Written by Raymond H.
Contemporary nursing practice is a diverse and challenging field. Nurses are increasingly involved in complex decision-making as their roles expand in the health system (Cherry and Jacob, 2016). Underlying any care decision is the need to identify the source of the problem and then to develop a suitable approach to addressing this problem. To assist in decision-making, it is recommended that nurses adopt frameworks or models of problem-solving and care planning (Johansen and O’Brien, 2016). The assessment, planning, implementing and evaluating approach, also known as APIE (Yura and Walsh, 1967), is a commonly used approach to care planning in nursing practice. This approach encourages a systematic and rigorous approach to patient care, incorporating a holistic perspective of the care process. The aim of this paper is to evaluate the individual components of the APIE and the approach in its entirety with respect to nursing practice.
The first stage of the APIE is ‘assessing’, which entails a thorough analysis of the presenting complaint and the overall account of the individual patient (Hill, 2015). The assessing process is not a list of presenting problems, but a more systematic integration of quantitative and qualitative data. Quantitative data include the physiological status of the patient, including routine observations (temperature, weight, blood pressure, pulse) and more specific assessments, such as physical examination and interpretation of investigations (Lewis et al., 2016). While quantitative data alone can provide a clue as to the diagnosis of the patient, the holistic nature of nursing care demands consideration of subjective wellbeing and qualitative aspects of the patient, including ideas, expectations and concerns. These should be elicited to provide a basis for reassuring the patient or addressing emotional and psychological support needs early during the consultation (Hill, 2015).
The assessing process can be considered a fundamental part of patient care planning and forms the main data collection phase of the nurse-patient interaction (Lewis et al., 2016). Nurses use multiple techniques and approaches to collect data, including history taking, examination and ordering investigations, all of which may inform the decision-making process. Therefore, the initial stage of the APIE can be considered a valid approach to gathering data to inform care planning of the individual patient.
Only once a systematic and comprehensive assessment phase is complete is it possible to engage in effective care planning. Planning involves formulating suitable interventions and strategies to address the presenting problem, with consideration of the biological elements of the condition as well as the preferences of the patient (Doenges et al., 2016). Furthermore, care planning should include clear goal setting to ensure that the plan can be successfully implemented. These goals should be patient-centred, recordable, observable, directive, understandable, credible and time-related regarding available resources (Hayes and Llewellyn, 2010).
However, planning within the problem-solving APIE approach may be limited without consideration of additional models of nursing, including the activities of living model by Roper, Logan and Tierney (1985) and the self-care model of nursing by Orem (1985). These models provide a deeper context for applying the principles of the APIE, taking into account the necessity to generate patient-centred care planning and goals that are achievable and measurable with respect to the status of the patient (Flagg, 2015). Similarly, planning should take into consideration the ability of the patient to self-care, a crucial aspect of everyday function and wellbeing (Orem, 1985). Accordingly, nurses have a duty to support and promote patients in self-care activities and should facilitate these activities wherever possible as part of the care planning process.
Care plans should include highly structured and clear stages and steps that may be taken to achieving a specific goal, which may be followed by patients, nurses and other care professionals, as needed (Blais et al., 2006). Nurses may involve other members of the care team in decision-making at this point in order to maximise the potential benefits to the patient. Furthermore, a combination of personal experience and evidence-based guidance can be used to inform the optimal planning approach, suggesting that nurses need to apply critical thinking and a combination of intuition and guidelines in formulating appropriate care goals (Blais et al., 2006).
As with the planning phase, implementing appropriate care plans requires input not only from the nurse, but also the patient. Nurses need to ensure that the actions needed to address the patient’s needs are appropriate and practicable, including the direct delivery of interventions and referral of the patient to specialist care, as needed (Locke and Latham, 2013). However, the APIE approach focuses more precisely on the role of nurse-led interventions and overlooks the importance of supportive nursing roles during the implementation process.
In addition to nurse-led interventions, patients should be supported and educated to promote self-care (Wilkinson and Whitehead, 2009). Furthermore, careful consideration of available resources and support is needed to ensure that the care plan is suitable for the individual patient and their environment (e.g. hospital or community settings). Self-care ranges from the simple act of a patient managing their own medication to more complex processes, whereby patients are responsible for symptom identification and changes to lifestyle/behaviours. The Nursing and Midwifery Council (2018) publishes a code for nurses, which includes the role of the nurse in supporting self-care in a sensitive and compassionate manner. Therefore, to ensure adherence to practice standards and professional codes of conduct, the implementing process in the APIE scheme should balance the need for nurse-led therapies and strategies to promote individual wellbeing and empowerment in self-care.
Furthermore, the APIE problem-solving approach emphasizes the need for suitable implementation of a plan, but wider roles of nurse and the patient need to be considered to deliver personalised care. This includes the core components of respect and dignity of the patient, which should be preserved at all times, as well as the delivery of culturally-sensitive care (NMC, 2018). Indeed, nurses who are compassionate and considerate of other cultures and patient beliefs are more likely to develop strong therapeutic relationships, which have been shown to promote adherence to treatment plans and improve outcomes (Hagerty and Patusky, 2003).
The APIE approach culminates in an evaluation of the implementation of the care plan, which is essential in ensuring goals of care have been met, while allowing adjustment of the care plan where needs remain unmet. This evaluation process was initially conceptualised as a single assessment during patient follow-up or management review, but has developed into more extensive process of monitoring therapy and adjusting interventions over time (Barrett et al., 2014). Specific consideration needs to be made regarding the achievement of care goals and the suitability of these goals in future care episodes, based on patient factors and nurse factors.
However, the evaluation process is not simply a process of clinical review, but can be considered a core aspect of the overall professional development of the nurse and a key learning process (Barrett et al., 2014). Indeed, reflective practice is increasingly recognised as fundamental to the nursing profession, allowing practitioners to develop strengths and target weaknesses in patient care (Redmond, 2017). The evaluation process therefore allows practitioners to engage in personalized care planning for the patient as well as professional development based on reflection on the care delivered to date.
Extending and enhancing the APIE approach in practice
Although the APIE approach is a fundamental aspect of problem-solving in contemporary nursing practice, it is clear that the use of additional models and processes is essential to optimising care delivery for the individual patient. Furthermore, some authors have suggested that the APIE approach benefits from expansion of the terms and inclusion of additional areas (Hill, 2015). For instance, an extension of the APIE approach includes the use of further refinement stages and on-going follow-up of care planning, which are important additions to the problem-solving approach that recognise the importance of chronic disease management in contemporary practice.
In addition, some authors advocate the inclusion of a decision-making phase following assessing, which formalises the need to develop a plan based on all available evidence, both quantitative and qualitative (Lumbers, 2018). Achieving a suitable diagnosis also has the benefit of allowing clear communication of the nature of the planning phase across multiple professional groups and may provide the patient with guidance on their future care needs.
Indeed, the ASPIRE approach has largely replaced APIE and comprises assessing, systematic nursing diagnosis, planning, implementing, re-check and evaluation (Lumbers, 2018). This approach will be widely known to nurses and emphasizes the importance of a systematic approach to diagnosing and re-checking the implementation process prior to evaluation. Extensions of the APIE can be considered refinements that only serve to augment the basic structure of problem-solving inherent in the approach. Therefore, the APIE or ASPIRE approach remains a core element of clinical decision-making in contemporary nursing practice.
In summary, the APIE approach remains a commonly used and rationale approach to care planning in nursing practice. Each stage of the APIE is a justifiable component of the nursing process and can contribute to effective decision-making. However, the use of nursing models is often required to complement the APIE problem-solving approach, to ensure holistic wellbeing and a patient-centred approach to care. Therefore, the APIE can be considered a valuable tool in the context of wider nursing models to facilitate care planning and decision-making.
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