create possible explanations and consequences for the behaviour and actions shown by Joe and the nurses. APIE is a nursing process which guides health professionals through the problem solving approach, which promotes the individualised, holistic delivery of care.
It is tailored around the patient’s needs and allows nurses to holistically assess the patient, then plan and set goals according to the information gathered. These plans and goals are then implemented into the care delivery and evaluated for effectiveness (Wilson, 2012). Assessment Assessment requires looking at the patient holistically and establishing what the patient was like before being admitted and what they are like now. If there is any change between the two, then the cause of this change must be identified.
Once this is established, a detailed plan can be derived to tackle the actual problem and potential problems which may arise as a result. Assessment is important because it views the person as an individual (Barrett, Wilson and Woollands, 2009). The consequences of wrongly assessing a patient are that at the planning stage, care may be tailored incorrectly to their gender, religion and other factors which are paramount to that individual. This will in turn affect the way care is implemented.
An individual’s culture, values and beliefs are highly influential in establishing what the carer may do for them and what they prefer to do themselves (Baldwin, Longhurst, Smith, et al, 2003). Information collected may be objective or subjective. Objective data is measurable and verifiable whereas subjective data is determined by the individual in order to understand their experience (Long, Phipps and Cassmeyer, 1995). In order to validate and verify the information collected during assessment, it is crucial to relay the information collected back to the patient (Lippincott, Williams and Wilkins, 2007).
One explanation of Joe’s behaviour is the Cognitive Dissonance Theory (Festinger, 1954) in the sense that he expresses an idealistic view by saying that he would not change anything about the implementation of his care and stating that all the nurses are lovely. These statements are contradicted by the fact the nurses do not acknowledge him when he repeatedly asks for his glasses, and they talk over him and ignore him as he is getting out of bed. He makes excuses for their bad practice by stating that the nurses are busy and that it does not matter anyway because he does not have anywhere to go.
Joe may be using cognitive dissonance as a coping strategy to maintain harmony and avoid the truth (McLeod, 2008). Coping strategies are a way of the individual dealing with their problem to make it more manageable. These strategies, whether adaptive or maladaptive, should be identified though patient interaction in the assessment stage. If the coping strategy is maladaptive thenit should be identified by the nurses and then plans and goals should be set out to find the cause of this behaviour and how to rectify it. Joe may be using a coping strategy to cope with hisdeterioration in independence, since becoming immobile and incontinent.
The reasons behind these problems occurring should be identified at this stage, before moving on to the planning stage (Barrett et al, 2009). Physiologically, Joe is at Stage Eight of Erikson’s (1980) Development which means he should be at a stage where he is evaluating his life and passing on his wisdom to others, however Joe is not able to communicate in the home as he is sat alone at meal times and is not listened to by the carers. Erikson (1980) states that we continue developing until we die and that by Joe’s stage, all the ego strengths from the past seven stages come together and are used to evaluate one’s life.
On observation however, it seems clear that some of the ego strengths are being damaged – will power, purpose and confidence and fidelity are undermined by the fact he is called “silly thing” and ignored when he repeatedly asks for his glasses. Stage Two autonomy is also undermined as he is not given the independence of choosing him own meals or choosing what time he wakes up or eats breakfast. This shows that Joe was not assessed in accordance with his age.
To rectify this problem, Joe needs to be made more autonomous, given encouragement to use the urinal instead of a catheter and allowing him to make his own choices. The government White Paper (2006) focuses on the need for individualised care and calls for service to be tailored around the needs of the individual and not the service provider. It aims to place the individual in control of their life and promote independence, by providing a more flexible service, with a view to a reaching and fulfilling a healthy old age. In addition, violence, stress and abuse which pose a threat to an individual’s overall well being, must be identified and addressed.
The nurses did not view Joe as an individual because they did not give him the opportunity to choose what he wanted to eat, or allow him to get dressed before leaving his room. To adopt a more individualised approach, the nurses should have let him choose what tine to get up in a morning, allowing him to get dressed and further choose what he wanted to eat for breakfast, therefore adhering to The White Paper guidelines. Planning Planning is important because it clearly sets out SMART Goals which are patient centered and therefore involve the patient directly, when the goals are being established (Barrett et al, 2009).
A consequence of not involving the patient directly or clarifying details to the patient is that the goals will not be met, or goals will be set which are irrelevant. Important goals may be omitted or set goals will not be beneficial to the individual. A Systematic Nursing Diagnosis should gather information from the patient about the consequences of living with their particular condition and the impact it has on their life. A way of doing so, is establishing a baseline – what was the patient like before the condition arose, and what are they like now.
In addition to this, it should be identified how the patient copes with this change. For example, Joe should have been asked what it is like for him having a catheter. Joe’s daily continence routine before wearing a catheter should have been established, in order to compare it to his current daily routine. Then Joe should be asked how he is coping with this change and how this change affects his life. The same method should also have been used to assess his immobility, so that a needs statement may be written, along with a baseline, in order to make progress measurable (Barrett et al, 2009).
Joe used to be able to walk when he was admitted, now he is in a wheelchair. He says he cannot get to the bathroom on his own, and because of this, his independence has been compromised. The nurses should take into account the psychological, sociological and biological implications of this change in mobility. If APIE, was done correctly, the cause of Joe’s impaired mobility should be established, as well as what can be done to avoid any potential problems arising from immobility such as constipation, oedema, decreased muscle mass and compromised circulation(Carpenito-Moyet, 2009).
A further goal which was not identified at this stage was to maintain Joe’s identity and masculinity by letting him wear his own clothes and asking what he wanted to wear, as oppose to sitting in pyjamas all day. This is bad practice because sitting in pyjamas all day assumes Joe into The Sick Role, a Functionalist role identified by Talcott Parsons (1951)as withdrawing from normal social behaviour and adopting a more deviant role, which deems them excluded from the social responsibilities and normal day to day functioning(Bilton, Bonnett, Jones, Lawson, Skinner, Stanworth and Webster,2002).
The nurses further show signs of this behaviour because they seat Joe alone at breakfast, thus excluding him from social interaction. An explanation of this may be that the nurses gain a sense of power if they are able to assume someone into a passive role, because the sick role gives the health professional authority over a patient’s health, plus the right to gain personal information from them. A consequence of the nurses behaving in this way, may lead to the self-fulfilling prophecy whereby Joe adapts and begins to conform to the sick role which is assumed of him.
This process of conforming to deviance is also known as deviance amplification (Bilton et al, 2002). The reasons for the carers not setting a goal for this aspect of Joe’s life may be due to the nurses not being aware of the implications of sitting someone in pyjamas all day. Another explanation may be that the nurses automatically ‘labelled’ Joe as being ill, thus assuming him into a sick role without pre meditation of doing so. Joe may not feel comfortable asking to wear his own clothes in case he is seen as being a difficult patient, due to sociological cognition that the practitioner is dominant and the patient must conform to their rulings (Bilton et al, 2002).
A suggestion to alleviate this problem may be to put a goal in place for Joe to wear his own clothes. Implementation Implementation is important because it puts into action what has been set out in the care plan and in the goal setting process. The consequence of not implementing care properly is that a standardised method of care may be implemented as oppose to a holistic method, which respects individual needs and cultural diversity (Barrett et al, 2009).
The NMC Code (2008) supports this by emphasising the need to treat patients as individuals as well as listening to them and responding accordingly. The nurses did not implement Joe’s care properly because they did not respond to his request for his glasses, which he asked for several times. A possible explanation for their behaviour may be due to ageist views. To support this theory, studies have highlighted a preference amongst care workers to work with children or young adults – an ageist view which has resulted in older people often not properly assessed or receiving thorough care.
Overall, this age group often do not benefit from the up most efforts of medical staff (Gross, 1992). Another theory to explain Joe’s and the nurses’ behaviour may be explained by the Social Disengagement Theory which illustrates co-operation of the elderly individual in the process of disengagement between them and society. Erikson (1951)guides an individual through life up until old age, from which point, the individual is left to mature and develop by reflecting on their past, thus disengaging with their role in society and conforming to a more submissive role.
(Cumming, Dean and Newell, 1960). Some argue that the ageist view is justified. A. B. Shaw, of Bradford Royal Infirmary (1994) argues that in an age of limited healthcare, ageism towards the elderly is a positive method in reserving healthcare facilities for those who will most benefit, i. e. the younger generation. This argument however is not in keeping with the NMC Code (2008) which states that you must not offer care which is discriminatory in any way. A. B. Shaw’s view however, may be the same view adopted by the nurses, which could explain their behaviour.
The nurses could possibly have implemented his care better by taking a holistic approach to Joe, and not simply viewing him as another statistic. If the assessment and planning stages had been one correctly then the implementation of his care would have been at a higher standard and more patient centered. Joe’s undesirable learned behaviour is to keep quiet and shut up. He has learnt this by the fact that every time he speaks, he is ignored. Learning is a process which results in permanent changes in behaviour. Joe’s catheter (also mentioned in the planning stage) was not checked in the morning.
Joe complains that his catheter often gets full and pulls. The consequences of not checking his catheter regularly are that signs of dehydration or infection may go unnoticed. The amount of urine should also be checked because if the amount is low, it may be that that the catheter is blocked or obstructed (McMillen and Pitcher, 2010). Normal urinary output should be around 30ml per hour. (Colvin, Guffey, Hoelscher and Smith, 2011). The nurses should be familiar with catheter care and should initiate learning of such procedures, in order to benefit the patient and promote Joe’s wellbeing.
Evaluation There are two types of evaluation: summative evaluation and formative evaluation. Summative evaluations evaluate how effective the general approach to care and the process of care were. It determines whether a holistic approach to care was used and how effective the assessment process was in defining the nursing diagnosis; in order to lead to patient centered planning regards their needs statements and baselines. Goals are also assessed in terms of relevance and how realistic they were.
Formative evaluations rely on direct nurse to patient interaction to determine whether the problem has got better or worse. For this to be effective, a baseline must be in place for each goal, in order to assess whether the patient has moved away from or towards the goal. Patient activity and behaviour also are scrutinised to fulfill this evaluation. Interaction with the patient, in order to learn about their experiences, is key to this type of evaluation as they know themselves better than anyone Evaluation is important because it reviews the effectiveness of the current plan.
If the current plan is not deemed to be beneficial to the patient then it is important to return to the assessment stage and correct any problems (Barrett et al, 2009). The consequence of not evaluating correctly is that the process has therefore been ineffective in establishing any potential problems with the previous stages. The elderly have different nutritional requirements to younger adults due to age related biological changes such as changes in metabolism, digestive enzyme ability and changes in the gastrointestinal tract (Long et.
al. , 1995). On admission, Joe was asked to write down which foods he liked to eat, yet he is given porridge every day and was told it was his ‘favourite’. The Evaluation Stage should involve interaction with Joe to identify whether his needs were met in the previous three stages(Long et. al. , 1995). The Evaluation stage here has therefore been unsuccessful because it has not identified that the assessment process has failed to produce a patient centered nursing diagnosis for his diet and fluid intake.
The consequences of feeding someone that same food every day is that Joe is at risk of Protein Energy Malnutrition, onset by inadequate protein, carbohydrates and fats in the diet, or vitamin deficiencies (Waugh and Grant, 2010). The consequences of malnutrition in the elderly, if sustained are fatigue, muscle loss due to the body using muscle for energy, impaired immune response and organ function (due to lack of the nutrients required to perform) and eventually death (Cope, 1996).
Joe mentions that all he would like is a lovely cup of tea, because when they do give him a drink, it is lukewarm, so he probably does not wish to drink it. The consequences of Joe not been given a drink with his breakfast is that he may become dehydrated. The elderly are at an increased risk of dehydration due to biological factors such as reduced thirst perception, body water mass, reduced kidney ability and vasopressin, so it is even more important to evaluate fluid intake in this age group, therefore the nurses should be ensuring Joe’s fluid intake meets the recommended guidelines (Lavizzo-Mourey, 1997).
Becoming dehydrated may also lead to Joe experiencing mental confusion, fatigue, constipation, loss of appetite (which will contribute to malnutrition), concentrated urine, fatigue and irritability (Denby, Baic and Rinzler, 2006). Oedema is a further manifestation of dehydration, a problem which may be made worse by Joe’s immobility. Other manifestations include confusion (which will be heightened by the fact Joe cannot see properly without his glasses) and if not treated may lead to coma.
Untreated, dehydration leads to shock were tissues begin to malfunction and major organs such as the liver and kidney become damaged due to a reduction in circulating blood volume (Rosdahl and Kowalski, 2007). Nurses should be aware of these signs in order to recognise when a patient is suffering from dehydration and malnutrition, in order to rectify the problem within a safe timescale. Tea is also not a recommended drink to give older adults with a meal because it inhibits iron absorption. Low iron levels may cause anaemia, as well as memory loss and fatigue.
His diet should therefore be evaluated to include more red meat, oily fish, eggs and breakfast cereals which are fortified with iron. Finding a substitute to drinking tea at mealtimes may also be considered at this stage (Denby, Baic and Rinzler, 2006). As supported by the evidence shown above, it can be concluded that the behaviour of the nurses does not support the guidelines illustrated in the stages of A. P. I. E, therefore the nurses have failed to successfully use a problem solving process.
Information gathered during the assessment stage was not sufficient enough to devise suitable plans and goals, therefore the implementation stage failed. Evaluation was also unsuccessful as it did not identify were the previous stages had gone wrong. Because all of the stages are interrelated, failure in one stage has a knock on effect to the other stages (Barrett et al, 2009). Because the nurses failed at the assessment stage, it automatically affected the rest of the process. 201101791.
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