Roper Logan and Tierney Model of Reflection

Introduction

The Roper Logan model was named after the author of the model, Nancy Roper, Logan and Tierney. It was
first developed in 1980 based upon the work by Nancy Roper in 1976. The model is based on the 12
activities of living in order to live.

The purpose of the Roper Logan theory is as an assessment used throughout the patient’s care. As a nurse
you should use the model to assess the patient’s relative independence and potential for independence in
the activities of daily living. The patient’s independence is looked at on a continuum that ranges from
complete dependence to complete independence. This helps to determine what interventions will lead to
increased independence as well as what ongoing support is needed to offset any dependency that still
exists.

The 12 Activities of Daily Living

Roper states that the twelve activities of daily living should be viewed “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
organization of her care,” and that nurses deepen their understanding of the model and its application.
The patient should be assessed on admission, and his or her dependence and independence should be
reviewed throughout the care plan and evaluation. By looking at changes in the dependence-independence
continuum, the nurse can see whether the patient is improving or not, and make changes to the care
provided based on the evidence presented.

The 12 activities of living listed in the Roper-Logan-Tierney Model of Nursing are:

1. maintaining a safe environment
2. communication
3. breathing
4. eating and drinking
5. elimination
6. washing and dressing
7. controlling temperature
8. mobilization
9. working and playing
10. expressing sexuality
11. sleeping
12. death

Factors influencing activities of living

The Roper Logan model also considers the five factors listed below, these are the factors which make
the model holistic, Roper believes that failure to consider these factors means that the resulting
assessment is both incomplete and flawed. Therefore it is recommended that nurses make use of the
model through promoting an understanding of these factors as an element of the model.

The following variables are factors that impact on the individual and affect their levels of
dependence / independence.

• 
  Biological
  
  : The biological factor addresses the impact of the overall health, of current injury
  and
  illness, and the scope of the patient’s anatomy and physiology.
• 
  Physiological
  
  : The psychological factor addresses the impact of emotion, cognition, spiritual
  beliefs, and the ability to understand. According to Roper, this is about “knowing, thinking,
  hoping, feeling and believing.”
• 
  Socio-cultural
  
  : The sociocultural factor is the impact of society and culture as experienced by
  the
  individual patient. This includes expectations and values based on class and status, and culture
  within the sociocultural factor relates to the beliefs, expectations, and values held by the
  individual patient for him or herself, as well as by others pertaining to independence in and
  ability to carry out the activities of daily living.
• 
  Environmental
  
  : The model recommends consideration of not only the impact of the environment on
  the
  activities of daily living, but also the impact of the individual’s ALs on the environment.
• 
  Politico-economic
  
  : this is the impact of government, politics and the economy on ALs. 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 public and private) all are considered under this factor.

Evaluation of the Roper, Logan and Tierney Model

The Roper, Logan and Tierney model 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.

Introduction

Health literacy is the “capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions” (Centers for Disease Control and Prevention, 2014). Smoking is a common addictive behavior and is bad for health status in many ways. According to World Health Organization (2014) tobacco kills nearly six million people per year. Therefore, it is important to promote people’s health literacy of smoking through effective intervention to improve health condition. Brief intervention is an effective method to deliver suitable information and increase the motivation of clients to change the substance use (Substance abuse and mental health service, 2014). Nurses can make good use of brief intervention to improve the health literacy among clients with resultant better health outcomes. This essay will firstly describe the potential health impacts of smoking on individual in Australia and globally. Secondly, it will use a case to analyze the smoking through stage of change model and discuss three approaches to change the behavior. Thirdly, it will choose the most sustainable strategy to provide health literacy to the client. Lastly, I will discuss how changing a singles person’s behavior can contribute to global health.

Overview of smoking

Cigarette contains more than 7,000 chemical substances and most of them are harmful to our body. Once inhaled into the lung, these chemical compounds will be carried to all the tissues of our body through blood (Centers for Disease Control and Prevention, 2014). Smoking will impair the normal growth and function of the cells and result in cancer tumor growth. Research showed that smoking can cause many kinds of cancers in our body such as larynx, lung, mouth, nose, and throat cancer (U.S. Department of Health and Human Services, 2010). For the cardiovascular system, smoking will damage our blood vessels with plaque formation and produce thicker vessel walls and narrower lumen. Therefore, smoking is a major risk factor for stroke and coronary heart disease (U.S. Department of Health and Human Services, 2010). Smoking also causes damage to the respiratory system, especially the airway and alveoli. The research showed that chronic obstructive pulmonary disease including emphysema and chronic bronchitis are most commonly related to smoking. In addition, smoking will also affect the fertility and immune system and increase the chance to have type 2 diabetes (Centers for Disease Control and Prevention, 2014). Last but not least, secondhand smoke causes adverse effects such as cardiovascular and respiratory diseases to the peers, family and community. In conclusion, smoking might impact the whole body and result in serious health problem.

According to World Health Organization (2014), smoking is related to more than 6 million people’s death; 5 million die directly due to tobacco use and 600,000 people die from exposure to secondhand smoke. In Australia, around 3.1 million people (19.5%) are current smokers aged over 18 years old and among them 20.4% male and 16.3% female are daily smokers (Australian Bureau of Statistics, 2011). Smoking was responsible for 20% of cancer death in Australia and around 45,000 hospitalisations in New South Wales were related to smoking (Cancer Council NSW, 2013). In addition, nearly 600,000 people (3.6%) reported at risk of having heart disease and other chronic conditions due to using tobacco products (Australian Institute of Health and Welfare, 2013). Smoking is a common unhealthy behavior not only in Australia but all over the world and contributes to many diseases and death.

Incident of smoking

Mr. C is a 55 year old man who comes from Taiwan and works as an accountant in a computer company. He had a history of smoking around 30 years since graduated from senior high school. He usually smokes 10-12 cigarettes a day. Mr. C has the medical history of type 2 diabetes. He believes that smoking can help him release the stress and anxiety. He really enjoys the moment of smoking and states that smoking can stimulate thinking. However, Mr. C developed productive cough recently and had shortness of breath when climbing the stairs. He went to see a general practitioner and the physician informed him that the productive cough and shortness of breath are related to smoking. Therefore, the general practitioner gave Mr. C a handbook about the information of smoking and suggested him to quit smoking. After seeing the general practitioner, Mr. C read through the handbook and tried to search the internet for relevant information. He also discussed with his family and all of his family supported him to quit smoking. Mr. C hesitated about stopping smoking. Because he thought that smoking was a good method for him to relieve the stress and serve as a social skill to maintain the relationship with friends and colleagues. In addition, he also considers that to quit smoking will be a long process and takes a lot of time to give up smoking and will incur a lot of physical discomfort. Mr. C is now feeling ambivalent about quitting smoking but he wants the symptoms such as productive cough and shortness of breath to go away. Therefore, he still considers smoking to be an enjoyable hobbit and cannot really give up smoking.

Stage of change model

Stage of change model (Transtheoretical model) is a theory of behavior change which was developed by Prochaska and DiClemente. It contains 5 stages of changes: precontemplation, contemplation, preparation, action and maintenance (Australia government Department of health, 2004; Prochaska, DiClemente & Norcross, 1992, p. 1103). Stage of change model is a good method to assess the readiness of clients to change the additive behavior such as smoking (Mallin, 2002, p. 1107). According to Prochaska, DiClemente and Norcross (1992, p.1103), contemplation is the stage that clients are aware the adverse effects due to the behavior and consider to change, however have not determined to establish a plan of action. In this incident, Mr. C has some physical discomfort such as productive cough and shortness of breath during the activity. Therefore, Mr. C went to a general practitioner for the assessment and found out that smoking was the root cause of the symptoms. Mr. C started to search the information about smoking and also discussed with his family. However, Mr. C did not make a promise to quit smoking. Due to these features, Mr. C is at the stage of contemplation.

Another concept of the contemplation stage is that patient is ambivalent about the advantage and disadvantage of the behavior (Prochaska, DiClemente & Norcross, 1992, p. 1103). The client realizes the behavior will be harmful to the health condition but still considers the behavior to be with value (Australia government Department of health, 2004). In this case, Mr. C states that smoking is a good method for him to relieve the stress and a social tool to maintain the relationship with friends and colleagues. He did not want to give up this 30 years hobbit. However, Mr. C also wanted to improve the symptoms. Mr. C is hesitated in making the decision to quit smoking. Therefore, it is obvious that Mr. C is at the stage of contemplation.

Multiple approaches to change smoking

Motivational interviewing is a counseling technique which can assist clients to increase the motivation to change the addictive behavior (Miller, 2010, p. 247; Ridner, Cloud, Ostapchuk, Myers, Jorayeva & Ling, 2014, p. 314). Clients can be explored and their ambivalence could be resolved about quitting smoking through motivational interviewing (Lai, Cahill, Qin & Tang, 2010). The four principles of motivational interviewing are expression of empathy, develop discrepancy, roll with resistance and support self-efficacy (Miller, 2010, p. 248). During the motivational interviewing, nurses can understand the ambivalent feelings of the clients, the difficulties of changing and discuss the advantage and disadvantage of quitting smoking with clients. In addition, it might enhance the client’s desire to change. Nurses might use the reflective listening, open-ended questions, affirmation and summarization techniques to understand the clients’ position and have good communication (Miller, 2010, p. 249; New South Wales Department of Health, 2005). A research (Ridner, Cloud, Myers, Jorayeva & Ling, 2014) found out that after the motivational interviewing, the patients smoked less cigarettes, had a higher score of self-efficacy and lower nicotine dependence. Soria, Legido, Escolano, Lopez Yeste and Montoya (2006) pointed out that motivational interviewing group has higher success rate compared to anti-smoking advice group. In addition, the article also showed that motivational interviewing could help clients move to the next stage of change model. The above evidence showed that motivational interviewing is an effective brief intervention to increase the motivation of clients to seek the health information of smoking and its treatment, and therefore, increase the willingness of quitting.

5As (ask, assess, advice, assist and arrange) is a brief intervention to increase the motivation of the patient with addictive behavior (DiClemente, Delahanty, Kofeldt, Dixon, Goldberg & Lucksted, 2011, p. 261). The first step is to ask the client’s smoking behavior and obtain the basic information about the client. Secondly, the readiness and motivation of clients to quit smoking will be assessed. In this step, stages of change model is a good tool to assess the motivation of client. Then, nurses can deliver the advice to the clients about the pros and cons of health on smoking followed by provision of the effective tips for clients to quit smoking. Fourthly, assist the clients to increase the motivation about quitting smoking and encourage patient to quit smoking. Lastly, the nurses should arrange the follow-up program to provide further support (Dawson, Noller & Skinner, 2013, p. 132; Scanlon, 2006, p. 25 – 26). A study conducted 5As intervention at the mental health community center to the patients with smoking behavior in the community. They found following the implementation of 5As, the rate of tobacco use decreased and more people quit smoking (Dixon et al., 2009). Therefore, 5As is an effective brief intervention to assist clients to quit smoking through enhancing their motivations and providing necessary support.

Nurses are the most important health education provider, who delivers education to the clients. The research showed that good health education program can increase the smoking caseation rate. Health education can provide the impacts on health and lead to the change the attitude of using cigarette (Salaudeen, Musa, Akande & Bolarinwa, 2011, p. 217). Internet is a very useful tool to enhance the effectiveness of health education and promotion. According to Dijk, Nooijer, Heinrich and Vries (2007, p. 122), they found out that the knowledge of tobacco cessation will be delivered better through the internet to the clients. The internet is the preferred education method of adolescents and teenagers. The interviewer indicated that the web site contains the colorful pictures and interesting animation which will increase the motivation to learn and understand information of quitting smoking and also stimulate the client to take action. Therefore, the health education delivery through the internet is a good intervention to spread the health information and increase the health literacy of the clients.

The sustainable strategy to the incident

In this incident, motivational interviewing is the most sustainable brief intervention for Mr. C to improve health literacy and result in quitting smoking. Mr. C had noticed that he has some symptoms such as shortness of breath and productive cough which impact his health condition. However, he is still considering the benefits that he gets from smoking including relieve the stress and anxiety and the social tool to maintain the relationship with peers and collogues. He is ambivalence about take action to change. Therefore, nurses can use motivational interviewing to assist client to evaluate the pons and cons of quitting smoking. Encourage patient to express his idea and identify the barrier of quitting smoking. In addition, nurses can assist the client to resolve the ambivalence and difficulties which lead to higher motivation to quit smoking.

In this stage, there is no apparent health problem on Mr. C, therefore, he did not seriously consider that quitting smoking is an urgent matter for him. During the motivational interviewing, the nurses can provide adverse effects on health to the patient and assist patient to image the healthier future without smoking. Thus, he may seek the related information actively. Motivational interviewing may enhance the client’s motivation to obtain the health information and make the correct decision. Therefore, motivational interviewing is an effective brief intervention which can increase the health literacy and more willing to quit smoking.

Global Health

Dijk, Nooijer, Heinrich and Vries (2007, p. 115) indicated that the clients have smoking behavior will easily influence others’ attitude of smoking. The smoking cessation rate is higher in the family whose member has already quit smoking. Accordingly, the concept of stop smoking can be delivered from individuals to their peers, family even the whole community. When the concept of quit smoking can be deeply installed in everyone’s thought, as a result the occurrence of smoking-related disease will be decrease. The World Health Assembly (2013) pointed out that if the tobacco cessation rate decrease 30%, it will decrease 200 million death related to smoking in 2050. In addition, secondhand smoke can also be decreased. As the result, the overall health of population in the world can be improved. Therefore a single person’s behavior change can be a big contribution of the improvement of the global health.

Conclusion

Smoking is a common unhealthy behavior which will cause adverse effects not only to the individual but also the whole society. Therefore, it is important for nurses to use different approaches to encourage clients to quit smoking. Motivational intervention is a counseling technique which can increase the motivation of the client to take action to give up smoking. 5As is an evidence-based intervention that can help clients to quit smoking through increase willingness and provide essential support. In addition, using internet can increase the effeteness of health education delivery. The incident in this essay is at the contemplation of the stage of change models. Motivational intervention is a sustainable brief intervention for this case which can improve the health literacy and encourage him to stop smoking. The concepts of quitting smoking can delivery from individual to family, peers and community. Consequently, these approaches can improve the health literacy and result in increasing the tobacco cessation rate and improve the health status of global.

Policy Proposal

In 1995, John Kingdon proposed a policy stream model to explain how policy is effectively formed or rectified. In Kingdon’s model three streams; the problem stream, the policy stream, and the politics stream, must come together to pass through a policy window simultaneously. (Mason, Gardner, Hopkins Outlaw, & O’Grady, 2016). For a policy to be considered by lawmakers, each stream must combine at the right time to pass through the policy window and become active. For this paper, the proposed policy to screen individuals who have recently received a major cardiac intervention for depression will be broken down following Kingdon’s policy streams for evaluation.

Problem Stream

Medical conditions can be affected tremendously by psychological conditions. After receiving a cardiac intervention such as a Coronary Artery Bypass Graft (CABG), valve replacement/repair, or Percutaneous Coronary Intervention (PCI), patients receive specific discharge instructions. In the discharge instructions, the patient obtains all the information they will need regarding follow-up visits, physical activities and limitations, dietary guidelines, and medication schedules.

However, there are no instructions or suggestions on how to handle any psychological effects due to the surgery or recuperation time. A patient can begin to feel down or depressed after surgery due to the surgery itself or a change in their lifestyle. Post-operatively, a patient may experience fatigue or physical limitations that will affect their mood. Depressive mood or sadness then has an adverse effect on a patient’s participation in cardiac rehabilitation. The increase in the depressive state can then exacerbate a patient’s cardiac condition; leading to worsening of physical health, complications of primary cardiac intervention, and possible hospital re-admissions.

Multiple studies show that depression in a post-cardiac intervention patient increases hospital re-admissions for complications and increase mortality rates. Niewuwsma et al., (2017), found that 65% of patients who had an acute coronary treatment had elevated depressive symptoms subsequently. Also, another 20% qualified for the diagnosis of major depression after discharge. Freedland et al., (2016) found that “depression is an independent risk factor for multiple all-cause re-hospitalizations of a patient with heart failure,” (Freedland et al., 2016, p. 7). In their study, 19.2% of their patients have been readmitted to the hospital within the first 30 days of discharge (Freedland et al., 2016).

The American Academy of Family Physicians (AAFP) developed a guideline for the detection and management of post-myocardial infarction in 2009. In the AAFP guideline, it is recommended to regularly screen and treat post-myocardial infarction patients for depression. Treatment of depression is considered secondary prevention for cardiac patients (“AAFP guideline,” 2009).

The Center for Disease Control and Prevention (CDC) issued a recommendation to screen and treat anyone over the age of sixty-five for depression. In the recommendation, the CDC ascertained that depression could be common in individuals who have a chronic medical condition such as congestive heart failure or diabetes, or in individuals who have developed any physical or functional limitation associated with significant medical conditions, such as a CABG or a stroke. While the feelings of depression are common, they should be treated and not ignored merely due to the initial medical condition. The CDC pointed out that depression in older adults is often misdiagnosed or undertreated due to the belief that depression is typical for those over the age of sixty-five.

Misdiagnosis or under treatment can lead to worsening of chronic conditions and increased hospitalizations for physical ailments. Depression is reported in 1-5% of individuals over the age of sixty-five, regardless of medical conditions. For patients who are are hospitalized, as well as those needing home health care, show an increase in depression: 11.5% and 13.5% respectively (“CDC recommendation,” 2018). The number of patients affected by depression is significant enough to warrant a policy developed to limit the number of patients who experience depression and go untreated.

Policy Stream

In the Policy stream, the proposed policy should be a suggested alternative to current policies, in order for the proposed policy to become effective. The proposed policy’s goals are threefold. First, to screen post-cardiac intervention patients for depression. Post-cardiac intervention patients are evaluated for depression by answering the Patient Health Questionnaire, PHQ-9, within the first 30 days of discharge.

The second goal is to treat post-cardiac intervention patients who do show symptoms of a depressive disorder. The third is to decrease hospital re-admissions rates for patients who have been depressed after the cardiac intervention. A patient may not avoid depression, but early detection and treatment may lead to minimal effects on recuperation time by diminishing the chances of hospital re-admissions and complications associated with cardiac interventions.

The screening of patients will coincide with the patient’s cardiac rehabilitation. Cardiac rehabilitation nurses and cardiac physical therapists will be trained in how to communicate with patients regarding their feelings and how to offer help. Medical staff will be trained under the Healthy IDEAS program by Baylor College of Medicine on how to screen, educate and assess patients’ depressive states while working with them.

Healthy IDEAS stands for Identifying Depression and Empowering Activities for Seniors. The program is one of three recommended program in the CDC Recommendation, “CDC Recommendation,” 2018. Healthy IDEAS teaches the patient how to decrease depression symptoms, reduce physical pain, and physical and mental self-care (Healthy IDEAS, 2017). The program is available for other sites to use. Cardiac rehabilitation nurses and physical therapists can be trained by a certified Healthy IDEAS regional trainer and provided consultation as well.

Prior to training, the Healthy IDEAS program requires new sites to complete four readiness tasks. The tasks are designed to help develop a strong foundation and support in order to allow the program to become beneficial for the patients. The tasks include; creating a leadership team, developing effective partnerships with local providers to evaluate and treat depression, installing the core Healthy IDEAS components into policies, forms, and documentation, and finally to establish a system for collecting and monitoring client outcomes. Once all readiness tasks are completed staff training can begin (Healthy IDEAS, 2017).

The patient’s PHQ-9 will be administered by a cardiac rehabilitation nurse, ideally at the first cardiac rehabilitation treatment. The nurse will score the questionnaire and provide referral information if a patient scores high enough to be considered moderate to severely depressed. Each patient who qualifies for depression treatment will be offered counseling and medication to help with their depression. Patients will be given the PHQ-9 several times during their cardiac rehabilitation program. Patients will be followed throughout their cardiac rehabilitation program and offered treatment if at any time they high score enough to meet criteria for care psychological care.

Political Stream

Individuals within our national and state government will be pivotal in assisting the proposed policy to be developed and implemented. Medicare/Medicaid, Department of Economic Security- Division of Aging and Adult Services, and Arizona Center for Aging are some of the organizations that could benefit from the proposed policy. Medicare covers cardiac rehabilitation after a major cardiac intervention. Depression screening is covered as well by Medicare. Coverage of these two areas will benefit the proposed policy’s program.

Several political and governmental factors are involved in the political stream for the proposed policy. The first factor is the aging baby boomers. The average age of a patient undergoing a CABG or a percutaneous coronary intervention (PCI) is seventy-four (Weintraub et al., 2012). As baby boomers age, the need for cardiac interventions will continue to rise as well. An issue that affects a significant number of the population will have significant political power to develop policy changes.

Another factor is the financial ramifications of caring for patients medically after the cardiac intervention. Baqar et al., (2018), found that depression, ethnicity and gender were all associated with increase hospital costs in heart failure patients. The average cost of hospitalization of a heart failure patient was $77,417. This was 45% higher than the average hospitalization cost of a patient without heart failure. The authors determined that the screening and treatment of depression reduced hospital costs (Baqar et al., 2018). The cost of the proposed policy should be less than hospitalization.

Economically the proposed policy will be beneficial to insurance companies, Medicare/Medicaid and hospitals. The proposed policy would decrease patient’s hospital readmission rates, saving companies money due to re-hospitalization. Tully et al., (2008) showed post-operative depression in CABG patients predicted hospital readmission independently to any other medical condition. Tripathi et al. estimated that 12% of post-cardiac intervention patients were re-hospitalized within the first 30 days after discharge. The mean cost of hospital readmission after major cardiac surgery is $39,634 (Tripathi et al., 2017). Having the proposed policy can decreased post-operative complications which will be financial fiscal.

Health care costs are continuing to rise. According to the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS), national health care spending increased by 5.8 % in 2015 and another 4.3 % in 2016. CMS anticipates the cost of health care to continue to grow at an average rate of 5.5 % yearly till 2026 (National Conference of State Legislatures, 2018).

The Hospital Reduction Program (HRRP) monitors several medical conditions that have a high incident of hospital re-admissions. Two of the conditions, congestive heart failure (CHF) and acute myocardial infarction (AMI), are directly affected by the proposed policy. The HRRP reduces Medicare reimbursement to hospitals by three percent if they view the hospital re-admission rates to be above national averages for those conditions (“MPA Commission,” 2018).

In the current political landscape, Medicare benefits and costs are up for political discussion and change. Government downsizing and decreased budgets are at the center of the Medicare coverage debate. Policies that indorse decreasing the overall financial burdens on Medicare have a strong stance in the political stream. Hospitals and insurance companies are motivated to see changes that would financially benefit them. The Medicare’s potential revenue loss due to the HRRP reimbursement reduction can facilitate policy changes from a local level to insurance lobbyists, and to the government.

Policy Window

Guldbrandsson & Fossum describe the policy streams approach as focusing, “on the continual interplay and sharing of agendas between decision makers,”(Guldbrandsson & Fossum, 2009, table 1). The three streams listed by Kingdon are self-involved streams that are independent of each other. However, in order for a policy to be adequately developed and accepted all three streams must enter the policy window concurrently.

The adage that may be used is when the policy becomes the “perfect storm.” The proposed policy is a perfect storm. The lack of acknowledgment regarding post-operative patients having depression and treatment for the psychological well-being of a patient after a significant medical condition or procedure should lead to the development of a policy to combat the deficiencies. An increase in patients affected by the proposed policy due to an aging baby boomer population and a political environment desiring to cut health care costs nationally creates the right climate to develop and engage the proposed policy. The cost of the proposed policy would be less than the current financial burden of hospital readmissions and death.

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