Nursing Theories

Nursing Theories INTRODUCTION TO NURSING THEORIES INTRODUCTION Nursing has made phenomenal achievement in the last century that has lead to the recognition of nursing as an academic discipline and a profession. A move towards theory-based practice has made contemporary nursing more meaningful and significant by shifting nursing’s focus from vocation to an organised profession. The need for knowledge-base to guide professional nursing practice had been realised in the first half of the twentieth century and many theoretical works have been contributed by nurses ever since, first with the goal of making nursing a recognised profession and later with the goal of delivering care to patients as professionals.

A theory is a group of related concepts that propose action that guide practice. A nursing theory is a set of concepts, definitions, relationships, and assumptions or propositions derived from nursing models or from other disciplines and project a purposive, systematic view of phenomena by designing specific interrelationships among concepts for the purposes of describing, explaining, predicting, and /or prescribing.. Based on the knowledge structure levels the theoretical works in nursing can be studied under the following headings: •

Metaparadigm (Person, Environment, Health & Nursing) – (Most abstract)

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Nursing philosophies.

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Conceptual models and Grand theories.

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Nursing theories and Middle range theories (Least abstract) NURSING PHILOSOPHIES Theory

Key emphasis

Florence Nightingale’s Legacy of caring

Focuses on nursing and the patient environment relationship. Helping process meets needs through the art of individualizing care.

Ernestine Wiedenbach: The helping art of clinical nursing

Nurses should identify patients ‘need-for – help’ by: Observation Understanding client behaviour Identifying cause of discomfort Determining if clients can resolve problems or have a need for help

Virginia Henderson’s Definition of Nursing

Patients require help towards achieving independence. Derived a definition of nursing Identified 14 basic human needs on which nursing care is based.

Faye G.Abedellah’s Typology of twenty one Nursing problems

Patient’s problems determine nursing care

Lydia E. Hall :Care, Cure, Core model

Nursing care is person directed towards self love.

Jean Watson’s Philosophy and Science of caring

Caring is moral ideal: mind -body – soul engagement with one and other. Caring is a universal, social phenomenon that is only effective when practiced interpersonally considering humanistic aspects and caring.

Patricia Benner’s Primacy of caring

Caring is central to the essence of nursing. It sets up what matters, enabling connection and concern. It creates possibility for mutual helpfulness. Caring creates - possibilities of coping possibilities for connecting with and concern for others, possibilities for giving and receiving help Described systematically five stages of skill acquisition in nursing practice – novice, advanced beginner, competent, proficient and

expert.

CONCEPTUAL MODELS AND GRAND THEORIES Dorothea E. Orem’s Self care deficit theory in nursing

Self–care maintains wholeness. Three Theories: Theory of Self-Care Theory of Self-Care Deficit Theory of Nursing Systems Wholly compensatory (doing for the patient) Partly compensatory (helping the patient do for himself or herself) Supportive- educative (Helping patient to learn self care and emphasizing on the importance of nurses’ role

Myra Estrin Levine’s: The conservation model

Holism is maintained by conserving integrity Proposed that the nurses use the principles of conservation of: Client Energy Personal integrity Structural integrity Social integrity A conceptual model with three nursing theories – Conservation Redundancy Therapeutic intention

Martha E.Roger’s: Science of unitary human beings

Person environment are energy fields that evolve negentropically Martha proposed that nursing was a basic scientific discipline Nursing is using knowledge for human betterment. The unique focus of nursing is on the unitary or irreducible human being and the environment (both are energy fields) rather

than health and illness

Dorothy E.Johnson’s Behavioural system model

Individuals maintain stability and balance through adjustments and adaptation to the forces that impinges them. Individual as a behavioural system is composed of seven subsystems. Attachment, or the affiliative subsystems – is the corner stone of social organisations. Behavioural system also includes the subsystems of dependency, achievement, aggressive, ingestive-eliminative and sexual. Disturbances in these causes nursing problems.

Sister Callista: Roy‘s Adaptation model

Stimuli disrupt an adaptive system The individual is a biopsychosocial adaptive system within an environment. The individual and the environment provide three classes of stimuli-the focal, residual and contextual. Through two adaptive mechanisms, regulator and cognator, an individual demonstrates adaptive responses or ineffective responses requiring nursing interventions

Betty Neuman’s : Health care systems model

Reconstitution is a status of adaptation to stressors A conceptual model with two theories “Optimal patient stability and prevention as intervention” Neuman’s model includes intrapersonal, interpersonal and extrapersonal stressors. Nursing is concerned with the whole person. Nursing actions (Primary, Secondary, and Tertiary levels of prevention) focuses on the variables affecting the client’s response to

stressors.

Imogene King’s Goal attainment theory

Transactions provide a frame of reference toward goal setting. A conceptual model of nursing from which theory of goal attainment is derived. From her major concepts (interaction, perception, communication, transaction, role, stress, growth and development) derived goal attainment theory. · Perceptions, Judgments and actions of the patient and the nurse lead to reaction, interaction, and transaction (Process of nursing).

Nancy Roper, WW.Logan and A.J.Tierney A model for nursing based on a model of living

Individuality in living. A conceptual model of nursing from which theory of goal attainment is derived. Living is an amalgam of activities of living (ALs). Most individuals experience significant life events which can affect ALs causing actual and potential problems. This affects dependence – independence continuum which is bi-directional. Nursing helps to maintain the individuality of person by preventing potential problems, solving actual problems and helping to cope.

Hildegard E. Peplau: Psychodynamic Nursing Theory

Interpersonal process is maturing force for personality. Stressed the importance of nurses’ ability to understand own behaviour to help others identify perceived difficulties. The four phases of nurse-patient relationships are: 1. Orientation 2. Identification 3. Exploitations 4. Resolution The six nursing roles are: 1. Stranger 2. Resource person 3. Teacher 4. Leader 5. Surrogate 6. Counselor

Ida Jean Orlando’s Nursing Process Theory

Interpersonal process alleviates distress. Nurses must stay connected to patients and assure that patients get what they need, focused on patient’s verbal and non verbal expressions of need and nurse’s reactions to patient’s behaviour to alleviate distress. Elements of nursing situation: 1. Patient 2. Nurse reactions 3. Nursing actions

Joyce Travelbee’s Human To Human Relationship Model

Therapeutic human relationships. Nursing is accomplished through human to human relationships that began with: The original encounter and then progressed through stages of Emerging identities Developing feelings of empathy and sympathy, until the nurse and patient attained rapport in the final stage.

Kathryn E. Barnard’s Parent Child Interaction Model

Growth and development of children and mother–infant relationships

Ramona T.Mercer’s :Maternal Role Attainment

Parenting and maternal role attainment in diverse populations

Individual characteristics of each member influence the parent–infant system and adaptive behaviour modifies those characteristics to meet the needs of the system.

A complex theory to explain the factors impacting the development of maternal role over time. Katharine Kolcaba’s Theory of comfort

Comfort is desirable holistic outcome of care. Health care needs are needs for comfort, arising from stressful health care situations that cannot be met by recipients’ traditional support system. These needs include physical, psycho spiritual, social and environmental needs. Comfort measures include those nursing interventions designed to address the specific comfort needs.

Madeleine Leininger’s

Caring is universal and varies transculturally.

Transcultural nursing, culture-care theory

Major concepts include care, caring, culture, cultural values and cultural variations Caring serves to ameliorate or improve human conditions and life base. Care is the essence and the dominant, distinctive and unifying feature of nursing

Rosemarie Rizzo Parse’s :Theory of human becoming

Indivisible beings and environment co-create health. A theory of nursing derived from Roger’s conceptual model. Clients are open, mutual and in constant interaction with environment. The nurse assists the client in interaction with the environment and co creating health

Nola J.Pender’s :The Health promotion; model

Promoting optimum health supersedes disease prevention. Identifies cognitive, perceptual factors in clients which are modified by demographical and biological characteristics, interpersonal influences, situational and behavioural factors that help predict in health promoting behaviour

CONCLUSION The conceptual and theoretical nursing models help to provide knowledge to improve practice, guide research and curriculum and identify the goals of nursing practice. The state of art and science of nursing theory is one of continuing growth. Using the internet the nurses of the world can share ideas and knowledge, carrying on the work begun by nursing theorists and continue the growth and development of new nursing knowledge. It is important the nursing knowledge is learnt, used, and applied in the theory based practice for the profession and the continued development of nursing and academic discipline REFERENCES •

George B. Julia , Nursing Theories- The base for professional Nursing Practice, 3rd ed. Norwalk, Appleton & Lange.

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Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.

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Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

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Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

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Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

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Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002

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Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia, 2002.

DEVELOPMENT OF NURSING THEORIES Introduction Theories are a set of interrelated concepts that give a systematic view of a phenomenon (an observable fact or event) that is explanatory & predictive in nature. Theories are composed of concepts, definitions, models, propositions & are based on assumptions. They are derived through two principal methods; deductive reasoning and inductive reasoning. Nursing theorists use both of these methods. Theory is “a creative and rigorous structuring of ideas that projects a tentative, purposeful, and systematic view of phenomena”. A theory makes it possible to “organize the relationship among the concepts to describe, explain, predict, and control practice” Definition • •

Concepts are basically vehicles of thought that involve images. Concepts are words that describe objects, properties, or events & are basic components of theory. Types: Empirical concepts Inferential concepts Abstract concepts

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Models are representations of the interaction among and between the concepts showing patterns. Propositions are statements that explain the relationship between the concepts. Process it is a series of actions, changes or functions intended to bring about a desired result. During a process one takes systemic & continuous steps to meet a goal & uses both assessments & feedback to direct actions to the goal. A particular theory or conceptual frame work directs how these actions are carried out. The delivery of nursing care within the nursing process is directed by the way specific conceptual frameworks & theories define the person (patient), the environment, health & nursing. The terms ‘model’ and ‘theory’ are often wrongly used interchangeably, which further confounds matters. In nursing, models are often designed by theory authors to depict the beliefs in their theory (Lancaster and Lancaster 1981). They provide an overview of the thinking behind the theory and may demonstrate how theory can be introduced into practice, for example, through specific methods of assessment. Models are useful as they allow the concepts in nursing theory to be successfully applied to nursing practice (Lancaster and Lancaster 1981).

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Their main limitation is that they are only as accurate or useful as the underlying theory.

Importance of nursing theories 1. Nursing theory aims to describe, predict and explain the phenomenon of nursing (Chinn and Jacobs1978). 2. It should provide the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future (Brown 1964). 3. Theory is important because it helps us to decide what we know and what we need to know (Parsons1949). 4. It helps to distinguish what should form the basis of practice by explicitly describing nursing. 5. The benefits of having a defined body of theory in nursing include better patient care, enhanced professional status for nurses, improved communication between nurses, and guidance for research and education (Nolan 1996). In addition, because 6. The main exponent of nursing – caring – cannot be measured, it is vital to have the theory to analyze and explain what nurses do. 7. As medicine tries to make a move towards adopting a more multidisciplinary approach to health care, nursing continues to strive to establish a unique body of knowledge. 8. This can be seen as an attempt by the nursing profession to maintain its professional boundaries. The characteristics of theories Theories are • • • • • • •

interrelating concepts in such a way as to create a different way of looking at a particular phenomenon. logical in nature. generalizable. bases for hypotheses that can be tested. increasing the general body of knowledge within the discipline through the research implemented to validate them. used by the practitioners to guide and improve their practice. consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated.

Basic processes in the development of nursing theories Nursing theories are often based on & influenced by broadly applicable processes & theories. Following theories are basic to many nursing concepts. General System Theory It describes how to break whole things into parts & then to learn how the parts work together in “systems”. These concepts may be applied to different kinds of systems,

e.g. Molecules in chemistry, cultures in sociology, and organs in Anatomy & Health in Nursing. Adaptation Theory •

It defines adaptation as the adjustment of living matter to other living things & to environmental conditions. • Adaptation is a continuously occurring process that effects change & involves interaction & response. Human adaptation occurs on three levels : The internal (self) The social (others) & the physical (biochemical reactions)

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Developmental Theory 1. It outlines the process of growth & development of humans as orderly & predictable, beginning with conception & ending with death. 2. The progress & behaviors of an individual within each stage are unique. 3. The growth & development of an individual are influenced by heredity, temperament, emotional, & physical environment, life experiences & health status. Common concepts in nursing theories Four concepts common in nursing theory that influence & determine nursing practice are: • • • •

The person (patient). The environment Health Nursing (goals, roles, functions)

Each of these concepts is usually defined & described by a nursing theorist, often uniquely; although these concepts are common to all nursing theories. Of the four concepts, the most important is that of the person. The focus of nursing, regardless of definition or theory, is the person. Historical perspectives and key concepts • • • • •

Nightingale (1860): To facilitate “the body’s reparative processes” by manipulating client’s environment Peplau 1952: Nursing is; therapeutic interpersonal process. Henderson 1955: The needs often called Henderson’s 14 basic needs Abdellah 1960: The nursing theory developed by Faye Abdellah et al (1960) emphasizes delivering nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family. Orlando 1962: To Ida Orlando (1960), the client is an individual; with a need; that, when met, diminishes distress, increases adequacy, or enhances wellbeing.

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Johnson’s Theory 1968: Dorothy Johnson’s theory of nursing 1968 focuses on how the client adapts to illness and how actual or potential stress can affect the ability to adapt. The goal of nursing to reduce stress so that; the client can move more easily through recovery. Rogers 1970: to maintain and promote health, prevent illness, and care for and rehabilitate ill and disabled client through “humanistic science of nursing” Orem1971: This is self-care deficit theory. Nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental, or social needs. King 1971: To use communication to help client reestablish positive adaptation to environment. Neuman 1972: Stress reduction is goal of system model of nursing practice. Roy 1979: This adaptation model is based on the physiological, psychological, sociological and dependence-independence adaptive modes. Watson’s Theory 1979: Watson’s philosophy of caring 1979 attempts to define the outcome of nursing activity in regard to the; humanistic aspects of life.

Classification of nursing theories Depending On Function (Polit et al 2001) Descriptive To identify the properties and workings of a discipline Explanatory To examine how properties relate and thus affect the discipline Predictive

To calculate relationships between properties and how they occur

Prescriptive

To identify under which conditions relationships occur

Depending on the Generalisability of their principles • Metatheory: the theory of theory. Identifies specific phenomena through abstract concepts. • Grand theory: provides a conceptual framework under which the key concepts and • Principles of the discipline can be identified. • Middle range theory: is more precise and only analyses a particular situation with a limited number of variables. •

Practice theory: explores one particular situation found in nursing. It identifies explicit goals and details how these goals will be achieved. Based on the philosophical underpinnings of the theories ■ “Needs “theories. ■ “Interaction” theories. ■ “Outcome “theories.

■ Humanistic theories. “Needs” theories • •

These theories are based around helping individuals to fulfill their physical and mental needs. The basis of these theories is well-illustrated in Roper, Logan and Tierney’s Model of Nursing (1980). Needs theories have been criticized for relying too much on the medical model of health and placing the patient in an overtly dependent position.

“Interaction” theories • •

As described by Peplau (1988), these theories revolve around the relationships nurses form with patients. Such theories have been criticized for largely ignoring the medical model of health and not attending to basic physical needs.

“Outcome” theories • •

These portray the nurse as the changing force, who enables individuals to adapt to or cope with ill health (Roy 1980). Outcome theories have been criticized as too abstract and difficult to implement in practice (Aggleton and Chalmers 1988).

“Humanistic” Theories • • • • •

Humanistic theories developed in response to the psychoanalytic thought that a person’s destiny was determined early in life. Humanistic theories emphasize a person’s capacity for self-actualization. Humanists believe that the person contains within himself the potential for healthy & creative growth. Carl Rogers developed a person –centered model of psychotherapy that emphasizes the uniqueness of the individual. The major contribution that Rogers added to nursing practice is the understandings that each client is a unique individual, so, person-centered approach now practice in nursing.

Models of nursing • • • • •

Until fairly recently, nursing science was derived principally from social, biologic, and medical science theories. However, from the 1950s to the present, an increasing number of nursing theorists have developed models of nursing that provide bases for the development of nursing theories and nursing knowledge. A model, as an abstraction of reality, provides a way to visualize reality to simplify thinking. A conceptual model shows how various concepts are interrelated and applies theories to predict or evaluate consequences of alternative actions. According to Fawcett (2000),

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A conceptual model “gives direction to the search for relevant questions about the phenomena of central interest to a discipline and suggests solutions to practical problems” Four concepts are generally considered central to the discipline of nursing: the person who receives nursing care (the patient or client); the environment (society); nursing (goals, roles, functions); and health. These four concepts form a metaparadigm of nursing. The term metaparadigm comes from the Greek prefix “meta,” which means more comprehensive or transcending, and the word Greek word “paradigm,” which means a philosophical or theoretical framework of a discipline upon which all theories, laws, and generalizations are formulated (MerriamWebster’s Collegiate Dictionary, 1994).

Growth and Stability Models of Change • • • • •

There are two major differences in philosophical beliefs, or world views, about the nature of change. “The world view of change uses the growth metaphor, and the persistence view focuses on stability” (Fawcett, 1989,). Within the change world view, change and growth are continual and desirable, “progress is valued, and realization of one’s potential is emphasized” (Fawcett). Persistence is endurance in time Persistence world view emphasizes equilibrium and balance.

Categories of Conceptual Models •

Ten conceptual models of nursing have been classified according to two criteria: • the world view of change reflected by the model (growth or stability); and • the major theoretical conceptual classification with which the model seems most consistent (systems, stress/adaptation, caring, or growth/development).

Systems Theory as a Framework • • • •

Systems theory is concerned with changes caused by interactions among all the factors (variables) General systems theory is emphasized A system is defined as “a whole with interrelated parts, in which the parts have a function and the system as a totality has a function” (Auger, 1976, A general systems approach allows for consideration of the subsystems levels of the human being, as a total human being, and as a social creature who networks himself with others in hierarchically arranged human systems of increasing complexity. Thus the human being, from the level of the individual to the level of society, can be conceptualized as the client and becomes the target system for nursing intervention (Sills & Hall, 1977).

An example of systems interaction

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Input (Diet teaching) Throughput (Assimilation of information) Output (Food intake) Feedback (Weight record, Hb estimation etc.) Two nursing models based on systems theory: • Imogene King’s systems interaction model, and • Betty Neuman’s health care systems model. Major Concepts as Defined in King’s Model Person (human being) A personal system that interacts with interpersonal and social systems Environment A context “within which human beings grow, develop, and perform daily activities” Health dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living” Nursing A process of human interaction

Imogene King’s Systems Interaction Model •

In interaction model, the purpose of nursing is to help people attain, maintain, or restore health. King’s model conceptualizes three levels of dynamic interacting systems. 1. Individuals are called “personal systems.” 2. Groups (two or more persons) form “interpersonal systems.” 3. Society is composed of “social systems.”

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As the person interacts with the environment, he or she must continuously adjust to stressors in the internal and external environment (King, 1981). Health assumes achievement of maximum potential for daily living and an ability to function in social roles. It is the “dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living” (King, 1981,). “Illness is a deviation from normal, that is, an imbalance in a person’s biological structure or in his psychological makeup, or a conflict in a person’s social relationships” (King, 1989). “The goal of nursing is to help individuals and groups attain, maintain, and restore health” Stress: “a dynamic state whereby a human being interacts with the environment to maintain balance for growth, development, and performance”

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Betty Neuman’s Health Care Systems Model •

Betty Neuman specifies that the purpose of nursing is to facilitate optimal client system stability.

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Normal line of defense: an adaptational level of health considered normal for an individual Lines of resistance: protection factors activated when stressors have penetrated the normal line of defense Neuman’s model, organized around stress reduction, is concerned primarily with how stress and the reactions to stress affect the development and maintenance of health. The person is a composite of physiologic, psychological, sociocultural, developmental, and spiritual variables considered simultaneously. “Ideally the five variables function harmoniously or are stable in relation to internal and external environmental stressor influences” (Neuman, 2002). A person is constantly affected by stressors from the internal, external, or created environment. Stressors are tension-producing stimuli that have the potential to disturb a person’s equilibrium or normal line of defense. This normal line of defense is the person’s “usual steady state.” It is the way in which an individual usually deals with stressors. Stressors may be of three types:

Intrapersonal: forces arising from within the person Interpersonal: forces arising between persons Extrapersonal: forces arising from outside the person • •

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Resistance to stressors is provided by a flexible line of defense, a dynamic protective buffer made up of all variables affecting a person at any given moment the person’s resistance to any given stressor or stressors. If the flexible line of defense is no longer able to protect the person against a stressor, the stressor breaks through, disturbs the person’s equilibrium, and triggers a reaction. The reaction may lead toward restoration of balance or toward death. Neuman intends for the nurse to “assist clients to retain, attain, or maintain optimal system stability” (Neuman, 1996). Thus, health (wellness) seems to be related to dynamic equilibrium of the normal line of defense, where stressors are successfully overcome or avoided by the flexible line of defense. Neuman defines illness as “a state of insufficiency with disrupting needs unsatisfied” (Neuman, 2002). Illness appears to be a separate state when a stressor breaks through the normal line of defense and causes a reaction with the person’s lines of resistance.

Stress/Adaptation Theory as a Framework • • •

In contrast to systems theory, stress and adaptation theories view change caused by person–environment interaction in terms of cause and effect. The person must adjust to environmental changes to avoid disturbing a balanced existence. Adaptation theory provides a way to understand both how the balance is maintained and the possible effects of disturbed equilibrium. This theory has been widely applied to explain, predict, and control biologic (physiologic and psychological) phenomenon.

A unique body of knowledge • • • • •

The drive for a unique body of knowledge is based on the assumption that ‘borrowed’ knowledge is less worthy. However, nurse education is based on theory borrowed from other disciplines, such as sociology and psychology. It has been argued that applying knowledge from different disciplines only serves to dilute nursing practice. Nevertheless, as the occupation is focused on humans, perhaps it is inevitable that nursing uses knowledge from other social sciences. It has been argued that no knowledge is exclusive, and because of nursing’s diverse nature it is impossible for it to have a unique body of knowledge and one unified body of theory (Castledine 1994, Levine 1995).

Criticisms of nursing theories To understand why nursing theory is generally neglected on the wards it is necessary to take a closer look at the main criticisms of nursing theory and the role that nurses play in contributing to its lack of prevalence in practice. Use of language •

Scott (1994) states that the crucial ingredients of nursing theory should be accessibility and clarity. However, one of the main criticisms of nursing theory is its use of overtly complex language (Kenny 1993). It is important that the language used in the development of nursing theory be used consistently.

Not part of everyday practice •

Despite theory and practice being viewed as inseparable concepts, a theorypractice gap still exists in nursing (Upton 1999). Yet despite the availability of a vast amount of literature on the subject, nursing theory still means very little to most practicing nurses. Perhaps this is because the majority of nursing theory is developed by and for nursing academics (Lathlean 1994). It has been recognised that traditionally nurses are used to ‘speaking with their hands’ (Levine 1995). Therefore, many nurses have not had the training or experience to deal with the abstract concepts presented by nursing theory. This makes it difficult for the majority of nurses to understand and apply theory to practice (Miller 1985).

Summarization 1. 2. 3. 4. 5. 6. 7. 8. 9.

Definition Importance of Nursing Theories The characteristics of theories: Basic Processes in the Development Of Nursing Theories: Nursing theories are often based on & influenced ANA definition of Nursing Practice Common concepts in Nursing Theories: Historical Perspectives & Key Concepts Clasification of Nursing Theories

10. Models Of Nursing 11. Growth and Stability Models of Change 12. Betty Neuman’s Health Care Systems Model 13. Stress/Adaptation Theory as a Framework 14. A unique body of knowledge 15. Criticisms of nursing theories Conclusion Littlejohn (2002) comments that, irrespective of nursing theories nurses will continue to exhibit a caring response to the ‘sick and troubled’. If this is true, perhaps nurses are ‘nursing’ without the knowledge of theories and theory is irrelevant. However, theory and practice are related, and if nursing is to continue to develop, the concept of theory must be addressed. If nursing theory does not drive the development of nursing, it will continue to develop in the footsteps of other disciplines such as medicine Reference • • • • • • •

George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott. Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott. Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book. Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-15 Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):225

Nursing Theorists Definitions Theory- a set of related statements that describes or explains phenomena in a systematic way Concept-a mental idea of a phenomenon Construct- a phenomena that cannot be observed and must be inferred Proposition- a statement of relationship between concepts Conceptual model- made up of concepts and propositions Nursing Theorists •

Florence Nightingale,

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Hildegard Peplau

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Virginia Henderson

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Fay Abdella

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Ida Jean Orlando

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Dorothy Johnson

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Martha Rogers

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Dorothea Orem

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Imogene King

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Betty Neuman

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Sister Calista Roy,

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Jean Watson

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Rosemary Rizzo Parse

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Madeleine Leininger

• Patricia Benner Concepts in the nursing Metaparadigm •

Person

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Recipient of care, including physical, spiritual, psychological, and sociocultural components

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Individual, family, or community

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Environment

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All internal and external conditions, circumstances, and influences affecting the person

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Health

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Degree of wellness or illness experienced by the person

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Nursing

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Actions, characteristics and attributes of person giving care

Florence Nightingale- Environmental Theory •

First nursing theorist

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Unsanitary conditions posed health hazard (Notes on Nursing, 1859)

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5 components of environment

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ventilation, light, warmth, effluvia, noise

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External influences can prevent, suppress or contribute to disease or death

Nightingale’s Concepts •

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Person o

Patient who is acted on by nurse

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Affected by environment

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Has reparative powers

Environment o

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Foundation of theory. Included everything, physical, psychological, and social

Health o

Maintaining well-being by using a person’s powers

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Maintained by control of environment

Nursing o

Provided fresh air, warmth, cleanliness, good diet, quiet to facilitate person’s reparative process

Hildegard Peplau -Interpersonal Relations Model •

Based on psychodynamic nursing

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using an understanding of one’s own behavior to help others identify their difficulties

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Applies principles of human relations

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Patient has a felt need

Peplau’s Concepts •

Person o

An individual; a developing organism who tries to reduce anxiety caused by needs

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Lives in instable equilibrium

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Environment- Not defined

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Health o

Implies forward movement of the personality and human processes toward creative, constructive, productive, personal, and community living

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Nursing o

A significant, therapeutic, interpersonal process that functions cooperatively with others to make health possible

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Involves problem-solving

Virginia Henderson -The Nature of Nursing "The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. She must in a sense, get inside the skin of each of her patients in order to know what he needs". Fay Abdella- Topology of 21 Nursing Problems •

A list of 21 nursing problems

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Condition presented or faced by the patient or family.

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Problems are in 3 categories

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physical, social and emotional

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The nurse must be a good problem solver

Abdella’s Concepts •

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Nursing o

A helping profession

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A comprehensive service to meet patient’s needs

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Increases or restores self-help ability

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Uses 21 problems to guide nursing care

Health o

Excludes illness

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No unmet needs and no actual or anticipated impairments

Person o

One who has physical, emotional, or social needs

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The recipient of nursing care.

Environment o

Did not discuss much

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Includes room, home, and community

Ida Jean Orlando- Deliberative Nursing Process •

The deliberative nursing process is set in motion by the patient’s behavior

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All behavior may represent a cry for help. Patient’s behavior can be verbal or non-verbal.

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The nurse reacts to patient’s behavior and forms basis for determining nurse’s acts.

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Perception, thought, feeling

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Nurses’ actions should be deliberative, rather than automatic

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Deliberative actions explore the meaning and relevance of an action.

Dorothy Johnson-Behavioral Systems Model •

The person is a behavioral system comprised of a set of organized, interactive, interdependent, and integrated subsystems

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Constancy is maintained through biological, psychological, and sociological factors.

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A steady state is maintained through adjusting and adapting to internal and external forces.

Johnson’s 7 Subsystems •

Affiliative subsystem o

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Dependency o

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procreation and gratification

Aggressive o

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excretion

Sexual o

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food intake

Eliminative o

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helping or nuturing

Ingestive o

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social bonds

self-protection and preservation

Achievement o

efforts to gain mastery and control

Johnson’s Concepts •

Person o

•

Environment o

•

Not specifically defined but does say there is an internal and external environment

Health o

•

A behavioral system comprised of subsystems constantly trying to maintain a steady state

Balance and stability.

Nursing o

External regulatory force that is indicated only when there is instability.

Martha Rogers -Unitary Human Beings •

Energy fields

•

o

Fundamental unity of things that are unique, dynamic, open, and infinite

o

Unitary man and environmental field

Universe of open systems o

•

•

Energy fields are open, infinite, and interactive

Pattern o

Characteristic of energy field

o

A wave that changes, becomes complex and diverse

Pandimensionality o

A nonlinear domain with out time or space

Roger’s Definitions •

Integrality o

•

Resonancy o

•

Continuous and mutual interaction between man and environment Continuous change longer to shorter wave patterns in human and environmental fields

Helicy o

Continuous, probabilistic, increasing diversity of the human and envrionmental fields.

o

Characterized by nonrepeating rhymicities

o

Change

Dorothea Orem- Self-Care Model •

Self-care comprises those activities performed independently by an individual to promote and maintain person well-being

•

Self care agency is the individual’s ability to perform self care activities

•

Self- care deficit occurs when the person cannot carry out self-care

•

The nurse then meets the self-care needs by acting or doing for; guiding, teaching, supporting or providing the environment to promote patient’s ability

•

Wholly compensatory nursing system-Patient dependent

•

Partially compensatory- Patient can meet some needs but needs nursing assistance

•

Supportive educative-Patient can meet self care requisites, but needs assistance with decision making or knowledge

Imogene King-Goal Attainment Theory •

Open systems framework

•

Human beings are open systems in constant interaction with the environment

•

Personal System

•

o

individual; perception, self, growth, development, time space, body image

o

Interpersonal

o

Society

Personal System o

•

Interpersonal o

•

Individual; perception, self, growth, development, time space, body image Socialization; interaction, communication and transaction

Society o

Family, religious groups, schools, work, peers

•

The nurse and patient mutually communicate, establish goals and take action to attain goals

•

Each individual brings a different set of values, ideas, attitudes, perceptions to exchange

Betty Neuman - Health Care Systems Model •

The person is a complete system, with interrelated parts

•

maintains balance and harmony between internal and external environment by adjusting to stress and defending against tensionproducing stimuli

•

Focuses on stress and stress reduction

•

Primarily concerned with effects of stress on health

•

Stressors are any forces that alter the system’s stability

•

Flexible lines of resistance Surround basic core Internal factors that help defend against stressors

•

Normal line of resistance Normal adaptation state

•

Flexible line of defense Protective barrier, changing, affected by variables

•

Wellness is equilibrium

•

Nursing interventions are activates to: strengthen flexible lines of defense strengthen resistance to stressors maintain adaptation

Sister Calista Roy - Adaptation Model •

Five Interrelated Essential Elements Patiency- The person receiving care Goal of nursing- Adapting to change

Health-Being and becoming a whole person Environment Direction of nursing activities- Facilitating adaptation •

The person is an open adaptive system with input (stimuli), who adapts by processes or control mechanisms (throughput)

•

The output can be either adaptive responses or ineffective responses

Jean Watson - Philosophy and Science of Caring •

Caring can be demonstrated and practiced

•

Caring consists of carative factors

•

Caring promotes growth

•

A caring environment accepts a person as he is and looks to what the person may become

•

A caring environment offers development of potential

•

Caring promotes health better than curing

•

Caring is central to nursing

Watson’s 10 Carative Factors •

Forming humanistic-altruistic value system

•

Instilling faith-hope

•

Cultivating sensitivity to self and others

•

Developing helping-trust relationship

•

Promoting expression of feelings

•

Using problem-solving for decision making

•

Promoting teaching-learning

•

Promoting supportive environment

•

Assisting with gratification of human needs

•

Allowing for existential-phenomenological forces

Watson’s Concepts •

Person o

•

Environment o

•

Society

Health o

•

Human being to be valued, cared for, respected, nurtured, understood and assisted

Complete physical, mental and social well-being and functioning

Nursing o

Concerned with promoting and restoring health, preventing illness

Rosemary Parse - Human Becoming Theory •

Human Becoming Theory includes Totality Paradigm

o

Man is a combination of biological, psychological, sociological and spiritual factors

• Simultaneity Paradigm o •

Man is a unitary being in continuous, mutual interaction with environment

Originally Man-Living-Health Theory

Parse’s Three Principles •

•

Meaning o

Man’s reality is given meaning through lived experiences

o

Man and environment cocreate

Rhythmicity o

•

•

Cotranscendence o

Refers to reaching out and beyond the limits that a person sets

o

One constantly transforms

Person o

•

•

Open being who is more than and different from the sum of the parts

Environment o

Everything in the person and his experiences

o

Inseparable, complimentary to and evolving with

Health o

•

Man and environment cocreate ( imaging, valuing, languaging) in rhythmical patterns

Open process of being and becoming. Involves synthesis of values

Nursing o

A human science and art that uses an abstract body of knowledge to serve people

Madeleine Leininger - Culture Care Diversity and Universality •

Based on transcultural nursing, whose goal is to provide care congruent with cultural values, beliefs, and practices

•

Sunrise model consists of 4 levels that provide a base of knowledge for delivering cultural congruent care

•

Modes of nursing action

•

Cultural care preservation o

•

help maintain or preserve health, recover from illness, or face death

Cultural care accommodation o

help adapt to or negotiate for a beneficial health status, or face death

•

Cultural care re-patterning o

help restructure or change lifestyles that are culturally meaningful

Patricia Benner - From Novice to Expert •

Described 5 levels of nursing experience and developed exemplars and paradigm cases to illustrate each level

•

Levels reflect: o

movement from reliance on past abstract principles to the use of past concrete experience as paradigms

o

change in perception of situation as a complete whole in which certain parts are relevant 

Novice



Advanced beginner



Competent



Proficient



Expert

Importance of Theoretical Frameworks 1. Foundation of any profession is the development of a specialized body of knowledge. Theories should be developed in nursing, not borrow theories form other disciplines 2. Responsibility of nurses to know and understand theorists 3. Critically analyze theoretical frameworks Reference •

Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia, 2002.

•

Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002.

•

George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton and Lange.

•

Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williamsand wilkins.

•

Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and Progress 3rd ed. Philadelphia, Lippincott.

•

Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

•

Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing –Concepts Process and Practice 3rd ed. London Mosby Year Book.

NURSING THEORIES: AN OVERVIEW Theory Kerlinger ---views theories as a set of interrelated concepts that give a systematic view of a phenomenon ( an observable fact or event ) that is explanatory and predictive in nature. Theories are composed of concepts, definitions, models , propositions and are based on assumptions. They are derived through two principal methods: 1) Deductive reasoning 2) Inductive reasoning. Nursing theorists use both of these methods. Nursing Theory: Barnum(1998)---- " attempts to describe or explain the phenomenon (process, occurrence and event) called nursing" Theories for Professional Nursing •

Theory is "a creative and rigorous structuring of ideas that projects a tentative, purposeful, and systematic view of phenomena"

•

A theory makes it possible to "organize the relationship among the concepts to describe, explain, predict, and control practice"

Definition •

Concepts--- are basically vehicles of thought that involve images. Concepts are words that describe objects , properties, or events and are basic components of theory . Types : Empirical concepts Inferential concepts Abstract concepts.

•

Models ----- are representations of the interaction among and between the concepts showing patterns.

•

Propositions---- are statements that explain the relationship between the concepts.

•

Process ---- it is a series of actions , changes or functions intended to bring about a desired result . During a process one takes systemic and continuous steps to meet a goal and uses both assessments and feedback to direct actions to the goal.

•

A particular theory or conceptual frame work directs how these actions are carried out . The delivery of nursing care within the nursing process is directed by the way specific conceptual frameworks and theories define the person (patient), the environment , health and nursing.

•

The terms ‘model’ and ‘theory’ are often wrongly used interchangeably, which further confounds matters.

•

In nursing, models are often designed by theory authors to depict the beliefs in their theory (Lancaster and Lancaster 1981).

•

They provide an overview of the thinking behind the theory and may demonstrate how theory can be introduced into practice, for example, through specific methods of assessment.

•

Models are useful as they allow the concepts in nursing theory to be successfully applied to nursing practice (Lancaster and Lancaster 1981).

•

Their main limitation is that they are only as accurate or useful as the underlying theory.

Importance of Nursing Theories •

Nursing theory aims to describe, predict and explain the phenomenon of nursing (Chinn and Jacobs1978).

•

It should provide the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future (Brown 1964).

•

Theory is important because it helps us to decide what we know and what we need to know (Parsons1949).

•

It helps to distinguish what should form the basis of practice by explicitly describing nursing.

•

The benefits of having a defined body of theory in nursing include better patient care, enhanced professional status for nurses, improved communication between nurses, and guidance for research and education (Nolan 1996). In addition, because the main exponent of nursing – caring – cannot be measured, it is vital to have the theory to analyze and explain what nurses do.

•

As medicine tries to make a move towards adopting a more multidisciplinary approach to health care, nursing continues to strive to establish a unique body of knowledge.

•

This can be seen as an attempt by the nursing profession to maintain its professional boundaries.

The characteristics of theories Theories: •

interrelate concepts in such a way as to create a different way of looking at a particular phenomenon.

•

are logical in nature.

•

are generalizable.

•

are the bases for hypotheses that can be tested.

•

increase the general body of knowledge within the discipline through the research implemented to validate them.

•

are used by the practitioners to guide and improve their practice.

•

are consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated

Basic Processes in the Development Of Nursing Theories: Nursing theories are often based on and influenced by broadly applicable processes and theories. Following theories are basic to many nursing concepts. General System Theory: It describes how to break whole things into parts and then to learn how the parts work together in " systems". These concepts may be applied to different kinds of systems, e.g.. Molecules in chemistry , cultures in sociology, organs in Anatomy and health in Nursing. Adaptation Theory

It defines adaptation as the adjustment of living matter to other living things and to environmental conditions. Adaptation is a continuously occurring process that effects change and involves interaction and response . Human adaptation occurs on three levels: --- the internal ( self ) --- the social (others) --- and the physical ( biochemical reactions ) Developmental Theory It outlines the process of growth and development of humans as orderly and predictable , beginning with conception and ending with death. The progress and behaviors of an individual within each stage are unique. The growth and development of an individual are influenced by heredity , temperament , emotional, and physical environment , life experiences and health status. Common concepts in Nursing Theories: Four concepts common in nursing theory that influence and determine nursing practice are -- The person( patient) . --- The environment -- Health --- Nursing (goals, roles, functions) •

Each of these concepts is usually defined and described by a nursing theorist , Often uniquely; although these concepts are common to all nursing theories.

•

Of the four concepts , the most important is that of the person. The focus of nursing , regardless of definition or theory , is the person.

Historical Perspectives and Key Concepts Nightingale (1860): To facilitate "the body’s reparative processes" by manipulating client’s environment Paplau 1952: Nursing is; therapeutic interpersonal process. Henderson 1955: The needs often called Henderson’s 14 basic needs Abdellah 1960: The nursing theory developed by Faye Abdellah et al (1960) emphasizes delivering nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family. Orlando 1962: To Ida Orlando (1960), the client is an individual; with a need; that, when met, diminishes distress, increases adequacy, or enhances well-being. Johnson’s Theory 1968: Dorothy Johnson’s theory of nursing 1968 focuses on how the client adapts to illness and how actual or potential stress can affect the ability to adapt. The goal of nursing to reduce stress so that; the client can move more easily through recovery. Rogers 1970: to maintain and promote health, prevent illness, and care for and rehabilitate ill and disabled client through "humanistic science of nursing" Orem1971: This is self-care deficit theory. Nursing care becomes

necessary when client is unable to fulfill biological, psychological, developmental, or social needs. King 1971: To use communication to help client reestablish positive adaptation to environment. Neuman 1972: Stress reduction is goal of system model of nursing practice. Roy 1979: This adaptation model is based on the physiological, psychological, sociological and dependence-independence adaptive modes. Watson’s Theory 1979: Watson’s philosophy of caring 1979 attempts to define the outcome of nursing activity in regard to the; humanistic aspects of life. Classification of Nursing Theories Depending On The Generalisability Of Their Principles •

Metatheory: the theory of theory. Identifies

•

specific phenomena through abstract concepts.

•

Grand theory: provides a conceptual framework under which the key concepts and

•

principles of the discipline can be identified.

•

Middle range theory: is more precise and only analyses a particular situation with a limited number of variables.

•

Practice theory: explores one particular situation found in nursing. It identifies explicit goals and details how these goals will be achieved.

Theories can also be categorised as: •

"Needs "theories.

•

"Interaction" theories.

•

"Outcome "theories.

•

"Humanistic theories"

•

These categories indicate the basic philosophical underpinnings of the theories

"Needs" theories •

These theories are based around helping individuals to fulfill their physical and mental needs. The basis of these theories is well-illustrated in Roper, Logan and Tierney’s Model of Nursing (1980).

•

Needs theories have been criticized for relying too much on the medical model of health and placing the patient in an overtly dependent position.

"Interaction" theories •

As described by Peplau (1988), these theories revolve around the relationships nurses form with patients.

•

Such theories have been criticized for largely ignoring the medical model of health and not attending to basic physical needs.

"Outcome" theories •

These portray the nurse as the changing force, who enables individuals to adapt to or cope with ill health (Roy 1980).

•

Outcome theories have been criticized as too abstract and difficult to implement in practice (Aggleton and Chalmers 1988).

"Humanistic" Theories: •

Humanistic theories developed in response to the psychoanalytic thought that a person’s destiny was determined early in life.

•

Humanistic theories emphasize a person’s capacity for self actualization .

•

Humanists believes that the person contains within himself the potential for healthy and creative growth.

•

Carl Rogers developed a person –centered model of psychotherapy that emphasizes the uniqueness of the individual.

•

The major contribution that Rogers added to nursing practice is the understanding that each client is a unique individual, so person-centered approach now practice in Nursing.

MODELS OF NURSING •

Until fairly recently, nursing science was derived principally from social, biologic, and medical science theories.

•

However, from the 1950s to the present, an increasing number of nursing theorists have developed models of nursing that provide bases for the development of nursing theories and nursing knowledge.

•

A model, as an abstraction of reality, provides a way to visualize reality to simplify thinking.

•

A conceptual model shows how various concepts are interrelated and applies theories to predict or evaluate consequences of alternative actions.

•

According to Fawcett (2000),

•

A conceptual model "gives direction to the search for relevant questions about the phenomena of central interest to a discipline and suggests solutions to practical problems"

•

. Four concepts are generally considered central to the discipline of nursing: the person who receives nursing care (the patient or client); the environment (society); nursing (goals, roles, functions); and health.

•

These four concepts form a metaparadigm of nursing.

•

The term metaparadigm comes from the Greek prefix

•

"meta," which means more comprehensive or transcending,

•

and the word Greek word "paradigm," which means a philosophical or theoretical framework of a discipline

•

upon which all theories, laws, and generalizations are formulated (MerriamWebster’s Collegiate Dictionary, 1994).

Growth and Stability Models of Change •

There are two major differences in philosophical beliefs, or world views, about the nature of change.

•

"The world view of change uses the growth metaphor, and the persistence view focuses on stability" (Fawcett, 1989,).

•

Within the change world view, change and growth are continual and desirable, "progress is valued, and realization of one’s potential is emphasized" (Fawcett).

•

Persistence is endurance in time

•

persistence world view emphasizes equilibrium and balance.

Categories of Conceptual Models •

Ten conceptual models of nursing have been classified according to two criteria:

•

the world view of change reflected by the model (growth or stability); and

•

the major theoretical conceptual classification with which the model seems most consistent (systems, stress/adaptation, caring, or growth/development).

Systems Theory as a Framework •

Systems theory is concerned with changes caused by interactions among all the factors (variables)

•

General systems theory is emphasized

•

A system is defined as "a whole with interrelated parts, in which the parts have a function and the system as a totality has a function" (Auger, 1976)

•

A general systems approach allows for consideration of the subsystems levels of the human being, as a total human being, and as a social creature who networks himself with others in hierarchically arranged human systems of increasing complexity. Thus the human being, from the level of the individual to the level of society, can be conceptualized as the client and becomes the target system for nursing intervention. (Sills and Hall, 1977).

An example of systems interaction

1. Input (Diet teaching) •

Throughput (Assimilation of information)

•

Output (Food intake)

•

Feedback (Weight record ,Hb estimation etc.)

Two nursing models based on systems theory:

2. Imogene King’s systems interaction model, and 3. Betty Neuman’s health care systems model. Imogene King’s Systems Interaction Model •

interaction model, the purpose of nursing is to help people attain, maintain, or restore health

•

King’s model conceptualizes three levels of dynamic interacting systems.

•

1. Individuals are called "personal systems."

•

2. Groups (two or more persons) form "interpersonal systems."

•

3. Society is composed of "social systems."

•

As the person interacts with the environment, he or she must continuously adjust to stressors in the internal and external environment (King, 1981).

•

Health assumes achievement of maximum potential for daily living and an ability to function

•

in social roles. It is the "dynamic life experiences of a human being, which implies continuous

•

adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living" (King, 1981,).

•

"Illness is a deviation from normal, that is, an imbalance in a person’s biological structure or in his psychological makeup, or a conflict in a person’s social relationships" (King, 1989).

•

"The goal of nursing is to help individuals and groups attain, maintain, and restore health"

•

Stress: "a dynamic state whereby a human being interacts with the environment to maintain balance for growth, development, and performance"

Betty Neuman’s Health Care Systems Model •

Betty Neuman specifies that the purpose of nursing is to facilitate optimal client system stability.

•

Normal line of defense: an adaptational level of health considered normal for an individual

•

Lines of resistance: protection factors activated when stressors have penetrated the normalline of defense

•

Neuman’s model, organized around stress reduction, is concerned primarily with how stress and the reactions to stress affect the development and maintenance of health.

•

The person is a composite of physiologic, psychological, sociocultural, developmental, and spiritual variables considered simultaneously.

•

"Ideally the five variables function harmoniously or are stable in relation to internal and external environmental stressor influences" (Neuman, 2002).

•

A person is constantly affected by stressors from the internal, external, or created environment.

•

Stressors are tension-producing stimuli that have the potential to disturb a person’s equilibrium or normal line of defense.

•

This normal line of defense is the person’s "usual steady state."

•

It is the way in which an individual usually deals with stressors.

•

Stressors may be of three types:

•

Intrapersonal: forces arising from within the person

•

Interpersonal: forces arising between persons

•

Extrapersonal: forces arising from outside the person

•

Resistance to stressors is provided by a flexible line of defense, a dynamic protective buffer made up of all variables affecting a person at any given moment the person’s resistance to any given stressor or stressors.

•

If the flexible line of defense is no longer able to protect the person against a stressor, the stressor

•

breaks through, disturbs the person’s equilibrium, and triggers a reaction. The reaction may lead

•

toward restoration of balance or toward death.

•

Neuman intends for the nurse to "assist clients to retain, attain, or maintain optimal system stability" (Neuman, 1996).

•

Thus, health (wellness) seems to be related to dynamic equilibrium of the normal line of defense, where stressors are successfully overcome or avoided by the flexible line of defense.

•

Neuman defines illness as "a state of insufficiency with disrupting needs unsatisfied" (Neuman, 2002).

•

Illness appears to be a separate state when a stressor breaks through the normal line of defense and causes a reaction with the person’s lines of resistance.

Stress/Adaptation Theory as a Framework •

In contrast to systems theory, stress and adaptation theories view change caused by person–environment interaction in terms of cause and effect.

•

The person must adjust to environmental changes to avoid disturbing a balanced existence. Adaptation theory provides a way to understand

•

both how the balance is maintained and the possible effects of disturbed equilibrium.

•

This theory has been widely applied to explain, predict, and control biologic (physiologic and psychological)

A unique body of knowledge •

The drive for a unique body of knowledge is based

•

on the assumption that ‘borrowed’ knowledge is

•

less worthy.

•

However, nurse education is based on theory borrowed from other disciplines, such as sociology and psychology.

•

It has been argued that applying knowledge from different disciplines only serves to dilute nursing practice.

•

Nevertheless, as the occupation is focused on

•

humans, perhaps it is inevitable that nursing uses

•

knowledge from other social sciences.

•

It has been argued that no knowledge is exclusive, and because of nursing’s diverse nature it is impossible for it to have a unique body of knowledge and one unified body of theory (Castledine 1994, Levine 1995).

Criticisms of nursing theories •

To understand why nursing theory is generally neglected on the wards it is necessary to take a closer look at the main criticisms of nursing theory and the role that nurses play in contributing to its lack of prevalence in practice.

•

Use of language Scott (1994) states that the crucial ingredients of nursing theory should be accessibility and clarity. However, one of the main criticisms of nursing theory is its use of overtly complex language (Kenny 1993).

•

It is important that the language used in the

•

development of nursing theory be used consistently.

•

Not part of everyday practice Despite theory and practice being viewed as inseparable concepts, a theory-practice gap still exists in nursing (Upton 1999).

•

Yet despite the availability of a vast amount of literature on the subject, nursing theory still means very little to most practicing nurses. Perhaps this is because the majority of nursing theory is developed by and for nursing academics (Lathlean 1994).

•

It has been recognised that traditionally nurses are used to ‘speaking with their hands’ (Levine 1995).

•

Therefore, many nurses have not had the training or experience to deal with the abstract concepts presented by nursing theory.

•

This makes it difficult for the majority of nurses to understand and apply theory to practice (Miller 1985).

Summary •

Definition

•

Importance of Nursing Theories

•

The characteristics of theories:

•

Basic Processes in the Development Of Nursing Theories:

•

Nursing theories are often based on and influenced

•

ANA definition of Nursing Practice

•

Common concepts in Nursing Theories:

•

Historical Perspectives and Key Concepts

•

Classification of Nursing Theories

•

Models Of Nursing

•

Growth and Stability Models of Change

•

Betty Neuman’s Health Care Systems Model

•

Stress/Adaptation Theory as a Framework

•

A unique body of knowledge

•

Criticisms of nursing theories

Conclusion: Littlejohn (2002) comments that irrespective of nursing theories, nurses will continue to exhibit a caring response to the ‘sick and troubled’. If this is true, perhaps nurses are ‘nursing’ without the knowledge of theories and theory is irrelevant. However, theory and practice are related, and if nursing is to continue to develop, the concept of theory must be addressed. If nursing theory does not drive the development of nursing, it will continue to develop in the footsteps of other disciplines such as medicine Reference:

1. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton and Lange.

2. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williamsand wilkins.

3. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and Progress 3rd ed. Philadelphia, Lippincott.

4. Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

5. Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing –Concepts Process and Practice 3rd ed. London Mosby Year Book.

UNDERSTANDING THE WORK OF NURSE THEORISTS ……… Creative Beginning Theories of Nursing •

Theory is "an internally consistent group of relational statements (concepts, definitions and propositions) that present a systematic view about a phenomenon and which is useful for description, explanation, prediction and control".

•

Theories are road maps that provide a framework for selecting and organizing information: o What to ask o

What to observe

o

What to focus on

o

What to think about

•

Nursing theory is an organized and systematic articulation of a set of statements related to questions in the discipline of nursing. Uses of Theory Theory is used to: • Describe •

Explain

•

Predict

•

Prescribe

Uses of Nursing Theory • Define relationships among the variables of

a given field of inquiry

•

Guide research, practice and communication

•

Allow the prediction of the consequences of care

•

Allow the prediction of a range of patient responses

Levels of Theory There are four levels of theory • Metatheory •

Grand Theory

•

Middle Range Theory

•

Practice Theory

Types of Theory In Nursing there are four types of theories: • Needs •

Interaction

•

Outcome

•

Humanistic

Practice value of theory • Enhances understanding and explanation for events •

Influence our behavior.

•

Makes to think differently about a problem or a situation

•

Helps to try new approaches or altering behavior.

•

We can gain a new perspective of events

•

Basis for challenge of its speculative tenets or propositions

•

Challenges subsequent discovery of new ideas or knowledge that might explain and predict events not yet understood In practice • Assist nurses to describe, explain, and predict everyday experiences. •

Serve to guide assessment, intervention, and evaluation of nursing care.

•

Provide a rationale for collecting reliable and valid data about the health status of clients, which are essential for effective decision making and implementation. Help to establish criteria to measure the quality of nursing care

• •

Help build a common nursing terminology to use in communicating with other health professionals. Ideas are developed and words defined. • Enhance autonomy (independence and self-governance) of nursing by defining its own independent functions. In education • Provide a general focus for curriculum design. •

Guide curricular decision making

In research • Offer a framework for generating knowledge and new ideas. • •

Assist in discovering knowledge gaps in specific field of study.

Offer a systematic approach to identify questions for study, select variables, interpret findings, and validate nursing interventions. An illustration…… The germ theory • Explains the phenomenon of disease transmission

• • • • •

Means of speculative explanation and prediction of certain observable events Allows us to effectively function to prevent transmission of communicable disease. Viable basis upon which to make decisions about how to prevent certain illnesses. There are phenomena we do not understand that are related to germ transmission, Example-the communicability of cancer.

"Nursing Practice." All experiences and events a practicing nurse encounters in the process of providing nursing care. Events….. • Some may be experienced by the client, •

Others by the nurse

•

Some may be observed in the environment

•

May be observed in the nurse-client interaction.

•

In situations of daily work or living,

…………..but as long as they are observable during the process of providing direct nursing care, they are considered part of nursing practice. Approaches to inter relationships between practice and theory • How nursing practice contributes to the process of theory development.. •

How theory contributes to nursing practice…

Contribution of practice to theory development • Theory development within nursing occurs in the context of practice. • •

Two activities contribute significantly to the overall process of developing theory in nursing. Concept analysis and

•

Practical validation of theory.

Concept analysis

•

Identify and verify abstract concepts

•

"what events in practice can be linked with abstract concept x"

•

Application of theory in practice

•

Nursing process operation of analysis of assessment data.

•

Used as scientific rationale supporting judgments in nursing care plans.

Concepts • Concepts may be (a) readily observable, or concrete, ideas such as thermometer, rash, and lesion; (b) indirectly observable, or inferential, ideas such as pain and temperature; or c) non-observable, or abstract, ideas such as equilibrium, adaptation, stress, and powerlessness • nursing theories address and specify relationships among four major abstract concepts referred to as the metaparadigm of nursing. • Four concepts are considered to be central to nursing : • •

•

Person or client, the recipient of nursing care (includes individuals, families, groups, and communities). Environment, the internal and external surroundings that affect the client. This includes people in the physical environment, such as families, friends, and significant others. Health, the degree of wellness or well-being that the client experiences.

•

Nursing, the attributes, characteristics, and actions of the nurse providing care on behalf of, or in conjunction with, the client Nightingale’s environmental theory • "the act of utilizing the environment of the patient to assist him in his recovery" • She linked health with five environmental factors : •

Pure or fresh air

•

Pure water

•

Efficient drainage

•

Cleanliness

•

Light, especially direct sunlight

•

Deficiencies in these five factors produced lack

•

Of health or illness.

Peplau’s interpersonal relations model • Nurses enter into a personal relationship with an individual when a felt need is present Henderson’s definition of nursing • Henderson conceptualized the nurse’s role as assisting sick or well individuals to gain independence in meeting 14 fundamental needs (Henderson) • Breathing normally •

Eating and drinking adequately

•

Eliminating body wastes

•

Moving and maintaining a desirable position

•

Sleeping and resting

•

Selecting suitable clothes

• •

Maintaining body temperature within normal range by adjusting clothing and modifying the environment. Keeping the body clean and well groomed to protect the integument.

•

Avoiding dangers in the environment and avoiding injuring others

• •

Communicating with others in expressing emotions, needs, fears, or opinions Worshipping according to one’s faith

•

Working in such a way that one feels a sense of accomplishment

•

Playing or participating in various forms of recreation.

•

Learning, discovering, or satisfying the curiosity that leads to normal development and health, and using available health facilities Roger’s science of unitary human beings • She states that humans are dynamic energy fields in continuous exchange with environmental fields, both of which are infinite. • Nurses applying Roger's theory in practice (a) focus on the person’s wholeness, (b) seek to promote symphonic interaction between the two energy fields (human and environment) to strengthen the coherence and integrity of the person, c) coordinate the human field with the rhythmicities of the environmental field, and (d) direct and redirect patterns of interaction between the two energy fields to promote maximum health potential Orem’s general theory of nursing • Orem’s self-care deficit theory explains not only when nursing is needed but also how people can be assisted through five methods of helping: acting or doing for, guiding, teaching, supporting, and providing an environment that promotes the individual’s abilities to meet current and future demands. King’s goal attainment theory • King’s theory offers insight into nurses’ interactions with individuals and groups within the environment. It highlights the importance of client’s participation in decision that influence care and focuses on both the process of nurse-client interaction and the outcomes of care. Neuman’s systems model • The model is based on the individual’s relationship to stress, the reaction to it, and reconstitution factors that are dynamic in nature. • Betty Neuman's model of nursing is applicable to a variety of nursing practice settings involving individuals, families, groups, and communities. Roy’s adaptation model • Roy focuses on the individual as a biopsychosocial adaptive system that employs a feedback cycle of input (stimuli), throughput (control processes), and output (behaviors or adaptive responses). Watson’s human caring theory • Jean Watson (1979) believes the practice of caring is central to nursing; it is the unifying focus for practice. • Nursing interventions related to human care are referred to as carative factors.

•

Watson’s theory of human caring has receiving worldwide recognition and is a major force in redefining nursing as a caring-healing health model. Parse’s human becoming theory • Parse’s model of human becoming emphasizes how individuals choose and bear responsibility for patterns of personal health. Leininger’s cultural care diversity and universality theory • She emphasizes that human caring, although a universal phenomenon, varies among cultures in its expressions, processes, and patterns; it is largely culturally derived. Orem’s general theory of nursing Assessing • Involves collecting data about the client’s capacities (knowledge, skills, and motivation) to perform universal, developmental, and health-deviation selfcare requisites. Determine self-care deficits. Diagnosing • Stated in terms of the client’s limitations for maintaining self care (a deficit in self-care agency) Planning • Involves considering and designing, with the client’s participation, an appropriate nursing system (wholly compensatory, partially compensatory, supportive-educative, or a mix) that will help the client achieve an optimal level of self care Implementing • Assisting the client Evaluating 1. Determining the client’s level of achievement References 1. Phipps J Wilma, Sands K Judith. Medical Surgical Nursing: concepts & clinical practice.6th edition. Philadelphia. Mosby publications. 1996. 2. Black M. Joice, Hawks hokanson Jane. Medical Surgical Nursing: Clinical Management for positive outcomes. St Lois, Missouri. 2005. 3. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002 4. Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia, 2002.

THEORIES & NURSING RESEARCH Introduction • • • • •

RESEARCH – Process of inquiry THEORY – Product of knowledge SCIENCE – Result of the relationship between research & theory To effectively build knowledge to research process should be developed within some theoretical structure that facilities analysis and interpretation of findings. Relationship between theory and research in nursing is not well understood. It may be give to the relative youth of the discipline and debates over philosophical world views. (Empiricism, constructivism, etc…)

Need to Link Theory and Research • • •

Research without theory results in discreet information or data which does not add to the accumulated knowledge of the discipline. Theory guides the research process, forms the research questions, aids in design, analysis and interpretation. It enables the scientist to weave the facts together.

Theories from Nursing or Other Disciplines?

• • •

Nursing science is blend of knowledge that is unique to nursing and knowledge that is borrowed from other disciplines. Debate is whether the use of borrowed theory has hindered the development of the discipline. It has contributed to problems connecting research and theory in nursing.

Historical Overview of Research and Theory in Nursing • • • • • • •

Florence Nightingale supported her theoretical propositions through research, as statistical data and prepared graphs were used to depict the impact of nursing care on the health of British soldiers. Afterwards, for almost century reports of nursing research were rare. Research and theory developed separately in nursing. Between 1928 and 1959 only 2 out of 152 studies reported a theoretical basis for the research design. In 1970’s growing number of nurse theorists were seeking researchers to test their models in research and clinical application Grand nursing theories are still not widely used. In 1990’s borrowed theories were used more. Now the focus of research and theory have moved more towards middle range theories

Purpose of Theory in Research • • • • • • •

To identify meaningful and relevant areas for study. To propose plausible approaches to health problems. To develop or refine theories Define the concepts and proposed relationships between concepts. To interpret research findings To develop clinical practice protocols. Generate nursing diagnosis.

Types of theory and corresponding research Type of theory • • •

Descriptive Explanatory

Type of research • Descriptive or explanatory •

Co relational

•

Experimental

Predictive

How Theory is used in Research

Causal theory of planned behaviour

Theory Generating Research • • •

It is designed to develop and describe relationships between and among phenomena without imposing preconceived notations. It is inductive and includes field observations and phenomenology. During the theory generating process, the researcher moves by logical thought from fact to theory by means of a proposition stated as an empirical generalization.

Grounded Theory Research •

Inductive research technique developed by Glazer and Strauss (1967)

•

Grounded theory provides a way to describe what is happening and understanding the process of why it happens.

•

•

Methodology – The researcher observes, collects data, organizes data and forms theory from the data at the same time. Data may be collected by interview, observation, records or a combination of these techniques. Data are coded in preparation for analysis.

•

Category development – Categories are identified and named

•

Category saturation – Comparison of similar characteristics in each of the categories Concept development – Defines the categories Search for additional categories – Continues to examine the data for additional categories Category reduction – Higher order categories are selected Linking of categories – The researcher seeks to understand relationships among categories Selective sampling of the literature Emergence of the core variable – Central theme are focus of the theory Concept modification and integration – Explaining the phenomenal

•

• • • • • • •

Theory testing research •

In theory testing research, theoretical statements are translated into questions and hypothesis. It requires a deductive reasoning process.

•

The interpretation determines whether the study supports are contradicts the propositional statement. If a conceptual model is used as a theoretical framework for research it is not theory testing. Theory testing requires detailed examination of theoretical relationships.

• •

Theory as a conceptual framework • • • • •

Problem being investigated is fit into an existing theoretical framework, which guides the study and enriches the value of its findings. The conceptual definitions are drawn from the framework The data collection instrument is congruent with the framework. Findings are interpreted in light of explanations provided by the framework. Implications are based on the explanatory power of a framework.

A Typology of Research • • • • • • •

Testing Analyzing Experimentation Deducting Deductive research Quantitative research The scientific method

• •

Theory / hypothesis testing Assaying

• • • • • • • • •

Refining Interpreting Reflecting Inducing Inductive research Qualitative research Phenomenological research Theory generation ‘Divining’; ‘heuristic’ research

Guidelines for writing about a research study’s theoretical framework In the study’s problem statement 1. 2. 3. 4.

Introduce the framework Briefly explain why it is a good fit for the research problem area At the end of the literature review Thoroughly describe the framework and explain its application to the present study. 5. Describe how the framework has been used in studies about similar problems 6. In the study’s methodology section 7. Explain how the framework is being operationalized in the study’s design. 8. Explain how data collection methods (such as questionnaire items) reflect the concepts in the framework. 9. In the study’s discussion section 10. Describe how study findings are consistent (or inconsistent) with the framework. 11. Offer suggestions for practice and further research that are congruent with the framework’s concepts and propositions. Conclusion The relationship between research and theory is undeniable, and it is important to recognize the impact of this relationships on the development of nursing knowledge. So interface theory and research by generating theories, testing the theories and by using it as a conceptual framework that drives the study. Reference • • •

George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton and Lange. Polit DF, Hungler BP. Nursing Research: Principles and Methods. Philadelphia: JB Lippincott Company; 1998. Burns N, Grove SK. The practice of Nursing Research. 4th Ed. Philadelphia: WB Saunders Publications; 2001.

•

Treece JW, Treece EW. Elements of Research in Nursing (3rded.). St. Louis: Mosby; 1982.

VIRGINIA HENDERSON’S NEED THEORY “Nursing theories mirror different realities, throughout their development; they reflected the interests of nurses of that time.” Introduction •

“The Nightingale of Modern Nursing”

•

“Modern-Day Mother of Nursing.”

•

"The 20th century Florence Nightingale."

•

"little Miss 3x5"

•

Born in Kansas City, Missouri, in 1897 and is the 5th child of a family of 8th children but spent her formative years in Virginia

•

Received a Diploma in Nursing from the Army School of Nursing at Walter Reed Hospital, Washington, D.C. in 1921.

•

Worked at the Henry Street Visiting Nurse Service for 2 years after graduation.

•

In 1923, she accepted a position teaching nursing at the Norfolk Protestant Hospital in Virginia, where she remained for several years

•

In 1929, Henderson determined that she needed more education and entered Teachers College at Columbia University where she earned her; Bachelor’s Degree in 1932, Master’s Degree in 1934.

•

Subsequently, she joined Columbia as a member of the faculty, where she remained until 1948(Herrmann,1998)

•

Since 1953, she has been a research associate at Yale University School of Nursing.

•

Died: March 19, 1996.

Achievements •

Is the recipient of numerous recognitions for her outstanding contributions to nursing?

•

VH was a well known nursing educator and a prolific author.

•

She has received honorary doctoral degrees from the o

Catholic University of America

o

Pace University,

o

University of Rochester,

o

University of Western Ontario,

o

Yale University

•

Her stature as a nurse, teacher, author, researcher, and consumer health advocate warranted an obituary in the New York Times, Friday March 22. 1996.

•

In 1985, Miss Henderson was honored at the Annual Meeting of the Nursing and Allied Health Section of the Medical Library Association.

Contribution •

In 1937 Henderson and others created a basic nursing curriculum for the National League for Nursing in which education was “patient centered and organized around nursing problems rather than medical diagnoses” (Henderson,1991)

•

In 1939, she revised: Harmer’s classic textbook of nursing for its 4th edition, and later wrote the 5th; edition, incorporating her personal definition of nursing (Henderson,1991)

•

Although she was retired, she was a frequent visitor to nursing schools well into her nineties.

•

O’Malley (1996) states that Henderson is known as the modern-day mother of nursing. Her work influenced the nursing profession in America and throughout the world

•

The founding members of ICIRN (Interagency Council on Information Resources for Nursing) and a passionate advocate for the use and sharing of health information resources.

•

In 1978 the fundamental concept of nursing was revisited by Virginia Henderson from Yale University School of Nursing ( USA ). She argued that nurses needed to be prepared for their role by receiving the broadest understanding of humanity and the world in which they lived.

Publications •

1956 (with B. Harmer)-Textbook for the principles and practices of Nursing.

•

1966-The Nature of Nursing. A definition and its implication for practice, Research and Education

•

1991- The Nature of Nursing Reflections after 20 years

Analysis of Nursing Theory •

Images of Nursing, 1950-1970

•

The First School of Thought: Needs

•

This school of thought includes theories that reflect an image of nursing as meeting the needs of clients and were developed in response to such questions as

•

What do nurses do?

•

What are their functions?

•

What roles do nurses play?

•

Answers to these questions focused on a number of theorist describing functions and roles of nurses.

•

Conceptualizing functions led theorists to consider nursing client in terms of a Hierarchy of needs. When any of these needs are unmet and when a person is unable to fulfill his own needs, the care provided by nurses is required.

•

Nurses then provide the necessary functions and play those roles that could help patients meet their needs. School of thought in Nursing Theories-1950-1970 Need theorists

Interaction theorists

Outcome theorists

Abdellah

King

Johnson

Henderson

Orlando

Levine

Orem

Peterson and Zderad

Rogers

Paplau

Roy

Travelbee Wiedenbach Analysis of nursing theories according to 1st School Focus

Problems

Human being

A set of needs or problems. A developmental being.

Patient

Need Deficit

Orientation

Illness, disease

Role of nurse

Dependent on medical practice. Beginnings of independent functions Fulfill needs requisites

Decision making

Primarily health care professional

Henderson’s Theory Background

•

Henderson’s concept of nursing was derived form her practice and education therefore, her work is inductive.

•

She called her definition of nursing her “concept” (Henderson1991)

•

Although her major clinical experiences were in medical-surgical hospitals, she worked as a visiting nurse in New York City. This experience enlarges Henderson’s view to recognize the importance of increasing the patient’s independence so that progress after hospitalization would not be delayed (Henderson,1991)

•

Virginia Henderson defined nursing as "assisting individuals to gain independence in relation to the performance of activities contributing to health or its recovery" (Henderson, 1966, p. 15).

•

She was one of the first nurses to point out that nursing does not consist of merely following physician's orders.

•

She categorized nursing activities into 14 components, based on human needs.

•

She described the nurse's role as substitutive (doing for the person), supplementary (helping the person), complementary (working with the person), with the goal of helping the person become as independent as possible.

•

Her famous definition of nursing was one of the first statements clearly delineating nursing from medicine: "The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible" (Henderson, 1966, p. 15).

The development of Henderson’s definition of nursing • •

Two events are the basis for Henderson’s development of a definition of nursing. First, she participated in the revision of a nursing textbook.

•

Second, she was concerned that many states had no provision for nursing licensure to ensure safe and competent care for the consumer.

•

In the revision she recognized the need to be clear about the functions of the nurse and she believed that this textbook serves as a main learning source for nursing practice should present a sound and definitive description of nursing. •

Furthermore, the principles and practice or nursing must be built upon and derived from the definition of the profession.

•

Although official statements on the nursing function were published by the ANA in 1932 and 1937, Henderson viewed these statements as nonspecific and unsatisfactory definitions of nursing practice.

•

Then in 1955, the earlier ANA definition was modified.

•

Henderson's focus on individual care is evident in that she stressed assisting individuals with essential activities to maintain health, to recover, or to achieve peaceful death.

•

She proposed 14 components of basic nursing care to augment her definition.

•

In 1955, Henderson’s first definition of nursing was published in Bertha Harmer’s revised nursing textbook.

The 14 components • • • • • • • • • • • • • •

Breathe normally. Eat and drink adequately. Eliminate body wastes. Move and maintain desirable postures. Sleep and rest. Select suitable clothes-dress and undress. Maintain body temperature within normal range by adjusting clothing and modifying environment Keep the body clean and well groomed and protect the integument Avoid dangers in the environment and avoid injuring others. Communicate with others in expressing emotions, needs, fears, or opinions. Worship according to one’s faith. Work in such a way that there is a sense of accomplishment. Play or participate in various forms of recreation. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities.

•

The first 9 components are physiological.

•

The tenth and fourteenth are psychological aspects of communicating and learning

•

The eleventh component is spiritual and moral

•

The twelfth and thirteenth components are sociologically oriented to occupation and recreation

Assumption The major assumption of the theory is that: •

Nurses care for patients until patient can care for themselves once again. •

Patients desire to return to health, but this assumption is not explicitly stated.

•

Nurses are willing to serve and that “nurses will devote themselves to the patient day and night”

•

A final assumption is that nurses should be educated at the university level in both arts and sciences.

Henderson’s theory and the four major concepts Individual •

Have basic needs that are component of health.

•

Requiring assistance to achieve health and independence or a peaceful death.

•

Mind and body are inseparable and interrelated.

•

Considers the biological, psychological, sociological, and spiritual components.

•

The theory presents the patient as a sum of parts with biopsychosocial needs, and the patient is neither client nor consumer.

Environment •

Settings in which an individual learns unique pattern for living.

•

All external conditions and influences that affect life and development.

•

Individuals in relation to families

•

Minimally discusses the impact of the community on the individual and family.

•

Supports tasks of private and public agencies

•

Society wants and expects nurses to act for individuals who are unable to function independently.

•

In return she expects society to contribute to nursing education.

•

Basic nursing care involves providing conditions under which the patient can perform the 14 activities unaided

Health •

Definition based on individual’s ability to function independently as outlined in the 14 components.

•

Nurses need to stress promotion of health and prevention and cure of disease.

•

Good health is a challenge.

•

Affected by age, cultural background, physical, and intellectual capacities, and emotional balance

•

Is the individual’s ability to meet these needs independently?

Nursing •

Temporarily assisting an individual who lacks the necessary strength, will and knowledge to satisfy 1 or more of 14 basic needs.

•

Assists and supports the individual in life activities and the attainment of independence.

•

Nurse serves to make patient “complete” “whole", or "independent."

•

Henderson's classic definition of nursing: "I say that the nurse does for others what they would do for themselves if they had the strength, the will, and the knowledge. But I go on to say that the nurse makes the patient independent of him or her as soon as possible."

•

The nurse is expected to carry out physician’s therapeutic plan

•

Individualized care is the result of the nurse’s creativity in planning for care.

•

Use nursing research

•

Categorized

o

Nursing : nursing care

o

Non nursing: ordering supplies, cleanliness and serving food.

•

In the Nature of Nursing “ that the nurse is and should be legally, an independent practitioner and able to make independent judgments as long as s/he is not diagnosing, prescribing treatment for disease, or making a prognosis, for these are the physicians function.”

•

“Nurse should have knowledge to practice individualized and human care and should be a scientific problem solver.”

•

In the Nature of Nursing o

Nurse role is,” to get inside the patient’s skin and supplement his strength will or knowledge according to his needs.” o

And nurse has responsibility to assess the needs of the individual patient, help individual meet their health need, and or provide an environment in which the individual can perform activity unaided.

Henderson's classic definition of nursing "I say that the nurse does for others what they would do for themselves if they had the strength, the will, and the knowledge. But I go on to say that the nurse makes the patient independent of him or her as soon as possible." Henderson’s and Nursing Process •

Henderson views the nursing process as “really the application of the logical approach to the solution of a problem. The steps are those of the scientific method.”

•

“Nursing process stresses the science of nursing rather than the mixture of science and art on which it seems effective health care service of any kind is based.”

Summarization of the stages of the nursing process as applied to Henderson’s definition of nursing and to the 14 components of basic nursing care. Nursing Process

Henderson’s 14 components and definition of nursing

Nursing Assessment

Henderson’s 14 components Analysis: Compare data to knowledge base of health and disease.

Nursing Diagnosis

Identify individual’s ability to meet own needs with or without assistance, taking into consideration strength, will or knowledge.

Nursing plan

Document how the nurse can assist the individual, sick or well.

Nursing implementation

Assist the sick or well individual in to performance of activities in meeting human needs to maintain health, recover from illness, or to aid in peaceful death.

Nursing implementation

Implementation based on the physiological principles, age, cultural background, emotional balance, and physical and intellectual capacities. Carry out treatment prescribed by the physician.

Nursing process

Henderson’s 14 components and definition of nursing

Nursing evaluation

Use the acceptable definition of ;nursing and appropriate laws related to the practice of nursing. The quality of care is drastically affected by the preparation and native ability of the nursing personnel rather that the amount of hours of care. Successful outcomes of nursing care are based on the speed with which or degree to which the patient performs independently the activities of daily living.

Comparison with Maslow's Hierarchy of Need MASLOW'S

HENDERSON

Physiological needs

Breathe normally Eat and drink adequately Eliminate by all avenues of elimination Move and maintain desirable posture Sleep and rest Select suitable clothing Maintain body temperature Keep body clean and well groomed and protect the integument

Safety needs

Avoid environmental dangers and avoid injuring others

Belongingness and love needs

Communicate with others

Esteem needs

Work at something providing a sense of accomplishment

Worship according to faith

Play or participate in various forms of recreation Learn, discover, or satisfy curiosity Self actualization needs Characteristic of Henderson’s theory •

Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon.

•

Concepts of fundamental human needs, biophysiology, culture, and interaction, communication and is borrowed from other discipline.E.g.. Maslow’s Hierarchy of human needs; concept of interactioncommunication i.e. nurse-patient relationship

•

Theories must be logical in nature.

•

Her definition and components are logical and the 14 components are a guide for the individual and nurse in reaching the chosen goal.

•

Theories should be relatively simple yet generalizable.

•

Her work can be applied to the health of individuals of all ages.

•

Theories can be the bases for hypotheses that can be tested.

•

Her definition of nursing cannot be viewed as theory; therefore, it is impossible to generate testable hypotheses.

•

However some questions to investigate the definition of nursing and the 14 components may be useful.

•

Is the sequence of the 14 components followed by nurses in the USA and the other countries?

•

What priorities are evident in the use of the basic nursing functions?

•

Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them.

•

Her ideas of nursing practice are well accepted throughout the world as a basis for nursing care.

•

However, the impact of the definition and components has not been established through research.

•

Theories can be utilized by practitioners to guide and improve their practice.

•

Ideally the nurse would improve nursing practice by using her definition and 14 components to improve the health of individuals and thus reduce illness.

•

Theories must be consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated.

Philosophical claims The philosophy reflected in Henderson's theory is an integrated approach to scientific study that would capitalize on nursing's richness and complexity, and not to separate the art from the science, the "doing" of nursing from the "knowing", the psychological from the physical and the theory from clinical care. Values and Beliefs •

Henderson believed nursing as primarily complementing the patient by supplying what he needs in knowledge, will or strength to perform his daily activities and to carry out the treatment prescribed for him by the physician.

•

She strongly believed in "getting inside the skin" of her patients in order to know what he or she needs. The nurse should be the substitute for the patient, helper to the patient and partner with the patient. Like she said... "The nurse is temporarily the consciousness of the unconscious, the love of life for the suicidal, the leg of the amputee, the eyes of the newly blind, a means of locomotion for the infant and the knowledge and confidence for the young mother..."

•

Henderson stated that “Thorndike’s fundamental needs of man” (Henderson, 1991, p.16) had an influence on her beliefs.

Value in extending nursing science •

From an historical standpoint, her concept of nursing enhanced nursing science this has been particularly important in the area of nursing education.

•

Her contributions to nursing literature extended from the 1930s through the 1990s and has had an impact on nursing research by strengthening the focus on nursing practice and confirming the value of tested interventions in assisting individuals to regain health.

Usefulness •

Nursing education has been deeply affected by Henderson’s clear vision of the functions of nurses.

•

The principles of Henderson’s theory were published in the major nursing textbooks used from the 1930s through the 1960s, and the principles embodied by the 14 activities are still important in evaluating nursing care in thee21st centaury.

•

Others concepts that Henderson (1966) proposed have been used in nursing education from the 1930s until the present O'Malley, 1996)

Testability •

Henderson supported nursing research, but believed that it should be clinical research (O’Malley, 1996). Much of the research before her time had been on educational processes and on the profession of nursing itself, rather than on; the practice and outcomes of nursing , and she worked to change that.

•

Each of the 14 activities can be the basis for research. Although the statements are not.

•

Written in testable terms, they may be reformulated into researchable questions. Further, the theory can guide research in any aspect of the individual’s care needs.

Limitations •

Lack of conceptual linkage between physiological and other human characteristics.

•

No concept of the holistic nature of human being.

•

If the assumption is made that the 14 components prioritized, the relationship among the components is unclear.

•

Lacks inter-relate of factors and the influence of nursing care.

•

Assisting the individual in the dying process she contends that the nurse helps, but there is little explanation of what the nurse does.

•

“Peaceful death” is curious and significant nursing role.

Purposes of nursing theories In Practice: •

Assist nurses to describe, explain, and predict everyday experiences.

•

Serve to guide assessment, interventions, and evaluation of nursing care.

•

Provide a rationale for collecting reliable and valid data about the health status of clients, which are essential for effective decision making and implementation.

•

Help to describe criteria to measure the quality of nursing care.

•

Help build a common nursing terminology to use in communicating with other health professionals.

•

Ideas are developed and words are defined.

•

Enhance autonomy (independence and self-governance) of nursing through defining its own independent functions.

In Education: •

Provide a general focus for curriculum design

•

Guide curricular decision making.

In Research: •

Offer a framework for generating knowledge and new ideas.

•

Assist in discovering knowledge gaps in the specific field of study.

•

Offer a systematic approach to identify questions for study; select variables, interpret findings, and validate nursing interventions.

Approaches to developing nursing theory •

Borrowing conceptual frameworks from other disciplines.

•

Inductively looking at nursing practice to discover theories/concepts to explain phenomena.

•

Deductively looking for the compatibility of a general nursing theory with nursing practice.

Questions from practicing Nurse about using Nursing theory Practice •

Does this theory reflect nursing practice as I know it?

•

Will it support what I believe to be excellent nursing practice?

•

Can this theory be considered in relation to a wide range of nursing situation?

Personal Interests, Abilities and Experiences •

What will it be like to think about nursing theory in nursing practice?

•

Will my work with nursing theory be worth the effort?

Summary 1. Background 2. Achievements 3. Publications 4. Analysis of Nursing theories 5. Development of Henderson’s definition of nursing 6. 14 components 7. Major four concepts 8. Nursing process with Henderson’s theory 9. Comparison with Maslow's Hierarchy need 10. Assumptions 11. Usefulness 12. Testability 13. Characteristics 14. imitation Conclusion In conclusion, Henderson provides the essence of what she believes is a definition of nursing. She didn’t intend to develop a theory of nursing but rather she attempted to define the unique focus of nursing. Her emphasis on basic human needs as the central focus of nursing practice has led to further theory development regarding the needs of the person and how nursing can assist in meeting those needs. Her definition of nursing and the 14 components of basic nursing care are uncomplicated and self-explanatory. Reference •

Timber BK. Fundamental skills and concepts in Patient Care, 7th edition, LWW, N

•

George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange.

•

Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing

Philadelphia. Lippincott Williams& wilkins. •

Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

•

Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

•

Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

•

Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-15

•

Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):225

•

Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice, 2nd edition, Thomson, NY, 2002

Theory of interpersonal relations Hildegard .E. Peplau Introduction •

Born in Reading, Pennsylvania [1909]

•

Graduated from a diploma program in Pottstown, Pennsylvania in 1931.

•

Done BA in interpersonal psychology from Bennington College in 1943.

•

MA in psychiatric nursing from Colombia University New York in 1947.

•

EdD in curriculum development in 1953.

•

Professor emeritus from Rutgers university

•

Started first post baccalaureate program in nursing

•

Published Interpersonal Relations in Nursing in 1952

•

1968 :interpersonal techniques-the crux of psychiatric nursing

•

Worked as executive director and president of ANA.

•

Worked with W.H.O, NIMH and nurse corps.

•

Died in 1999.

Psychodynamic nursing 1. Understanding of ones own behavior 2. To help others identify felt difficulties 3. To apply principles of human relations to the problems that arise at all levels of experience 4. In her book she discussed the phases of interpersonal process, roles in nursing situations and methods for studying nursing as an interpersonal process. 5. According to Peplau, nursing is therapeutic in that it is a healing art, assisting an individual who is sick or in need of health care. 6. Nursing is an interpersonal process because it involves interaction between two or more individuals with a common goal. 7. The attainment of goal is achieved through the use of a series of steps following a series of pattern. 8. The nurse and patient work together so both become mature and knowledgeable in the process. Definitions 1. Person :A developing organism that tries to reduce anxiety caused by needs 2. Environment : Existing forces outside the organism and in the context of culture

3. Health : A word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal and community living.

4. Nursing: A significant therapeutic interpersonal process. It functions cooperatively with other human process that make health possible for individuals in communities

Roles of nurse •

Stranger: receives the client in the same way one meets a stranger in other life situations provides an accepting climate that builds trust.

•

Teacher: who imparts knowledge in reference to a need or interest

•

Resource Person : one who provides a specific needed information that aids in the understanding of a problem or new situation

•

Counselors : helps to understand and integrate the meaning of current life circumstances ,provides guidance and encouragement to make changes

•

Surrogate: helps to clarify domains of dependence interdependence and independence and acts on clients behalf as an advocate.

•

Leader : helps client assume maximum responsibility for meeting treatment goals in a mutually satisfying way

Additional Roles include: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Technical expert Consultant Health teacher Tutor Socializing agent Safety agent Manager of environment Mediator Administrator Recorder observer Researcher

Theory of interpersonal relations •

Middle range descriptive classification theory

•

Influenced by Harry Stack Sullivan's theory of inter personal relations (1953)

•

Also influenced by Percival Symonds , Abraham Maslow's and Neal Elger Miller Identified four sequential phases in the interpersonal relationship: 1. Orientation 2. Identification 3. Exploitation 4. Resolution

•

Orientation phase •

Problem defining phase

•

Starts when client meets nurse as stranger

•

Defining problem and deciding type of service needed

•

Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and expectations of past experiences

•

Nurse responds, explains roles to client, helps to identify problems and to use available resources and services

Factors influencing orientation phase

Identification phase • •

Selection of appropriate professional assistance Patient begins to have a feeling of belonging and a capability of dealing with the problem which decreases the feeling of helplessness and hopelessness

Exploitation phase • • • • • • • •

Use of professional assistance for problem solving alternatives Advantages of services are used is based on the needs and interests of the patients Individual feels as an integral part of the helping environment They may make minor requests or attention getting techniques The principles of interview techniques must be used in order to explore ,understand and adequately deal with the underlying problem Patient may fluctuates on independence Nurse must be aware about the various phases of communication Nurse aids the patient in exploiting all avenues of help and progress is made towards the final step

Resolution phase • • • • •

Termination of professional relationship The patients needs have already been met by the collaborative effect of patient and nurse Now they need to terminate their therapeutic relationship and dissolve the links between them. Sometimes may be difficult for both as psychological dependence persists Patient drifts away and breaks bond with nurse and healthier emotional balance is demonstrated and both becomes mature individuals

Interpersonal theory and nursing process

• • •

Both are sequential and focus on therapeutic relationship Both use problem solving techniques for the nurse and patient to collaborate on, with the end purpose of meeting the patients needs Both use observation communication and recording as basic tools utilized by nursing Assessment Data collection and analysis [continuous] May not be a felt need Nursing diagnosis Planning Mutually set goals Implementation Plans initiated towards achievement of mutually set goals May be accomplished by patient , nurse or family Evaluation Based on mutually expected behaviors May led to termination and initiation of new plans

Orientation Non continuous data collection Felt need Define needs Identification Interdependent goal setting Exploitation Patient actively seeking and drawing help Patient initiated

Resolution Occurs after other phases are completed successfully Leads to termination

Peplau’s work and characteristics of a theory Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon. Four phases interrelate the different components of each phase. The nurse patient interaction can apply to the concepts of human being ,health, environment and nursing. Theories must be logical in nature Provides a logical systematic way of viewing nursing situations Key concepts such as anxiety, tension, goals, and frustration are indicated with explicit relationships among them and progressive phases Theories should be relatively simple yet generalizable It provides simplicity in regard to the natural progression of the NP relationship. Leads to adaptability in any nurse patient relationship.

The basic nature of nursing still considered an interpersonal process Theories can be the bases for hypothesis that can be tested. Has generated testable hypotheses. Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them. In 1950’s two third of the nursing research concentrated on N-P relation ship. Theories can be utilized by practitioners to guide and improve their practice. Peplau’s anxiety continuum is still used in anxiety patients Theories must be consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated. Consistent with various theories Limitations •

Intra family dynamics, personal space considerations and community social service resources are considered less Health promotion and maintenance were less emphasized Cannot be used in a patient who doesn’t have a felt need eg. With drawn patients, unconscious patients some areas are not specific enough to generate hypothesis

• • •

Research Based on Peplau’s Theory 1. Hays .D. (1961).Phases and steps of experimental teaching to patients of a concept of anxiety: Findings revealed that when taught by the experimental method, the patients were able to apply the concept of anxiety after the group was terminated. 2. Burd .S.F. Develop and test a nursing intervention framework for working with anxious patients: Students developed competency in beginning interpersonal relationship References •

Timber BK. Fundamental skills and concepts in Patient Care, 7th edition, LWW, N

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George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange.

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Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.

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Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

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Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

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Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

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Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-15

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Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):225

•

Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice, 2nd edition, Thomson, NY, 2002

FAYE GLENN ABDELLAH'S THEORY TWENTY ONE NURSING PROBLEMS INTRODUCTION •

Faye Glenn Abdellah, pioneer nursing researcher, helped transform nursing theory, nursing care and nursing education

•

Birth:1919

•

Dr Abdellah worked as Deputy Surgeon General

•

Former Chief Nurse Officer for the U.S Public Health Service , Department of Health and human services, Washington, D.C .

•

She has been a leader in nursing research and has over one hundred publications related to nursing care, education for advanced practice in nursing and nursing research.

•

In 1960, influenced by the desire to promote client-centred comprehensive nursing care, Abdellah described nursing as a service to individuals, to families, and, therefore to, to society.

•

According to her, nursing is based on an art and science that mould the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people , sick or well, cope with their health needs.

•

As a comprehensive service ,nursing includes; •

Recognizing the nursing problems of the patient

•

Deciding the appropriate course of action to take in terms of relevant nursing principles

•

Providing continuous care of the individuals total needs

•

Providing continuous care to relieve pain and discomfort and provide immediate security for the individual

•

Adjusting the total nursing care plan to meet the patient’s individual needs

•

Helping the individual to become more self directing in attaining or maintaining a healthy state of mind & body

•

Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations

•

8)Helping the individual to adjust to his limitations and emotional problems

•

9) Working with allied health professions in planning for optimum health on local, state, national and international levels

•

10) Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet the health needs of people

•

These original premises have undergone an evolutionary process. As result, in 1973, the item 3, - “providing continuous care of the individual’s total health needs” was eliminated.

•

From these premises, Abdellah’s theory was derived.

PHILOSOPHICAL UNDERPINNINGS OF THE THEORY •

Abdellah’s patient-centred approach to nursing was developed inductively from her practice and is considered a human needs theory.

•

The theory was created to assist with nursing education and is most applicable to the education of nurses.

•

Although it was intended to guide care of those in the hospital, it also has relevance for nursing care in community settings.

MAJOR ASSUMPTIONS, CONCEPTS & RELATIONSHIPS 1. The language of Abdellah’s framework is readable and clear. 2. Consistent with the decade in which she was writing, she uses the term ‘she’ for nurses, ‘he’ for doctors and patients, and refers to the object of nursing as ‘patient’ rather than client or consumer. 3. She referred to Nursing diagnosis during a time when nurses were taught that diagnosis was not a nurses’ prerogative. 4. Assumptions were related to 1. change and anticipated changes that affect nursing; 2. The need to appreciate the interconnectedness of social enterprises and social problems; 3. the impact of problems such as poverty, racism, pollution, education, and so forth on health care delivery; 4. changing nursing education 5. continuing education for professional nurses 6. development of nursing leaders from under reserved groups 5. Abdellah and colleagues developed a list of 21 nursing problems.

6. They also identified 10 steps to identify the client’s problems 7. 11 nursing skills to be used in developing a treatment typology 10 steps to identify the client’s problems 1. Learn to know the patient 2. Sort out relevant and significant data 3. Make generalizations about available data in relation to similar nursing problems presented by other patients 4. Identify the therapeutic plan 5. Test generalizations with the patient and make additional generalizations 6. Validate the patient’s conclusions about his nursing problems 7. Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his behavior 8. Explore the patient’s and family’s reaction to the therapeutic plan and involve them in the plan 9. Identify how the nurses feels about the patient’s nursing problems 10. Discuss and develop a comprehensive nursing care plan 11 nursing skills 1. Observation of health status 2. Skills of communication 3. Application of knowledge 4. Teaching of patients and families 5. Planning and organization of work 6. Use of resource materials 7. Use of personnel resources 8. Problem-solving 9. Direction of work of others 10. Therapeutic use of the self 11. Nursing procedures The twenty one nursing problems Three major categories •

Physical, sociological, and emotional needs of clients

•

Types of interpersonal relationships between the nurse and patient

•

Common elements of client care

21 NURSING PROBLEMS BASIC TO ALL PATIENTS •

To maintain good hygiene and physical comfort

•

To promote optimal activity: exercise, rest and sleep

•

To promote safety through the prevention of accidents, injury, or other trauma and through the prevention of the spread of infection

•

To maintain good body mechanics and prevent and correct deformities

SUSTENAL CARE NEEDS •

To facilitate the maintenance of a supply of oxygen to all body cells

•

To facilitate the maintenance of nutrition of all body cells

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To facilitate the maintenance of elimination

•

To facilitate the maintenance of fluid and electrolyte balance

•

To recognize the physiological responses of the body to disease conditions

•

To facilitate the maintenance of regulatory mechanisms and functions

•

To facilitate the maintenance of sensory function

REMEDIAL CARE NEEDS •

To identify and accept positive and negative expressions, feelings, and reactions

•

To identify and accept the interrelatedness of emotions and organic illness

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To facilitate the maintenance of effective verbal and non verbal communication

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To promote the development of productive interpersonal relationships

•

To facilitate progress toward achievement of personal spiritual goals

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To create and / or maintain a therapeutic environment

•

To facilitate awareness of self as an individual with varying physical , emotional, and developmental needs

RESTORATIVE CARE NEEDS •

To accept the optimum possible goals in the light of limitations, physical and emotional

•

To use community resources as an aid in resolving problems arising from illness

•

To understand the role of social problems as influencing factors in the case of illness

Abdellah's 21 problems are actually a model describing the "arenas" or concerns of nursing, rather than a theory describing relationships among phenomena. In this way, the theory distinguished the practice of nursing, with a focus on the 21 nursing problems, from the practice of medicine, with a focus on disease and cure. ABDELLAH’S THEORY AND NURSING •

Although Abdellah’s writings are not specific as to a theoretical statement, such a statement can be derived by using her three major concepts of health, nursing problems, and problem solving. Abdellah’s theory would state that nursing is the use of the problem solving approach with key nursing problems related to health needs of people. Such a statement maintains problem solving as the vehicle for the nursing problems as the client is moved toward health – the outcome

NURSING

•

Acc to her, nursing is based on an art and science that mould the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people, sick or well, cope with their health needs.

HEALTH •

Health is a dynamic pattern of functioning whereby there is a continued interaction with internal and external forces that results in the optimum use of necessary resources that serve to minimize vulnerabilities

NURSING PROBLEMS •

Nursing problem presented by a client is a condition faced by the client or client’s family that the nurse through the performance of professional functions can assist them to meet . The problem can be either an overt or covert nursing problem.

•

An overt nursing problem is an apparent condition faced by the patient or family, which the nurse can assist him or them to meet through the performance of her professional functions.

•

The covert nursing problem is a concealed or hidden condition faced, by the patient or family, which the nurse can assist him or them to meet through the performance of her professional functions

•

In her attempt to bring nursing practice into its proper relationship with restorative and preventive measures for meeting total client needs, she seems to swing the pendulum to the opposite pole, from the disease orientation to nursing orientation, while leaving the client somewhere in the middle.

PROBLEM SOLVING •

The problem solving process involves identifying the problem, selecting pertinent data, formulating hypothesis, testing hypothesis through the collection of data, and revising hypothesis where necessary on the basis of conclusions obtained from the data.

COMPARISON WITH OTHER THEORIES MASLOW

HENDERSON

ABDELLAH

1. Breathe normally 2. Eat and drink adequately Physiological needs 3. Eliminate by all avenues of elimination 4. Move & maintain desirable posture 5. Sleep & rest 6. Select suitable clothing

1. To facilitate the maintenance of a supply of oxygen to all body cells 2. To facilitate the maintenance of nutrition of all body cells 3. To facilitate the maintenance of fluid and electrolyte balance 4. To facilitate the maintenance of elimination 5. To maintain good body mechanics and prevent and correct deformities

7. Maintain body temperature

6. To promote optimal activity: exercise , rest and sleep 8. Keep body clean and7. To facilitate the maintenance well groomed & of regulatory mechanisms protect the and functions integument 8. To maintain good hygiene and physical comfort 9. Safety needs

Avoid environmental dangers & avoid injuring others

9. To promote safety through the prevention of accidents, injury, or other trauma and through the prevention of the spread of infection 10. To facilitate the maintenance of sensory function

Belongingness10. Communicate with 11.To facilitate the maintenance & love needs others of effective verbal and non verbal communication 11. Worship according to faith

12. To promote the development of productive interpersonal relationships 13. To facilitate progress toward achievement of personal spiritual goals

Esteem needs 12.

Work at something14. To accept the optimum providing a sense of possible goals in the light of accomplishment limitations, physical and emotional 13. Play or participate in various forms of 15. To recognize the recreation physiological responses of the body to disease 14. Learn, discover, or conditions satisfy curiosity 16.

To identify and accept positive and negative expressions, feelings, and reactions

17.

To identify and accept the interrelatedness of emotions and organic illness

18.

To create and / or maintain a therapeutic environment

19.

To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs

20.

To use community resources as an aid in resolving problems arising from illness

21.

To understand the role of social problems as influencing factors in the case of illness

Self actualization needs ABDELLAH’S THEORY AND THE FOUR MAJOR CONCEPTS Nursing •

Nursing is a helping profession. In Abdellah’s model, nursing care is doing something to or for the person or providing information to the person with the goals of meeting needs, increasing or restoring self-help ability, or alleviating impairment.

•

Nursing is broadly grouped into the 21 problem areas to guide care and promote use of nursing judgment.

•

She considers nursing to be comprehensive service that is based on art and science and aims to help people, sick or well, cope with their health needs.

Person

•

Abdellah describes people as having physical, emotional, and sociological needs. These needs may overt, consisting of largely physical needs, or covert, such as emotional and social needs.

•

Patient is described as the only justification for the existence of nursing.

•

Individuals (and families) are the recipients of nursing

•

Health, or achieving of it, is the purpose of nursing services.

Health •

In Patient –Centered Approaches to Nursing, Abdellah describes health as a state mutually exclusive of illness.

•

Although Abdellah does not give a definition of health, she speaks to “total health needs” and “a healthy state of mind and body” in her description of nursing as a comprehensive service.

Society/Environment •

Society is included in “planning for optimum health on local, state, national, and international levels”. However, as she further delineated her ideas, the focus of nursing service is clearly the individual.

•

The environment is the home or community from which patient comes.

ABDELLAH’S WORK AND CHARACTERISTICS OF A THEORY Characteristic1 •

Abdellah’s theory has interrelated the concepts of health, nursing problems, and problem solving as she attempts to create a different way of viewing nursing phenomenon

•

The result was the statement that nursing is the use of problem solving approach with key nursing problems related to health needs of people.

Characteristic2 •

Problem solving is an activity that is inherently logical in nature

Characteristic 3 •

Framework seems to focus quite heavily on nursing practice and individuals. This somewhat limit the ability to generalize although the problem solving approach is readily generalizable to clients with specific health needs and specific nursing problems

Characteristic4 •

One of the most important questions that arise when considering her work is the role of client within the framework. This question could generate hypothesis for testing and thus demonstrates the ability of Abdellah’s work to generate hypothesis for testing

Characteristic5 •

The results of testing such hypothesis would contribute to the general body of nursing knowledge

Characteristic6 •

Abdellah’s problem solving approach can easily be used by practitioners to guide various activities within their practice. This is true when considering

nursing practice that deals with clients who have specific needs and specific nursing problems Characteristic7 •

Although consistency with other theories exist, many questions remain unanswered

USE OF 21 PROBLEMS IN THE NURSING PROCESS ASSESSMENT PHASE •

Nursing problems provide guidelines for the collection of data.

•

A principle underlying the problem solving approach is that for each identified problem, pertinent data are collected.

•

The overt or covert nature of the problems necessitates a direct or indirect approach, respectively.

NURSING DIAGNOSIS •

The results of data collection would determine the client’s specific overt or covert problems.

•

These specific problems would be grouped under one or more of the broader nursing problems.

•

This step is consistent with that involved in nursing diagnosis

PLANNING PHASE •

The statements of nursing problems most closely resemble goal statements. Therefore, once the problem has been diagnosed, the goals have been established.

•

Given that these problems are called nursing problems, then it becomes reasonable to conclude that these goals are basically nursing goals.

IMPLEMENTATION •

Using the goals as the framework, a plan is developed and appropriate nursing interventions are determined.

EVALUATION •

According to the American Nurses’ Association Standards of Nursing Practice, the plan is evaluated in terms of the client’s progress or lack of progress toward the achievement of the stated goals.

•

This would be extremely difficult if not impossible to do for Abdellah’s nursing problem approach since it has been determined that the goals are nursing goals, not the client goals.

•

Thus, the most appropriate evaluation would be the nurse progress or lack of progress toward the achievement of the stated goals.

AN illustration of the implementation of Abdellah’s framework in Ryan’s care Consider a case of Ryan who experienced severe crushing chest pain ‘shortness of breath, tachycardia and profuse diaphoresis •

Stage of illness is basic to care

•

Selected Abdellah nursing problem

•

To maintain good hygiene and personal comfort

•

Classification and approach

•

Overt problem of pain; Direct and indirect method

•

Selected Nursing Interventions

•

administer oxygen

•

elevate headrest

•

reposition client

•

administer prescribed analgesic

•

remain with client

•

Criterion measure- Amount of pain

CONCEPT OF PROGRESSIVE PATIENT CARE 1. PPC is defined as better patient care through the organization of hospital facilities, services and staff around the changing medical and nursing needs of the patient 2. PPC is tailoring of hospital services to meet patients needs 3. PPC is caring for the right patient in the right bed with the right services at the right time 4. PPC is systematic classification of patients based on their medical needs Elements of PPC •

Intensive care o

•

Intermediate care o

•

Ambulatory patients who are convalescencing or require diagnosis or therapy may be cared for in this unit

Long term care unit o

•

Patients assigned to this unit are both the moderately ill and those for whom the treatment can only be palliative

Self care o

•

Critically and seriously ill patients requiring highly skilled nursing care, close and frequent if not constant, nursing observation are assigned to the ICU. One patient in an ICU requires at least three nurses to observe him in 24 hrs

This unit will provide services to certain patients now cared for in the general hospital, in nursing homes, or in their own homes and who would benefit by care in a hospital environment to achieve its maximum potential

Home care o

This programme makes it possible to extend needed services to the patient after he leaves the hospital and returns to his home in the community

Benefits of PPC PATIENT

•

better attention

•

better adjustment

•

minimized problems

• •

life saving care constant medical and nursing care

PHYSICIAN •

assuring best nursing care

•

drugs and equipments at hand

•

orders carried out effectively

•

better clinical an team service

HOSPITAL •

effective and efficient use of staff

•

improved public image

NURSING PERSONNEL •

individual skills can be used

•

more time with patient

•

helping pt. and family to solve problems

•

job satisfaction

•

in-service education

COMMUNITY •

continuity with hospital services

•

minimize the need of hospitalization

Implications of PPC for nursing education •

Many nurse educators feel that the PPC hospital where all five phases of care are available can provide clinical experience in which the nurse can learn to solve basic nursing problems in meeting patients’ needs.

•

The three month assignment of professional nurses may no longer be realistic in such a setting.

Organization of hospital and community services based on patients needs •

In the intensive care unit, the critically ill patients are concentrated regardless of diagnosis.

•

These patients are under the constant audio-visual observation of the nurse, with life saving techniques and equipment immediately available

•

In the intermediate care unit are concentrated patients requiring a moderate amount of nursing care, not of an emergency nature, who are ambulatory for short periods, and who are beginning to participate in he planning of their own care

•

The self-care unit provides for patients who are physically self-sufficient and require diagnostic and convalescent care in hotel-type

accommodations. This unit serves as a link between the hospital and the home. •

In the long-term care unit are concentrated patients requiring prolonged care. The grouping of such patients will permit staffing patterns that are less costly

•

Home care, the fifth element of progressive patient care, extends hospital services into the home to assist the physician in the care of his patients

USEFULNESS •

The patient centered approach was constructed to be useful to nursing practice, with impetus for it being nursing education.

•

Abdellah’s publications on nursing education began with her dissertation; her interest in education for nurses continues into the present.

•

Cont…

•

Abdellah has also published on nursing, nursing research, and public policy related to nursing in several international publications. She has been a strong advocate for improving nursing practice through nursing research

VALUE IN EXTENDING NURSING SCIENCE •

It helped to bring structure and organization to what was often a disorganized collection of lectures and experiences.

•

She categorized nursing problems based on the individual’s needs and developed developed a typology of nursing treatment and nursing skills..

NURSING RESEARCH •

She has been a leader in nursing research and has over one hundred publications related to nursing care, education for advanced practice in nursing and nursing research.

LIMITATIONS •

Very strong nursing centered

•

Little emphasis on what the client is to achieve

orientation

•

Her framework is inconsistent with the concept of holism

•

Potential problems might be overlooked

SUMMARY •

•

Using Abdellah’s concepts of health, nursing problems, and problem solving, the theoretical statement of nursing that can be derived is the use of the problem solving approach with key nursing problems related to health needs of people. From this framework, 21 nursing problems were developed

CONCLUSIONS •

Abdellah’s theory provides a basis for determining and organizing nursing care. The problems also provide a basis for organizing appropriate nursing strategies.

•

It is anticipated that by solving the nursing problems, the client would be moved toward health. The nurse’s philosophical frame of reference would

determine whether this theory and the 21 nursing problems could be implemented in practice. REFERENCES 1. George Julia B. Nursing theories: The base of professional nursing practice 3rd edition. Norwalk, CN: Appleton and Lange; 1990. 2. Abdellah, F.G. The federal role in nursing education. Nursing outlook. 1987, 35(5),224-225. 3. Abdellah, F.G. Public policy impacting on nursing care of older adults .In E.M. Baines (Ed.), perspectives on gerontological nursing. Newbury, CA: Sage publications. 1991. 4. Abdellah, F.G., & Levine, E. Preparing nursing research for the 21st century. New York: Springer. 1994. 5. Abdellah, F.G., Beland, I.L., Martin, A., & Matheney, R.V. Patient-centered approaches to nursing (2nd ed.). New York: Mac Millan. 1968. 6.

Abdellah, F.G. Evolution of nursing as a profession: perspective on manpower development. International Nursing Review, 1972); 19, 3..

7.

Abdellah, F.G.). The nature of nursing science. In L.H. Nicholl (Ed.), perspectives on nursing theory. Boston: Little, Brown, 1986.

JEAN WATSON'S PHILOSOPHY OF NURSING Introduction •

Born: West Virginia

•

Educated: BSN, University of Colorado, 1964, MS, University of Colorado, 1966, PhD, University of Colorado, 1973

•

Dr. Jean Watson is Distinguished Professor of Nursing and holds an endowed Chair in Caring Science at the University of Colorado Health Sciences Center.

•

She is founder of the original Center for Human Caring in Colorado and is a Fellow of the American Academy of Nursing. She previously served as Dean of Nursing at the University Health Sciences Center and is a Past President of the National League for Nursing

•

Dr. Watson has earned undergraduate and graduate degrees in nursing and psychiatric-mental health nursing and holds her PhD in educational psychology and counseling.

•

She is a widely published author and recipient of several awards and honors, including an international Kellogg Fellowship in Australia, a Fulbright Research Award in Sweden and six (6) Honorary Doctoral Degrees, including 3 International Honorary Doctorates (Sweden, United Kingdom, Quebec, Canada).

•

Her research has been in the area of human caring and loss.

•

The foundation of Jean Watson’s theory of nursing was published in 1979 in nursing: “The philosophy and science of caring”

•

In 1988, her theory was published in “nursing: human science and human care”.

•

Watson believes that the main focus in nursing is on carative factors. She believes that for nurses to develop humanistic philosophies and value system, a strong liberal arts background is necessary.

•

This philosophy and value system provide a solid foundation for the science of caring. A humanistic value system thus under grids her construction of the science of caring.

•

She asserts that the caring stance that nursing has always held is being threatened by the tasks and technology demands of the curative factors.

The seven assumptions Watson proposes even assumptions about the science of caring. The basic assumptions are: 1. Caring can be effectively demonstrated and practiced only interpersonally. 2. Caring consists of carative factors that result in the satisfaction of certain human needs. 3. Effective caring promotes health and individual or family growth. 4. Caring responses accept person not only as he or she is now but as what he or she may become. 5. A caring environment is one that offers the development of potential while allowing the person to choose the best action for himself or herself at a given point in time. 6. Caring is more “ healthogenic” than is curing. A science of caring is complementary to the science of curing. 7. The practice of caring is central to nursing. The ten primary carative factors The structure for the science of caring is built upon ten carative factors. These are:

•

The formation of a humanistic- altruistic system of values.

•

The installation of faith-hope.

•

The cultivation of sensitivity to one’s self and to others.

•

The development of a helping-trust relationship

•

The promotion and acceptance of the expression of positive and negative feelings.

•

The systematic use of the scientific problem-solving method for decision making

•

The promotion of interpersonal teaching-learning.

•

The provision for a supportive, protective and /or corrective mental, physical, socio-cultural and spiritual environment.

•

Assistance with the gratification of human needs.

•

The allowance for existential-phenomenological forces.

The first three carative factors form the “philosophical foundation” for the science of caring. The remaining seven carative factors spring from the foundation laid by these first three. 1. The formation of a humanistic- altruistic system of values •

Begins developmentally at an early age with values shared with the parents.

•

Mediated through ones own life experiences, the learning one gains and exposure to the humanities.

•

Is perceived as necessary to the nurse’s own maturation which then promotes altruistic behavior towards others.

2. Faith-hope •

Is essential to both the carative and the curative processes.

•

When modern science has nothing further to offer the person, the nurse can continue to use faith-hope to provide a sense of well-being through beliefs which are meaningful to the individual.

3. Cultivation of sensitivity to one’s self and to others •

Explores the need of the nurse to begin to feel an emotion as it presents itself.

•

Development of one’s own feeling is needed to interact genuinely and sensitively with others.

•

Striving to become sensitive, makes the nurse more authentic, which encourages self-growth and self-actualization, in both the nurse and those with whom the nurse interacts.

•

The nurses promote health and higher level functioning only when they form person to person relationship.

4. Establishing a helping-trust relationship •

Strongest tool is the mode of communication, which establishes rapport and caring.

•

She has defined the characteristics needed to in the helping-trust relationship. These are:

Congruence Empathy Warmth •

Communication includes verbal, nonverbal and listening in a manner which connotes empathetic understanding.

5. The expression of feelings, both positive and negative •

According to Watson, “feelings alter thoughts and behavior, and they need to be considered and allowed for in a caring relationship”.

•

According to her such expression improves one’s level of awareness.

•

Awareness of the feelings helps to understand the behavior it engenders.

6. The systematic use of the scientific problem-solving method for decision making •

According to Watson, the scientific problem- solving method is the only method that allows for control and prediction, and that permits selfcorrection.

•

She also values the relative nature of nursing and supports the need to examine and develop the other methods of knowing to provide an holistic perspective.

•

The science of caring should not be always neutral and objective.

7. Promotion of interpersonal teaching-learning •

The caring nurse must focus on the learning process as much as the teaching process.

•

Understanding the person’s perception of the situation assist the nurse to prepare a cognitive plan.

8. Provision for a supportive, protective and /or corrective mental, physical, socio-cultural and spiritual environment •

Watson divides these into eternal and internal variables, which the nurse manipulates in order to provide support and protection for the person’s mental and physical well-being.

•

The external and internal environments are interdependent.

•

Watson suggests that the nurse also must provide comfort, privacy and safety as a part of this carative factor.

9. Assistance with the gratification of human needs •

It is grounded in a hierarchy of need similar to that of the Maslow’s.

•

She has created a hierarchy which she believes is relevant to the science of caring in nursing.

•

According to her each need is equally important for quality nursing care and the promotion of optimal health. All the needs deserve to be attended to and valued.

Watson’s ordering of needs •

Lower order needs (biophysical needs) o

The need for food and fluid

•

•

•

o

The need for elimination

o

The need for ventilation

Lower order needs (psychophysical needs) o

The need for activity-inactivity

o

The need for sexuality

Watson’s ordering of needs o

Higher order needs (psychosocial needs)

o

The need for achievement

o

The need for affiliation

o

Higher order need (intrapersonal-interpersonal need)

o

The need for self-actualization

Research findings have established a correlation between emotional distress and illness. According to Watson, the current thinking of holistic care emphasizes that: o Factors of the etiological component interact and produce change through complex neuro-physiological and neuro-chemical pathways o Each psychological function has a physiological correlate o

Each physiological component has a psychological correlate

Example: Bulemia, anorexia and gastro-intestinal ulcers are a just few of the disorders that indicate a complex interaction between the physiological and psychological. 10. Allowance for existential-phenomenological forces • Phenomenology is a way of understanding people from the way things appear to them, from their frame of reference. • Existential psychology is the study of human existence using phenomenological analysis. • This factor helps the nurse to reconcile and mediate the incongruity of viewing the person holistically while at the same time attending to the hierarchical ordering of needs. • Thus the nurse assists the person to find the strength or courage to confront life or death. Watson’s theory and the four major concepts 1. Human being • She adopts a view of the human being as: “….. a valued person in and of him or herself to be cared for, respected, nurtured, understood and assisted; in general a philosophical view of a person as a fully functional integrated self. He, human is viewed as greater than and different from, the sum of his or her parts”. 2. Health • Watson believes that there are other factors that are needed to be included in the WHO definition of health. She adds the following three elements: • A high level of overall physical, mental and social functioning

3.

•

A general adaptive-maintenance level of daily functioning

•

The absence of illness (or the presence of efforts that leads its absence) Environment/society

•

According to Watson caring (and nursing) has existed in every society. A caring attitude is not transmitted from generation to generation. It is transmitted by the culture of the profession as a unique way of coping with its environment. 4. Nursing • According to Watson “ nursing is concerned with promoting health, preventing illness, caring for the sick and restoring health”. • It focuses on health promotion and treatment of disease. She believes that holistic health care is central to the practice of caring in nursing. • She defines nursing as….. “A human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human transactions”. Watson’s theory and nursing process • Watson points out that nursing process contains the same steps as the scientific research process. They both try to solve a problem. Both provide a framework for decision making. Watson elaborates the two processes as: 1. Assessment • Involves observation, identification and review of the problem; use of applicable knowledge in literature. • Also includes conceptual knowledge for the formulation and conceptualization of framework. • Includes the formulation of hypothesis; defining variables that will be examined in solving the problem. 2. Plan • It helps to determine how variables would be examined or measured; includes a conceptual approach or design for problem solving. It determines what data would be collected and how on whom. 3. Intervention • It is the direct action and implementation of the plan. • 4.

It includes the collection of the data.

Evaluation Analysis of the data as well as the examination of the effects of interventions based on the data. Includes the interpretation of the results, the degree to which positive outcome has occurred and whether the result can be generalized. • It may also generate additional hypothesis or may even lead to the generation of a nursing theory. Watson’s work and the characteristic of a theory • According to Watson, “a theory is an imaginative grouping of knowledge, ideas and experiences that are represented symbolically and seek to illuminate a given phenomenon” • She views nursing as, “….both a human science and an art and as such it cannot be considered qualitatively continuous with traditional, reductionistic, scientific methodology”. •

•

•

She suggests that nursing might want to develop its own science that would not be related to the traditional sciences but rather would develop its own concepts, relationships and methodology. Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon The basic assumptions for the science of caring in nursing and the ten carative factors that form the structure for that concept is unique in Watson’s theory. She describes caring in both philosophical and scientific terms.

•

Watson also indicates that needs are interrelated.

• •

•

The science of caring suggests that the nurse recognize and assist with each of the interrelated needs in order to reach the highest order need of selfactualization. Theories must be logical in nature • Watson’s work is logical in that the factors are based on broad assumptions which provide a supportive framework. • With these carative factors she delineates nursing from other professions •

These carative factors are logically derived from the assumptions and related to he hierarchy of needs. Theories should be relatively simple yet generalizable • The theory is relatively simple as it does not use theories from other disciplines that are familiar to nursing. • The theory is simple relatively but the fact that it de-emphasizes the pathophysiological for the psychosocial diminishes its ability to be generalizable. • She discusses this in the preface of her book when she speaks of the “trim” and the “core” of nursing. • She defines trim as the clinical focus, the procedure and the techniques. •

The core of the nursing is that which is intrinsic to the nurse-client interaction that produces a therapeutic result. Core mechanisms are the carative factors. Theories can be the basis for hypotheses that can be tested • Watson’s theory is based on phenomenological studies that generally ask questions rather than state hypotheses. Its purpose is to describe the phenomena, to analyze and to gain an understanding. • Theories contribute to and assist in increasing the general body within the discipline through research implemented to validate them • According to Watson the best method to test this theory is through field study. • An example is her work in the area of loss and caring that took place in Cundeelee, Western Australia and involved a tribe of aborigines. Theories can be utilized by practitioners to guide and improve their practice • Watson’s work can be used to guide and improve practice. •

•

It can provide the nurse with the most satisfying aspects of practice and can provide the client with the holistic care so necessary for human growth and development. Theories must be consistent with other validated theories, laws and principles but will leave open unanswered questions that need to be investigated

•

Watson’s work is supported by the theoretical work of numerous humanists, philosophers, developmentalists and psychologists. • She clearly designates the theories of stress, development, communication, teaching-learning, humanistic psychology and existential phenomenology which provide the foundation for the science of caring. Strengths • Besides assisting in providing the quality of care that client ought to receive, it also provides the soul satisfying care for which many nurses enter the profession. As the science of caring ranges from the biophysical through the intrapersonal, each nurse becomes an active coparticipant in the client’s struggle towards self-actualization. • The client is placed in the context of the family, the community and the culture. • It places the client as the focus of practice rather than the technology. Limitations • Given the acuity of illness that leads to hospitalization, the short length stay , and the increasing complex technology, such quality of care may be deemed impossible to give in the hospital. • While Watson acknowledges the need for biophysical base to nursing, this area receives little attention in her writings. • The ten caratiive factors primarily delineate the psychosocial needs of the person. • While the carative factors have a sound foundation based on other disciplines, they need further research in nursing to demonstrate their application to practice. Summary • Watson’s theory •

Its seven assumptions

•

The ten carative factors

•

Watson’s theory and the four major concepts

•

Watson’s theory and the nursing process

•

Watson’s work and the characteristic’s of the theory

•

Strengths

•

Limitations

Research related to Watson’s theory • Saint Joseph Hospital in Orange, California has selected Jean Watson’s theory of human caring as the framework base for nursing practice. • The effectiveness of Watson's Caring Model on the quality of life and blood pressure of patients with hypertension. J Adv Nurs. 2003 Jan;41(2):130-9. • This study demonstrated a relationship between care given according to Watson's Caring model and increased quality of life of the patients with hypertension. Further, in those patients for whom the caring model was practised, there was a relationship between the Caring model and a decrease in patient's blood pressure. The Watson Caring Model is recommended as a guide to nursing patients with hypertension, as one means of decreasing blood pressure and increase in quality of life.

•

Martin, L. S. (1991). Using Watson’s theory to explore the dimensions of adult polycystic kidney disease . ANNA Journal, 18, 403-406 . • Mullaney, J. A. B. (2000). The lived experience of using Watson’s actual caring occasions to treat depressed women . Journal of Holistic Nursing, 18(2), 129-142 • Martin, L. S. (1991). Using Watson’s theory to explore the dimensions of adult polycystic kidney disease . ANNA Journal, 18, 403-406 Conclusion 1. Watson provides many useful concepts for the practice of nursing. 2. She ties together many theories commonly used in nursing education and does so in a manner helpful to practioners of the art and science of nursing. 3. The detailed descriptions of the carative factors can give guidance to those who wish to employ them in practice or research. 4. Using her theory can add a dimension to practice that is both satisfying and challenging. Reference • Timber BK. Fundamental skills and concepts in Patient Care, 7th edition, LWW, N • George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange. • Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins. • Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott. • Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott. • Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book. • Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-15 • Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):225 • Cheng MY. Using King's Goal Attainment Theory to facilitate drug compliance in a psychiatric patient. Hu Li Za Zhi. 2006 Jun;53(3):90-7. • Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice, 2nd edition, Thomson, NY, 2002.

JOHNSON’S BEHAVIOUR SYSTEM MODEL Introduction • Dorothy E. Johnson was born August 21, 1919, in Savannah, Georgia. •

B. S. N. from Vanderbilt University in Nashville, Tennessee, in 1942; and her M.P.H. from Harvard University in Boston in 1948. • From 1949 until her retirement in 1978 she was an assistant professor of pediatric nursing, an associate professor of nursing, and a professor of nursing at the University of California in Los Angeles. • Dorothy Johnson has had an influence on nursing through her publications since the 1950s. Throughout her career, Johnson has stressed the importance of research-based knowledge about the effect of nursing care on clients. Johnson’s behavior system model • In 1968 Dorothy first proposed her model of nursing care as fostering of “the efficient and effective behavioral functioning in the patient to prevent illness". • She also stated that nursing was “concerned with man as an integrated whole and this is the specific knowledge of order we require”. • In 1980 Johnson published her conceptualization of “behavioral system of model for nursing” this is the first work of Dorothy that explicates her definitions of the behavioral system model. Definition of nursing She defined nursing as “an external regulatory force which acts to preserve the organization and integration of the patients behaviors at an optimum level under those conditions in which the behaviors constitutes a threat to the physical or social health, or in which illness is found” Based on this definition there are four goals of nursing are to assist the patient: • Whose behavior commensurate with social demands. •

Who is able to modify his behavior in ways that it supports biological imperatives • Who is able to benefit to the fullest extent during illness from the physicians knowledge and skill. • Whose behavior does not give evidence of unnecessary trauma as a consequence of illness Assumptions of behavioral system model There are several layers of assumptions that Johnson makes in the development of conceptualization of the behavioral system model (Johnson was influenced by Buckley ,Chin and Rapport) there are 4 assumptions of system:

1.

First assumption states that there is “organization, interaction, interdependency and integration of the parts and elements of behaviors that go to make up The system ” 2. A system “tends to achieve a balance among the various forces operating within and upon it', and that man strive continually to maintain a behavioral system balance and steady state by more or less automatic adjustments and adaptations to the natural forces impinging upon him.” 3. A behavioral system, which both requires and results in some degree of regularity and constancy in behavior, is essential to man that is to say, it is functionally significant in that it serves a useful purpose, both in social life and for the individual. 4. The final assumption states “system balance reflects adjustments and adaptations that are successful in some way and to some degree.”

1. The integration of these assumptions provides the behavioral system with the pattern of action to form “an organized and integrated functional unit that determines and limits the interaction between the person and his environment and establishes the relation of the person to the objects, events and situations in his environment.

2. The integration of these assumptions provides the behavioral system with the pattern of action to form “an organized and integrated functional unit that determines and limits the interaction between the person and his environment and establishes the relation of the person to the objects, events and situations in his environment.” Assumptions about structure and function of each subsystem 2. “from the form the behavior takes and the consequences it achieves can be inferred what “drive” has been stimulated or what “goal” is being sought” 3. Each individual has a “predisposition to act with reference to the goal, in certain ways rather than the other ways”. This predisposition is called as “set”. 4. Each subsystem has a repertoire of choices or “scope of action” 1. The fourth assumption is that it produce “observable outcome” that is the individual’s behavior. Each subsystem has three functional requirements 2. System must be “protected" from noxious influences with which system cannot cope”. 3. Each subsystem must be “nurtured” through the input of appropriate supplies from the environment. 1. Each subsystem must be “stimulated” for use to enhance growth and prevent stagnation Johnson believes each individual has patterned, purposeful, repetitive ways of acting that comprise a behavioral system specific to that individual. These actions and behaviors form an organized and integrated functional unit that determines and limits the interaction between the person and his environment and establishes the relationship of the person to the objects event situations in the environment. These behaviors are “orderly, purposeful and predictable and sufficiently stable and recurrent to be amenable to description and explanation” Johnson’s Behavioral Subsystem

2. Attachment or affiliative subsystem: “social inclusion intimacy and the formation and attachment of a strong social bond.”

3. Dependency subsystem: “approval, attention or recognition and physical assistance”

4. Ingestive subsystem: “the emphasis is on the meaning and structures of the social events surrounding the occasion when the food is eaten”

5. Eliminative subsystem: “human cultures have defined different socially acceptable behaviors for excretion of waste ,but the existence of such a pattern remains different from culture to Culture.”

6. Sexual subsystem:" both biological and social factor affect the behavior in the sexual subsystem”

7. Aggressive subsystem:" it relates to the behaviors concerned with

protection and self preservation Johnson views aggressive subsystem as one that generates defensive response from the individual when life or territory is being threatened”

1. Achievement subsystem:” provokes behavior that attempt to control

the environment intellectual, physical, creative, mechanical and social skills achievement are some of the areas that Johnson recognizes". Representation of Johnson's Model Goal ----Set --Choice of Behavior --Behavior Affiliation Dependency Sexuality Aggression Elimination Ingestion Achievement The four major concepts

2. Johnson views “human being” as having two major systems, the biological system and the behavioral system. It is role of the medicine to focus on biological system where as Nursling's focus is the behavioral system.

3. “Society” relates to the environment on which the individual exists.

According to Johnson an individual’s behavior is influenced by the events in the environment

4. “Health” is a purposeful adaptive response, physically mentally, emotionally, and socially to internal and external stimuli in order to maintain stability and comfort.

1. “Nursing” has a primary goal that is to foster equilibrium within the

individual .she stated that nursing is concerned with the organized and integrated whole, but that the major focus is on maintaining a balance in the Behavior system when illness occurs in an individual. Nursing process Assessment Grubbs developed an assessment tool based on Johnson’s seven subsystems plus a subsystem she labeled as restorative which focused on activities of daily living .An assessment based on behavioral model does not easily permit the nurse to gather detailed information about the biological systems:

1. Affiliation 2. Dependency 3. Sexuality 4. Aggression 5. Elimination 6. Ingestion 7. Achievement 8. Restorative Diagnosis Diagnosis tends to be general to the system than specific to the problem. Grubb has proposed 4 categories of nursing diagnosis derived from Johnson's behavioral system model: 1. Insufficiency 2. Discrepancy 3. Incompatibility 4. Dominance Planning and implementation Implementation of the nursing care related to the diagnosis may be difficult because of lack of clients input in to the plan. the plan will focus on nurses actions to modify clients behavior, these plan than have a goal ,to bring about homeostasis in a subsystem, based on nursing assessment of the individuals drive, set behavior, repertoire, and observable behavior. The plan may include protection, nurturance or stimulation of the identified subsystem. Evaluation Evaluation is based on the attainment of a goal of balance in the identified subsystems. If the baseline data are available for an individual, the nurse may have goal for the individual to return to the baseline behavior. If the alterations in the behavior that are planned do occur, the nurse should be able to observe the return to the previous behavior patterns. Johnson's behavioral model with the nursing process is a nurse centered activity, with the nurse determining the clients needs and state behavior appropriate for that need. Situation John Smith, 6 weeks brought into the clinic for a routine check-up. He presents with no weight gain since his check up at the age of 2 weeks .His mother stated she feeds him but he does not seem to eat much. He sleeps 4to 5 hour between the feedings. His mother holds him in her arms without trunk to trunk contact. As the assessment is made the nurse notes that Mrs. Smith never looks at Johnny and never speaks to him. She stated he was a planned baby but that she never realized how much work a baby could be. She says, her mother told her she was not a good mother because John is not gaining weight like he should. She states she had not called the nurse when she knew John was not gaining weight because she thought nurse would think she was a bad mother just like her own mother thought she was a bad mother. Assessment 1. Affiliative subsystem between mother and John. 2. Dependency subsystem between mother and John 3. Affiliative subsystem between Mrs.Smith and her mother. 4. Insufficiency ingesion subsystem.

Diagnosis 1. Insufficient development of the affiliative subsystem. 2. Insufficient development of the dependency subsystem Planning and implementation 1. Increasing mother’s awareness of the baby’s clues. 2. Assisting her to talk with the baby. 3. Teach her to bring a bond between her and the baby by touch, pat and cuddles etc. Evaluation 1. Johnny's weight gain or weight loss will be carefully assessed. 2. The –infant interaction could be reassessed, using the nursing child assessment feeding scale. 3. The interaction of Mrs. Smith with her mother. Johnson’s and Characteristics of a theory 1. Interrelate concepts to create a different way of viewing a phenomenon. 2. Theories must be logical in nature. 3. Theories must be simple yet generalizable 4. Theories can be bases of hypothesis that can be tested. 5. Theories contribute to and assist in increasing the body of knowledge within the discipline through the research implemented to validate them 6. Theories can be utilized by practitioners to guide and improve their practice. 7. Theories must be consistent with other validated theories, laws and principles but will leave unanswered questions that need to be investigated. Limitation • Johnson does not clearly interrelate her concepts of subsystems comprising the behavioral system model. • The definition of concept is so abstract that they are difficult to use. •

It is difficult to test Johnson's model by development of hypothesis.

•

The focus on the behavioral system makes it difficult for nurses to work with physically impaired individual to use this theory. The model is very individual oriented so the nurses working with the group have difficulty in its implementation. The model is very individual oriented so the family of the client is only considered as an environment. Johnson does not define the expected outcomes when one of the system is affected by the nursing implementation an implicit expectation is made that all human in all cultures will attain same outcome –homeostasis. Johnson’s behavioral system model is not flexible.

• • •

•

Summary Johnson’s Behavioral system model is a model of nursing care that advocates the fostering of efficient and effective behavioral functioning in the patient to prevent illness. The patient is defined as behavioral system composed of 7 behavioral subsystems. Each subsystem composed of four structural characteristics i.e. drives, set, choices and observable behavior. Three functional requirement of each subsystem includes (1) Protection from noxious influences, (2) Provision for the

nurturing environment, and (3) stimulation for growth. Any imbalance in each system results in disequilibrium .it is nursing role to assist the client to return to the state of equilibrium. Reference • • • •

George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton and Lange. Polit DF, Hungler BP. Nursing Research: Principles and Methods. Philadelphia: JB Lippincott Company; 1998. Burns N, Grove SK. The practice of Nursing Research. 4th Ed. Philadelphia: WB Saunders Publications; 2001. Treece JW, Treece EW. Elements of Research in Nursing (3rded.). St. Louis: Mosby; 1982.

IMOGENE KING: THEORY OF GOAL ATTAINMENT

Introduction of Theorist •

Born in 1923

•

Completed her Bachelor in science of nursing from St. Louis University in 1948

•

Completed her Master of science in nursing from St. Louis University in 1957

•

Completed her Doctorate from Teacher’s college, Columbia University

King’s Conceptual Framework It includes: •

Several basic assumptions

•

Three interacting systems

•

Several concepts relevant for each system

Basic assumptions •

Nursing focus is the care of human being

•

Nursing goal is the health care of individuals & groups

•

Human beings: are open systems interacting constantly with their environment

•

Interacting systems: personal system Interpersonal system Social system

•

Concepts are given for each system

Concepts for Personal System •

Perception

•

Self

•

Growth & development

•

Body image

•

Space

•

Time

Concepts for Interpersonal System •

Interaction

•

Communication

•

Transaction

•

Role

•

Stress

Concepts for Social System •

Organization

•

Authority

•

Power

•

Status

•

Decision making

Major Theses of King’s conceptual framework •

“Each human being perceives the world as a total person in making transactions with individuals and things in environment”

•

“Transaction represents a life situation in which perceiver & thing perceived are encountered and in which person enters the situation as an active participant and each is changed in the process of these experiences”

King’s Theory of Goal Attainment •

Theory of goal attainment was first introduced by Imogene King in the early 1960’s.

•

Theory describes a dynamic, interpersonal relationship in which a person grows and develops to attain certain life goals.

•

Factors which affects the attainment of goal are: roles, stress, space & time

Propositions of King’s Theory From the theory of goal attainment king developed predictive propositions, which includes: •

If perceptual interaction accuracy is present in nurse-client interactions, transaction will occur

•

If nurse and client make transaction, goal will be attained

•

If goal are attained, satisfaction will occur

•

Proposition cont…

•

If transactions are made in nurse-client interactions, growth & development will be enhanced

•

If role expectations and role performance as perceived by nurse & client are congruent, transaction will occur

•

If role conflict is experienced by nurse or client or both, stress in nurse-client interaction will occur

•

If nurse with special knowledge skill communicate appropriate information to client, mutual goal setting and goal attainment will occur.

Major concepts of king’s theory 1. Human being /person: is social being who are rational and sentient. Person has ability to : -perceive -think -feel -choose -set goals -select means to achieve goals -and to make decision According to King, human being has three fundamental needs:

(a) The need for the health information that is unable at the time when it is needed and can be used (b) The need for care that seek to prevent illness, and (c) The need for care when human beings are unable to help themselves. 2.

Health:

According to King, health involves dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living 3.

Environment

Environment is the background for human interactions. It involves: (a) Internal environment: transforms energy to enable person to adjust to continuous external environmental changes. (b) External environment: involves formal and informal organizations. Nurse is a part of the patient’s environment. 4.

Nursing

Nursing: is defined as “A process of action, reaction and interaction by which nurse and client share information about their perception in nursing situation.” and “ a process of human interactions between nurse and client whereby each perceives the other and the situation, and through communication, they set goals, explore means, and agree on means to achieve goals.” 1.

Action: is defined as a sequence of behaviors involving mental and physical action.

2.

Reaction: not specified, but might be considered as included in the sequence of behaviors described in action.

3.

In addition king discussed: (a)

goal

(b)

domain and

(c)

functions of professional nurse

4.

Goal of nurse: “To help individuals to maintain their health so they can function in their roles.”

5.

Domain of nurse: “includes promoting, maintaining, and restoring health, and caring for the sick, injured and dying.

6.

Function of professional nurse: “To interpret information in nursing process to plan, implement and evaluate nursing care.

King said in her theory, “A professional nurse, with special knowledge and skills, and a client in need of nursing, with knowledge of self and perception of personal problems, meet as strangers in natural environment. They interact mutually, identify problems, establish and achieve goals. Theory of Goal Attainment and Nursing Process Assumptions

Basic assumption of goal attainment theory is that nurse and client communicate information, set goal mutually and then act to attain those goals, is also the basic assumption of nursing process. Assessment •

King indicates that assessment occur during interaction. The nurse brings special knowledge and skills whereas client brings knowledge of self and perception of problems of concern, to this interaction.

•

During assessment nurse collects data regarding client (his/her growth & development, perception of self and current health status, roles etc.)

•

Perception is the base for collection and interpretation of data.

•

Communication is required to verify accuracy of perception, for interaction and transaction.

Nursing diagnosis •

The data collected by assessment are used to make nursing diagnosis in nursing process. Acc. to king in process of attaining goaI the nurse identifies the problems, concerns and disturbances about which person seek help.

Planning •

After diagnosis, planning for interventions to solve those problems is done.

•

In goal attainment planning is represented by setting goals and making decisions about and being agreed on the means to achieve goals.

•

This part of transaction and client’s participation is encouraged in making decision on the means to achieve the goals.

Implementations •

In nursing process implementation involves the actual activities to achieve the goals.

•

In goal attainment it is the continuation of transaction.

Evaluation 1. It involves to finding out weather goals are achieved or not. 2. In king description evaluation speaks about attainment of goal and effectiveness of nursing care. Nursing Process and Theory of Goal Attainment Nursing process method

Nursing process theory

A system of oriented actions A system of oriented concepts Assessment

Perception, communication and interaction of nurse and client

Planning

Decision making about the goals Be agree on the means to attain the goals

Implementation

Transaction made

Evaluation

Goal attained

References •

Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia, 2002.

•

George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange.

•

Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.

•

Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

•

Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

•

Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

•

Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002

BETTY NEUMANN’S SYSTEM MODEL INTRODUCTION •

Betty Neumann’s system model provides a comprehensive flexible holistic and system based perspective for nursing.

•

It focuses attention on the response of the client system to actual or potential environmental stressors.

•

And the use of primary, secondary and tertiary nursing prevention intervention for retention, attainment, and maintenance of optimal client system wellness.

HISTORY AND BACKGROUND OF THE THEORIST •

Betty Neumann was born in 1924, in Lowel, Ohio.

•

She completed BS in nursing in 1957 and MS in Mental Health Public health consultation, from UCLA in 1966. She holds a Ph.D. in clinical psychology

•

She was a pioneer in the community mental health movement in the late 1960s.

•

Betty Neumann began developing her health system model while a lecturer in community health nursing at University of California, Los Angeles.

•

The models was initially developed in response to graduate nursing students expression of a need for course content that would expose them to breadth of nursing problems prior to focusing on specific nursing problem areas.

•

The model was published in 1972 as “A Model for Teaching Total Person Approach to Patient Problems” in Nursing Research.

•

It was refined and subsequently published in the first edition of Conceptual Models for Nursing Practice, 1974, and in the second edition in 1980.

DEVELOPMENT OF THE MODEL •

Neumann’s model was influenced by a variety of sources.

•

The philosophy writers deChardin and cornu (on wholeness in system).

•

Von Bertalanfy, and Lazlo on general system theory.

•

Selye on stress theory.

•

Lararus on stress and coping.

BASIC ASSUMPTIONS •

Each client system is unique, a composite of factors and characteristics within a given range of responses contained within a basic structure.

•

Many known, unknown, and universal stressors exist. Each differ in it’s potential for disturbing a client’s usual stability level or normal LOD

•

The particular inter-relationships of client variables at any point in time can affect the degree to which a client is protected by the flexible LOD against possible reaction to stressors.

•

Each client/ client system has evolved a normal range of responses to the environment that is referred to as a normal LOD. The normal LOD can be used as a standard from which to measure health deviation.

•

When the flexible LOD is no longer capable of protecting the client/ client system against an environmental stressor, the stressor breaks through the normal LOD

•

The client whether in a state of wellness or illness, is a dynamic composite of the inter-relationships of the variables. Wellness is on a continuum of available energy to support the system in an optimal state of system stability.

•

Implicit within each client system are internal resistance factors known as LOR, which function to stabilize and realign the client to the usual wellness state.

•

Primary prevention relates to G.K. that is applied in client assessment and intervention, in identification and reduction of possible or actual risk factors.

•

Secondary prevention relates to symptomatology following a reaction to stressor, appropriate ranking of intervention priorities and treatment to reduce their noxious effects.

•

Tertiary prevention relates to adjustive processes taking place as reconstitution begins and maintenance factors move the back in circular manner toward primary prevention.

•

The client as a system is in dynamic, constant energy exchange with the environment.

CONCEPTS •

Content: - the variables of the person in interaction with the internal and external environment comprise the whole client system

•

Basic structure/Central core: - common client survival factors in unique individual characteristics representing basic system energy resources.

•

The basis structure, or central core, is made up of the basic survival factors that are common to the species (Neumann,2002).

•

These factors include:- - Normal temp. range, Genetic structure.- Response pattern. Organ strength or weakness, Ego structure

•

Stability, or homeostasis, occurs when the amount of energy that is available exceeds that being used by the system.

•

A homeostatic body system is constantly in a dynamic process of input, output, feedback, and compensation, which leads to a state of balance.

•

Degree to reaction: - the amount of system instability resulting from stressor invasion of the normal LOD.

•

Entropy: - a process of energy depletion and disorganization moving the system toward illness or possible death.

•

Flexible LOD: - a protective, accordion like mechanism that surrounds and protects the normal LOD from invasion by stressors.

•

Normal LOD: - It represents what the client has become over time, or the usual state of wellness. It is considered dynamic because it can expand or contract over time.

•

LOR: - The series of concentric circles that surrounds the basic structure.

•

Protection factors activated when stressors have penetrated the normal LOD, causing a reaction symptomatology. E.g. mobilization of WBC and activation of immune system mechanism

•

Input- output: - The matter, energy, and information exchanged between client and environment that is entering or leaving the system at any point in time.

•

Negentropy: - A process of energy conservation that increase organization and complexity, moving the system toward stability or a higher degree of wellness.

•

Open system:- A system in which there is continuous flow of input and process, output and feedback. It is a system of organized complexity where all elements are in interaction.

•

Prevention as intervention: - Interventions modes for nursing action and determinants for entry of both client and nurse in to health care system.

•

Reconstitution: - The return and maintenance of system stability, following treatment for stressor reaction, which may result in a higher or lower level of wellness.

•

Stability: - A state of balance of harmony requiring energy exchanges as the client adequately copes with stressors to retain, attain, or maintain an optimal level of health thus preserving system integrity.

•

Stressors: - environmental factors, intra (emotion, feeling), inter (role expectation), and extra personal (job or finance pressure) in nature, that have potential for disrupting system stability.

•

A stressor is any phenomenon that might penetrate both the F and N LOD, resulting either a positive or negative outcome.

•

Wellness/Illness: - Wellness is the condition in which all system parts and subparts are in harmony with the whole system of the client.

o

Illness is a state of insufficiency with disrupting needs unsatisfied (Neuman, 2002).

o

Illness is an excessive expenditure of energy… when more energy is used by the system in its state of disorganization than is built and stored; the outcome may be death (Neuman, 2002).

PREVENTION •

According to Neumann’s model, prevention is the primary nursing intervention. Prevention focuses on keeping stressors and the stress response from having a detrimental effect on the body.

PRIMARY PREVENTION •

Primary prevention occurs before the system reacts to a stressor. On the one hand, it strengthens the person (primary the flexible LOD) to enable him to better deal with stressors

•

On the other hand manipulates the environment to reduce or weaken stressors.

•

Primary prevention includes health promotion and maintenance of wellness.

SECONDARY PREVENTION •

Secondary prevention occurs after the system reacts to a stressor and is provided in terms of existing system.

•

Secondary prevention focuses on preventing damage to the central core by strengthening the internal lines of resistance and/or removing the stressor.

TERTIARY PREVENTION •

Tertiary prevention occurs after the system has been treated through secondary prevention strategies.

•

Tertiary prevention offers support to the client and attempts to add energy to the system or reduce energy needed in order to facilitate reconstitution.

FOUR MAJOR CONCEPTS PERSON •

The focus of the Neumann model is based on the philosophy that each human being is a total person as a client system and the person is a layered multidimensional being.

•

Each layer consists of five person variable or subsystems: o

Physiological- Refer of the physicochemical structure and function of the body.

o

Psychological- Refers to mental processes and emotions.

o

Socio-cultural- Refers to relationships; and social/cultural expectations and activities.

o

Spiritual- Refers to the influence of spiritual beliefs.

o

Developmental- Refers to those processes related to development over the lifespan.

ENVIRONMENT

•

The environment is seen to be the totality of the internal and external forces which surround a person and with which they interact at any given time.

•

These forces include the intrapersonal, interpersonal and extra-personal stressors which can affect the person’s normal line of defense and so can affect the stability of the system. •

The internal environment exists within the client system.

•

The external environment exists outside the client system.

•

Neumann also identified a created environment which is an environment that is created and developed unconsciously by the client and is symbolic of system wholeness.

HEALTH •

Neumann sees health as being equated with wellness. She defines health/wellness as “the condition in which all parts and subparts (variables) are in harmony with the whole of the client (Neumann, 1995)”.

•

The client system moves toward illness and death when more energy is needed than is available. The client system moved toward wellness when more energy is available than is needed

NURSING •

Neumann sees nursing as a unique profession that is concerned with all of the variables which influence the response a person might have to a stressor.

•

The person is seen as a whole, and it is the task of nursing to address the whole person.

•

Neuman defines nursing as “action which assist individuals, families and groups to maintain a maximum level of wellness, and the primary aim is stability of the patient/client system, through nursing interventions to reduce stressors.’’

•

Neuman states that, because the nurse’s perception will influence the care given, then not only must the patient/client’s perception be assessed, but so must those of the caregiver (nurse).

•

The role of the nurse is seen in terms of degree of reaction to stressors, and the use of primary, secondary and tertiary interventions

STAGES OF NURSING PROCESS (BY NEUMAN) NURSING DIAGNOSIS •

It depends on acquisition of appropriate database; the diagnosis identifies, assesses, classifies, and evaluates the dynamic interaction of the five variables.

•

Variances from wellness (needs and problems) are determined by correlations and constraints through synthesis of theory and data base.

•

Broad hypothetical interventions are determined, i.e. maintain flexible line of defense.

NURSING GOALS

•

These must be negotiated with the patient, and take account of patient’s and nurse’s perceptions of variance from wellness.

NURSING OUTCOMES •

Nursing intervention using one or more preventive modes.

•

Confirmation of prescriptive change or reformulation of nursing goals.

•

Short term goal outcomes influence determination of intermediate and long – term goals.

•

A client outcome validates nursing process.

NEUMANN’S SYSTEM MODEL FORMAT Neumann’s nursing process format designates the following categories of data about the client system as the major areas of assessment. ASSESSMENT •

Potential and actual stressors.

•

Condition and strength of basic structure factors and energy sources.

•

Characteristics of flexible and normal line of defenses, lines of resistance, degree of reaction and potential for reconstitution.

•

Interaction between client and environment.

•

Life process and coping factors (past, present and future) actual and potential stressors (internal and external) for optimal wellness external.

•

Perceptual difference between care giver and the client.

NURSING DIAGNOSIS •

The data collected are then interpreted to condition and formulate the Nursing diagnosis.

•

Health seeking behaviors.

•

Activity intolerance.

•

Ineffective coping.

•

Ineffective thermoregulation.

GOAL •

In Neumann’s systems model the goal is to keep the client system stable.

PLANNING •

Planning is focused on strengthening the lines of defense and resistance.

IMPLEMENTATION The goal of stabilizing the client system is achieved through three modes of prevention •

Primary prevention : actions taken to retain stability

•

Secondary prevention : actions taken to attain stability

•

Tertiary prevention : actions taken to maintain stability

EVALUATION •

The nursing process is evaluated to determine whether equilibrium is restored and a steady state maintained.

ACCEPTANCE BY THE NURSING COMMUNITY •

Neumann’s model has been described as a grand nursing theory by walker and Avant.

•

Grand theories can provide a comprehensive perspective for nursing practice, education, and research and Neuman’s model does.

PRACTICE •

The Neumann systems model has been applied and adapted to various specialties include family therapy, public health, rehabilitation, and hospital nursing.

•

The sub specialties include pulmonary, renal, critical care, and hospital medical units. One of the model’s strengths is that it can be used in a variety of settings

•

Using this conceptual model permits comparison of a nurse’s interpretation of a problem with that of the patient, so the patient and nurse do not work on two separate problems.

•

The role of the nurse in the model is to work with the patient to move him as far as possible along a continuum toward wellness.

•

Because this model requires individual interaction with the total health care system, it is indicative of the futuristic direction the nursing profession is taking.

•

The patient is being relabeled as a consumer with individual needs and wants.

EDUCATION •

The model has also been widely accepted in academic circles.

•

It has often been selected as a curriculum guide for a conceptual framework oriented more toward wellness than toward a medical model and has been used at various levels of nursing education.

•

In the associate degree program at Indiana University.

•

One of the objectives for nursing graduate is to demonstrate ability to use the Neumann health care system in nursing practice. This helps prepare the students for developing a frame of reference centered on holistic care.

•

At northwestern State University in Shreveport, Louisiana, the faculty determined that a systems model approach was preferred for their master’s program because of the universality framework.

•

Acceptance by the nursing community for education therefore is evident.

RESEARCH •

A study was published by Riehl and Roy to test the usefulness of the Neumann model in nursing practice.

•

There were two major objectives of the study. o

To test the model/assessment’ tool for its usefulness as a unifying method of collecting and analyzing data for identifying client problems.

o

To test the assessment tool for its usefulness in the identification of congruence between the client’s perception of stressors and the care giver’s perception of client stressors.

•

Results indicated that the model can help categorize data for assessing and planning care and for guiding decision making.

•

Neumann’s model can easily generate nursing research.

•

It does this by providing a framework to develop goals for desired outcomes. Acceptance by the nursing community for research applying this model is in the beginning stages and positive.

NEUMANN’S AND THE CHARACTERISTICS OF A THEORY •

•

•

•

•

Theories connects the interrelated concepts in such a way as to create a different way of looking at a particular phenomenon. o

The Neumann model represents a focus on nursing interest in the total person approach to the interaction of environment and health.

o

The interrelationships between the concepts of person, health, nursing and society/environment are repeatedly mentioned throughout the Neumann model and are considered to be basically adequate according to the criteria.

Theories must be logical in nature o

Neumann’s model in general presents itself as logically consistent.

o

There is a logical sequence in the process of nursing wherein emphasis on the importance of accurate data assessment is basic to the sequential steps of the nursing process.

Theories should be relatively simple yet generalizable. o

Neumann’s model is fairly simple and straightforward in approach.

o

The terms used are easily identifiable and for the most part have definitions that are broadly accepted.

o

The multiple use of the model in varied nursing situations (practice, curriculum, and administration) is testimony in itself to its broad applicability.

o

The potential use of this model by other health care disciplines also attests to its generalizability for use ion practice.

o

One drawback in relation to simplicity is the diagrammed model since it presents over 35 variables and tends to be awesome to the viewer.

Theories can be the bases for hypotheses that can be tested. o

Neumann’s model, due to its high level and breadth of abstraction, lends itself to theory development.

o

One are for future consideration as a beginning testable theory might be the concept of prevention as intervention, subsequent to basis concept refinement in the Neuman model.

Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them.

•

•

o

The model has provided clear, comprehensive guidelines for nursing education and practice in a variety of settings; this is its primary contribution to nursing knowledge.

o

The concept within the guidelines is clearly explicated and many applications of the theory have been published, little research explicitly derived from this model has been published to date.

Theories can be utilized by the practitioner to guide and improve their practice. o

One of the most significant attributes of the Neumann model is the assessment/intervention instrument together with comprehensive guidelines for its use with the nursing process.

o

These guidelines have provided a practical resource for many nursing practitioners and have been used extensively in a variety of setting in nursing practice, education and administration.

Theories must be consistent with other validated theories, laws and principles but will leave open unanswered questions that need to be investigated. o

In general, there is no direct conflict with other theories. There is, however, a lack of specificity in systems concepts such as “boundaries” which are indirectly addressed throughout the model.

Research Articles

1. “Using the Neuman Systems Model for Best Practices’’--Sharon A.

DeWan, Pearl N. Ume-Nwagbo, Nursing Science Quarterly, Vol. 19, No. 1, 31-35 (2006). 1. The purpose of this study was to present two case studies based upon Neuman systems model; one case is directed toward family care, and the other demonstrates care with an individual. Theorybased exemplars serve as teaching tools for students and practicing nurses. 2. These case studies illustrate how nurses' actions, directed by Neuman's wholistic principles, integrate evidence-based practice and generate high quality care

2. Melton L, Secrest J, Chien A, Andersen B.

“A community needs assessment for a SANE program using Neuman's model” J Am Acad Nurse Pract. 2001 Apr;13(4):178-86. 1. The purpose of the study was to present guidelines for a community needs assessment for a Sexual Assault Nurse Examiner (SANE) program using Neuman's Systems Model. 2. Sexual assault is a problem faced by almost every community. A thorough community assessment is an important first step in establishing programs that adequately meet a community's needs. 3. Guidelines for conducting such an assessment related to implementation of a SANE program are rare, and guidelines using a nursing model were not found in the literature

Reference

•

Timber BK. Fundamental skills and concepts in Patient Care, 7th edition, LWW, N

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George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton and Lange.

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Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.

•

Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

•

Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

•

Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

•

Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-15

•

Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):225

•

Cheng MY. Using King's Goal Attainment Theory to facilitate drug compliance in a psychiatric patient. Hu Li Za Zhi. 2006 Jun;53(3):90-7.

•

Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice, 2nd edition, Thomson, NY, 2002

LEVINE’S FOUR CONSERVATION PRINCIPLES Myra Estrine Levine Introduction •

Born in Chicago, raised with a sister and a brother with whom she shared a close loving relationship

•

Also very fond of her father who was often ill and frequently hospitalized with GI problem. This was the reason of choosing nursing as a career

•

Also called as renaissance women-highly principled, remarkable and committed to patient’s quality of care

•

Died in 1996

Educational Achievement •

Diploma in nursing:-Cook county SON, Chicago, 1944

•

BSN:-University of Chicago,1949

•

MSN:-Wayne state University, Detroit, 1962

•

Publication:-An Introduction to Clinical Nursing, 1969,1973 & 1989

•

Received honorary doctorate from Loyola University in 1992

Achievements •

Clinical experience in OT technique and oncology nursing

•

Civilian nurse at the Gardiner general hospital

•

Director of nursing at Drexel home in Chicago

•

Clinical instructor at Bryan memorial hospital in Lincoln, Nebraska

•

Administrative supervisor at university of Chicago

•

Chairperson of clinical nursing at cook country SON

•

Visiting professor at Tel Aviv university in Israel

Conservational model •

Goal: To promote adaptation and maintain wholeness using the principles of conservation

•

Model guides the nurse to focus on the influences and responses at the organismic level

•

Nurse accomplishes the goal of model through the conservation of energy, structure and personal and social integrity

Adaptation •

Every individual has a unique range of adaptive responses

•

The responses will vary by heredity, age, gender or challenges of illness experiences

•

Example: The response to weakness of cardiac muscle is an increased heart rate, dilation of ventricle and thickening of myocardial muscle

•

While the responses are same, the timing and manifestation of organismic responses will be unique for each individual pulse rate)

•

An ongoing process of change in which patient maintains his integrity within the realities of environment

•

Achieved through the "frugal, economic, contained and controlled use of environmental resources by individual in his or her best interest"

Wholeness •

Exist when the interaction or constant adaptations to the environment permits the assurance of integrity

•

Promoted by use of conservation principle

Conservation •

The product of adaptation

•

"Keeping together "of the life systems or the wholeness of the individual

•

Achieving a balance of energy supply and demand that is with in the unique biological realities of the individual

Nursing’s paradigm Person •

A holistic being who constantly strives to preserve wholeness and integrity

•

A unique individual in unity and integrity, feeling, believing, thinking and whole system of system

Environment • •

Competes the wholeness of person Internal

•

Homeostasis

•

Homeorrhesis

•

External

•

Preconceptual

•

Operational

•

Conceptual

Internal Environment •

Homeostasis: A state of energy sparing that also provide the necessary baselines for a multitude of synchronized physiological and psychological factors

•

A state of conservation

•

Homeorrhesis: A stabilized flow rather than a static state

•

Emphasis the fluidity of change within a space-time continuum

•

Describe the pattern of adaptation, which permit the individual’s body to sustain its well being with the vast changes which encroach upon it from the environment

External Environment •

Preconceptual: Aspect of the world that individual are able to intercept

•

Operational: Elements that may physically affects individuals but not perceived by hem: radiation, micro-organism and pollution

•

Conceptual: Part of person's environment including cultural patterns characterized by spiritual existence, ideas, values, beliefs and tradition

Person and environment •

Adaptation

•

Organismic response

•

Conservation

Adaptation Characteristics Historicity: Adaptations are grounded in history and await the challenges to which they respond Specificity: Individual responses and their adaptive pattern varies on the base of specific genetic structure Redundancy: Safe and fail options available to the individual to ensure continued adaptation Organismic response

•

A change in behavior of an individual during an attempt to adapt to the environment

•

Help individual to protect and maintain their integrity

•

They co-exist

•

They are four types 1. Flight or fight: An instantaneous response to real or imagined threat, most primitive response 2. Inflammatory: response intended to provide for structural integrity and the promotion of healing 3. Stress: Response developed over time and influenced by each stressful experience encountered by person 4. Perceptual: Involves gathering information from the environment and converting it in to a meaning experience

Nine models of guided assessment •

Vital’s signs

•

Body movement and positioning

•

Ministration of personal hygiene needs

•

Pressure gradient system in nursing interventions

•

Nursing determination in provision of nutritional needs

•

Pressure gradient system in nursing

•

Local application of heat and cold

•

Administration of medicine

•

Establishing an aseptic environment

Assumption •

The nurse creates an environment in which healing could occur

•

A human being is more than the sum of the part

•

Human being respond in a predictable way

•

Human being are unique in their responses

•

Human being know and appraise objects ,condition and situation

•

Human being sense ,reflects, reason and understand

•

human being action are self determined even when emotional

•

Human being are capable of prolonging reflection through such strategists raising questions

•

Human being make decision through prioritizing course of action

•

Human being must be aware and able to contemplate objects, condition and situation

•

Human being are agents who act deliberately to attain goal

•

Adaptive changes involve the whole individual

•

A human being has unity in his response to the environment

•

Every person possesses a unique adaptive ability based on one’s life experience which creates a unique message

•

There is an order and continuity to life change is not random

•

A human being respond organismically in an ever changing manner

•

A theory of nursing must recognized the importance of detail of care for a single patient with in an empiric framework that successfully describe the requirement of the all patient

•

A human being is a social animal

•

A human being is an constant interaction with an ever changing society

•

Change is inevitable in life

•

Nursing needs existing and emerging demands of self care and dependant care

•

Nursing is associated with condition of regulation of exercise or development of capabilities of providing care

Levine’s work & Characteristics of theory •

Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon

•

The concept of illness adaptation, using interventions, and the evaluation of nursing interventions are interrelated .they are combined to look at nursing care in a different way (more comprehensive view incorporating total patient care) form previous time.

•

Theories must be logical in nature.

•

Levine’s idea about nursing care are organized in such a way as to b sequential and logical. they can be used to explain the consequences of nursing action

•

Theories should be relatively simple yet generalizable.

•

Levine’s theory is easy to use .

•

It’s major elements are easily comprehensible and the relation ship have the potential for being complex but are easily manageable

•

Certain isolated aspect of the theory are the generalizable i.e. those related to the conservational principles

•

Theories can be the bases for hypotheses that can be tested.

•

Levine’s idea can be tested

•

Hypothesis can be derived from them .

•

The principle of conservation are specific enough to be testable

•

Levine’s work & Characteristics of theory

•

Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them.

•

Since Levine’s idea have not yet been widely researched ,it is hard o determine the contribution to the general body of knowledge with in the discipline

•

Theories can be utilized by the practitioner to guide and improve their practice.

•

Paula E.Crawford-gamble :-successfully applied Levine’s theory to the female patient undergoing surgery for the traumatic amputation of the fingers

•

These ideas lend themselves to use in practice particularly in acute care setting

•

Theories must be consistent with other validated theories, laws and principles but will leave open unanswered questions that need to be investigated .

•

Levine’s ideas seem to be consistent with other theories, laws and principles particularly those from the humanities and sciences

Conservational Principle •

Conservation of energy

•

Conservation of structural integrity

•

Conservation of personal integrity

•

Conservation of social integrity

1. Conservation of energy •

Refers to balancing energy input and output to avoid excessive fatigue

•

includes adequate rest, nutrition and exercise

Example: availability of adequate rest Maintenance of adequate nutrition 2. Conservation of structural integrity •

Refers to maintaining or restoring the structure of body preventing physical breakdown And promoting healing Example: Assist patient in ROM exercise Maintenance of patient’s personal hygiene 3. Conservation of personal integrity

•

Recognizes the individual as one who strives for recognition, respect, self awareness, selfhood and self determination Example: Recognize and protect patient’s space needs 4. Conservation of social integrity

•

An individual is recognized as some one who resides with in a family, a community ,a religious group, an ethnic group, a political system and a nation Example:

•

Position patient in bed to foster social interaction with other patients

•

Avoid sensory deprivation

•

Promote patient’s use of news paper, magazines, radio. TV

•

Provide support and assistance to family

Health •

Health is a wholeness and successful adaptation

•

It is not merely healing of an afflicted part ,it is return to daily activities, selfhood and the ability of the individual to pursue once more his or her own interest without constraints

•

Disease: It is unregulated and undisciplined change and must be stopped or death will ensue

Nursing •

"nursing is a profession as well as an academic discipline, always practiced and studied in concert with all of the disciplines that together from the health sciences"

•

The human interaction relying on communication ,rooted in the organic dependency of the individual human being in his relationships with other human beings

•

Nursing involves engaging in "human interactions"

Goal of Nursing •

To promote wholeness, realizing that every individual requires a unique and separate cluster of activities

•

The individual integrity is his abiding concern and it is the nurse’s responsibility to assist him to defend and to seek its realization

Nursing Process •

Assessment

•

Trophicognosis

•

Hypothesis

•

Interventions

•

Evaluation

Nursing Process Assessment •

Collection of provocative facts through observation and interview of challenges to the internal and external environment using four conservation principles

•

Nurses observes patient for organismic responses to illness, reads medical reports. talks to patient and family

•

Assesses factors which challenges the individual Trophicognosis

•

Nursing diagnosis-gives provocative facts meaning

•

A nursing care judgment arrived at through the use of the scientific process

•

Judgment is made about patient’s needs for assistance

Hypothesis •

Planning

•

Nurse proposes hypothesis about the problems and the solutions which becomes the plan of care

•

Goal is to maintain wholeness and promoting adaptation Interventions

•

Testing the hypothesis

•

Interventions are designed based on the conservation principles

•

Mutually acceptable

•

Goal is to maintain wholeness and promoting adaptation Evaluation

•

Observation of organismic response to interventions

•

It is assesses whether hypothesis is supported or not supported

•

If not supported, plan is revised, new hypothesis is proposed

Conservational models •

Conservational model provides the basis for development of two theories o

Theory of redundancy

o

Theory of therapeutic intention

Theory of redundancy •

Untested ,speculative theory that redefined aging and everything else that has to do with human life

•

Aging is diminished availability of redundant system necessary for effective maintenance of physical and social well being

Theory of therapeutic intention •

Goal: To seek a way of organizing nursing interventions out of the biological realities which the nurse has to confront

•

Therapeutic regimens should support the following goals:

•

Facilitate healing through natural response to disease

•

Provide support for a failing auto regulatory portion of the integrated system

•

Restore individual integrity and well being

Theory of therapeutic intention •

Provide supportive measure to ensures comfort

•

Balance a toxic risk against the threat of disease

•

Manipulate diet and activity to correct metabolic imbalance and stimulate physiological process

•

Reinforce usual response to create a therapeutic changes

Uses •

Critical, acute or long term care unit

•

Neonates, infant and young children, pregnant young adult and elderly care unit

•

Primary health care

•

OT

•

Community setting

Utility of Theory •

Nursing research

•

Nursing education

•

Nursing administration

•

Nursing practice Nursing research

•

Principles of conservation have been used for data collection in various researches

•

Conservational model was used by Hanson et al.in their study of incidence and prevalence of pressure ulcers in hospice patient

•

Newport used principle of conservation of energy and social integrity for comparing the body temperature of infant’s who had been placed on mother’s chest immediately after birth with those who were placed in warmer Nursing education

•

Conservational model was used as guidelines for curriculum development

•

It was used to develop nursing undergraduate program at Allentown college of St.Francis de sales, Pennsylvania

•

Used in nursing education program sponsored by Kapat Holim in Israel Nursing administration

•

Taylor described an assessment guide for data collection of neurological patients which forms basis for development of comprehensive nursing care plan and thus evaluate nursing care

•

McCall developed an assessment tool for data collection on the basis of four conservational principles to identify nursing care needs of epileptic patients

•

Family assessment tool was designed by Lynn-Mchale and Smith for families of patient in critical care setting Nursing practice

•

Conservational model has been used for nursing practice in different settings

•

Bayley discussed the care of a severely burned teenagers on the basis of four conservational principles and discussed patient’s perceptual, operational and conceptual environment

•

Pond used conservation model for guiding the nursing care of homeless at a clinic, shelters or streets

Nursing process according to Levine’s model

Mrs. Mona, a wife of an abusive husband, underwent a radical hysterectomy. Post operatively has pain ,weight loss, nausea and inability to empty bladder .Patient has history of smoking and stays in house which is less than sanitary Assessment •

Challenges to the internal env:-weight loss, nausea, loss of reproductive ability

•

Challenges to the external env:-abusive husband, insanitary condition in home

•

Energy conservation:-weight loss, nausea ,pain

•

Structural integrity:-threatened by surgical procedure, inability to pass urine

•

Personal integrity:-not able to give birth to more children

•

Social integrity:-Strained relationship with husband

Trophicognosis •

Inadequate nutritional status

•

Pain

•

Potential for wound and bladder infection

•

Need to learn self catheterization

•

Decreased self worth

•

Potential for abuse

Hypothesis •

Nutritional consultation

•

Teaching and return demonstration of urinary self catheterization

•

Care of surgical wound

•

Exploring concern regarding hysterectomy

Interventions Energy conservation •

Provide medication for pain and nausea

•

Allowing rest period Structural integrity

•

Administrating antibiotic for wound,

•

Teaching self catheterization Personal integrity

•

Exploring her feeling about uterus removal while respecting her privacy Social integrity

•

Assess potential abuse form husband

•

Support to the family

Organismic response

•

Controlled pain

•

Abdominal wound healing

•

Improved appetite ,weight gain

•

Clean urinary self catheterization

•

Assistance from husband

Critiquing the theory •

She values the holistic approach to all individual, well or sick

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Values patient’s participation in nursing care

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Comprehensive content in depth

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Provides direction of nursing research , education, administration and practice

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Logically congruent

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Shows high regard to adjunctive disciplines to develop theoretical basis for nursing

Limitation •

Limited attention can be focused on health promotion and illness prevention.

•

Nurse has the responsibility for determining the patient ability to participate in the care ,and if the perception of nurse and patient about the patient ability to participate in care don’t match, this mismatch will be an area of conflict.

•

The major limitation is the focus on individual in an illness state and on the dependency of patient.

Research Highlights •

A theory of health promotion for preterm infants based on conservational model of nursing. Nursing science quarterly,2004 Jul,17 (3) The article describes a new middle range theory of health promotion for preterm infants based on Levine’s conservational model that can be used to guide neonatal nursing practice.

Summary •

Introduction to the theorist

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Conservational model

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Concept of the model

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Adaptation

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Wholeness

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Conservation

1. Conservation principles 2. Nursing process

1. Assessment 2. Trophicogosis

3. Hypothesis 4. Interventions 5. Evaluation 3. Theory of redundancy 4. Theory of therapeutic intention 5. Utility of theory

1. Nursing research 2. Nursing education 3. Nursing administration 4. Nursing practices References •

Timber BK. Fundamental skills and concepts in Patient Care, 7th edition, LWW.

•

George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange.

•

Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.

•

Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

•

Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

•

Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

•

Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-15

•

Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):225

•

Cheng MY. Using King's Goal Attainment Theory to facilitate drug compliance in a psychiatric patient. Hu Li Za Zhi. 2006 Jun;53(3):90-7.

•

Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice, 2nd edition, Thomson, NY, 2002.

MARTHA ROGER’S SCIENCE OF UNITARY HUMAN BEINGS Introduction •

Born :May 12, 1914, Dallas, Texas

•

Diploma :Knoxville General Hospital School of Nursing(1936)

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Graduation in Public Health Nursing, George Peabody College, TN, 1937

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MA :Teachers college, Columbia university, New York, 1945

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MPH :Johns Hopkins University, Baltimore, MD, 1952

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Doctorate in nursing :Johns Hopkins University, Baltimore, 1954

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Fellowship: American academy of nursing

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Position: Professor Emerita, Division of Nursing, New York University, Consultant, Speaker

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Died : March 13 , 1994

Publications of Martha Rogers Theoretical basis of nursing (Rogers 1970) Nursing science and art :a prospective (Rogers 1988) Nursing :science of unitary, irreducible, human beings update (Rogers 1990) Vision of space based nursing (Rogers 1990) Rogers nursing theory Nursing is both a science and art. the uniqueness of nursing, like that of any other science, lies in the phenomenon central to its focus. Nurses long established concern with the people and the world they live is in a natural forerunner of an organized abstract system encompassing people and the environments. The irreducible nature of individuals is different from the sum of the parts. The integral ness of people and the environment that coordinate with a multidimensional universe of open systems points to a new paradigm :the identity of nursing as a science. The purpose of nurses is to promote health and well-being for all persons wherever they are. Evolution of abstract system The development of the abstract system was strongly influenced by an early grounding in arts and background of science and her keen interest in space The science of unitary human beings originated as a synthesis of facts and ideas from multiple sources of knowledge The uniqueness is in the central phenomena : people and environment The Rogerian view of a causality emerges from an infinite universe of open system Overview of Rogerian model •

Rogers model provides the way of viewing the unitary human being

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Humans are viewed as integral with the universe

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The unitary human being and the environment are one ,not dichotomous

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Nursing focus on people and the manifestations that emerge from the mutual human /environmental field process

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Change of pattern and organization of the human field and the environmental field is propagated by waves

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The manifestations of the field patterning that emerge are observable events

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The identification of the pattern provide knowledge and understanding of human experience

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Basic characteristics which describes the life process of human :energy field, openness, pattern, and pan dimensionality

•

Basic concepts include unitary human being ,environment, and homeodynamic principles

Concepts of Rogers model Energy field •

The energy field is the fundamental unit of both the living and nonliving

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This energy field "provide a way to perceive people and environment as irreducible wholes"

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The energy fields continuously varies in intensity, density, and extent Openness

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The human field and the environmental field are constantly exchanging their energy

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There are no boundaries or barrier that inhibit energy flow between fields Pattern

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Pattern is defined as the distinguishing characteristic of an energy field perceived as a single waves

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"pattern is an abstraction and it gives identity to the field" Pan dimensionality

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Pan dimensionality is defined as "non linear domain without spatial or temporal attributes"

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The parameters that human use in language to describe events are arbitrary.

•

The present is relative ;there is no temporal ordering of lives. Unitary Human Being (person)

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A unitary human being is an "irreducible, indivisible, pan dimensional (fourdimensional) energy field identified by pattern and manifesting characteristics that are specific to the whole and which cannot be predicted from knowledge of the parts" and "a unified whole having its own distinctive characteristics which cannot be perceived by looking at , describing, or summarizing the parts"

•

The people has the capacity to participate knowingly and probabilistically in the process of change Environment

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The environment is an "irreducible ,pan dimensional energy field identified by pattern and integral with the human field"

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The field coexist and are integral. Manifestation emerge from this field and are perceived. Health

•

Rogers defined health as an expression of the life process; they are the "characteristics and behavior emerging out of the mutual, simultaneous interaction of the human and environmental fields"

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Health and illness are the part of the sane continuum.

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The multiple events taking place along life's axis denote the extent to which man is achieving his maximum health potential and very in their expressions from greatest health to those conditions which are incompatible with the maintaining life process Nursing

•

The concept Nursing encompasses two dimensions

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Independent science of nursing An organized body of knowledge which is specific to nursing is arrived at by scientific research and logical analysis

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Art of nursing practice The creative use of science for the betterment of the human The creative use of its knowledge is the art of its practice

Assumptions about people and nursing •

Nursing exists to serve people………..it is the direct and overriding responsibility to the society

•

The safe practice of nursing depends on the nature and amount of scientific nursing knowledge the individual brings to practice…….the imaginative, intellectual judgment with which such knowledge is made in service to the man kind

•

People needs knowledgeable nursing

Homeodynamic principles •

The principles of homeodynamic postulates the way of perceiving unitary human beings

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The fundamental unit of the living system is an energy field

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Three principle of homeodynamic •

Resonancy

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Helicy

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integrality

Resonance •

Resonance is an ordered arrangement of rhythm

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characterizing both human field and environmental

•

field that undergoes continuous dynamic

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metamorphosis in the human environmental process

Helicy •

Helicy describes the unpredictable, but continuous, nonlinear evolution of energy fields as evidenced by non repeating rhythmicties

•

The principle of Helicy postulates an ordering of the humans evolutionary emergence

Integrality •

Integrality cover the mutual, continuous relationship of the human energy field and the environmental field .

•

Changes occur by by the continuous repatterning of the human and environmental fields by resonance waves

•

The fields are one and integrated but unique to each other

Rogerian theories Rogerian theories-Grand theories •

The theory of accelerating evolution

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The theory of paranormal phenomena

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The theory of rhythmicities

Theory of paranormal phenomena •

This theory focus on the explanations for precognition, déjàvu, clairvoyance, telepathy, and therapeutic touch

•

Clairvoyance is rational in a four dimensional human field in continuous mutual, simultaneous interaction with a four dimensional world; there is no linear time nor any separation of human and the environmental fields

The theory of accelerating evolution •

Theory postulates that evolutionary change is speeding up and that the range of diversity of life process is widening. Rogers explained that higher wave frequencies are associated with accelerating human development

Theory of Rhythmicity •

Focus on the human field rhythms

•

(these rhythms are different from the biological ,psychological rhythm)

•

Theory deals with the manifestations of the whole unitary man as changes in human sleep wake patterns, indices of human field motion, perception of time passing, and other rhythmic development

Theories derived from the science of unitary human beings •

The perspective rhythm model (Patrick 1983)

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Theory of health as expanding consciousness (Neumann, 1986)

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Theory of creativity, actualization and empathy (Alligood 1991)

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Theory of self transcendence (Reed1997)

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Power as knowing participation in change (Barrett 1998)

Rogers concepts of nursing •

Nursing is a learned profession-it is a science and art

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Nursing is the study of unitary. Irreducible, indivisible human and environmental energy fields

•

The art of nursing involves the imaginative and creative use of nursing knowledge

•

The purpose of nurses is to promote health and well-being for all person and groups wherever they are using the art and science of nursing

•

The health services should be community based

•

Rogers challenges nurses to consider nursing needs of all people ,including future generation of space kind ;as life continuous to evolve from earth to space and beyond.

•

Her view provides a different world view that encompasses a practice of nursing for the present time and for the imagined and for the yet to be imagined future

•

Rogers envisions a nursing practice of noninvasive modalities, such as therapeutic touch, humor, guided imagery, use of color, light, music, meditation focusing on health potential of the person.

•

Professional practice in nursing seeks to promote symphonic interaction between man and environment, to strengthen the coherence and integrity of the human field, and to direct and redirect patterning of the human and environmental fields for realization of maximum health potential

•

Nursing intervention seeks to coordinate environmental field and human field rhythmicities, participates in the process of change , to help people move toward better health

•

Nursing aims to assist people in achieving their maximum potential.

•

Nursing practice should be emphasized on pain management, supportive psychotherapy motivation for rehabilitation.

•

Maintenance and promotion of health, prevention of disease, nursing diagnosis, intervention, and rehabilitation encompasses the scope of nursing

Roger’s contribution to nursing knowledge •

Rogers was one of the first nurse scholars to explicitly identify the person (unitary man) as the central phenomena of nursing concern

•

Nursing abstract system is a matrix of concepts relevant to the life process in man

•

Rogers conceptual system provides a body of knowledge in nursing that will have relevance for all workers concerned with people, but with special relevance for nurses; because it matters to human beings; consequently to nurses

•

In the evolution it is properly subjected to reformulation and change as the knowledge grows, the the conceptual data will be more clearer and it will take new dimensions

•

The utilization of Rogerian model is used as a guide for theory development, research, nursing education, and in the direct patient care practice

Rules for nursing research guided by the Rogerian theory Rules for research •

The Rogerian research require both basic and applied research

•

The phenomena to be studied are unitary human beings and their environmental interaction

•

Study participants may be any person or group, with the provision that both person and environment are taken into account

Research methodology •

Qualitative and quantitative methods can be applied

•

Experimental researches are questionable because she rejects the notion of causality

•

Case study and longitudinal research are better than cross sectional study

•

Research instruments that are directly derived from science of unitary human beings should be used

•

Data analysis – multivariate analysis (canonical correlation studies)

Research tools derived from science of unitary human beings •

Perceived field motion scale

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Human field rhythm scale

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Temporal experience scale

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Assessment of dream experience scale

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Person environment participation scale

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Leddy healthiness scale

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Mutual exploration of the healing human-environment field scale

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Garon assessment of pain scale

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Family assessment tool

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Community health assessment tool

Rules for nursing education guided by Rogerian theory Focus of the curriculum •

Nursing education can be for professional nursing , technical nursing

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The focus is the transmission of the body of knowledge

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Teaching and practicing therapeutic touch

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Conducting regular in-service education

Nursing programs •

Baccalaureate degree program

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Masters program

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Doctoral program

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The major concepts are – principal of Resonancy, Helicy, Integrality

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The faculty in the nursing education must be prepared at doctoral level

Teaching- learning strategies

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Emphasis should be on developing self awareness as an aspect of the clients environmental energy field and the dynamic role of nurse pattern manifestation on the client

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Emphasis on laboratory study- the lab setting include homes, schools, industry, clinics, hospitals, other places where people lives

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Importance of use of media in education

Rules for nursing administration guided by Rogerian theory Purpose of nursing services •

Nursing services is the center of any health care system

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The purpose of nursing services is health promotion

Characteristics of nursing personnel •

The administrators should hold higher degrees in nursing and licensed

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Leaders must be visionary and willing to embrace innovative and creative change

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Leaders should be able to identify the patterning to ensure the integrated behaviors for client and employees

Management strategies and administrative policies •

Administrative policies foster an open and supportive administrative climate that enhances staff members self esteem , actualization, and freedom of choice and provide opportunity for staff development and continuing education

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The ultimate goal is the clients well-being

Rules for independent practitioner guided by Rogerian model •

Nursing is an independent science

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Nurse assumes the role of potentiater of care

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She proposes the independent role in various setting like school, industry, community, space (by 2050AD)

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Independent practitioner is an advanced practice registered registered nurse who focus on well-being or mutual patterning of individual, family, community across the life span ,at risk for developing dissonance/illness

Rules for nursing practice guided by Rogerian theory Areas of Rogerian model application •

SETTINGS •

All spheres of life •

School

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Industry

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Family

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Community

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Space

•

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SPECIALITIES •

Pediatrics

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Psychiatry

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Oncology

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Burns

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Geriatrics

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Neurology

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Cardiology

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Rehabilitative medicine

SPECIALIZED AREAS OF PRACTICE o

Neonatal ICU

o

Pediatric ICU

o

Post operative unit

o

Pre operative unit

o

Palliative care unit

o

Rehabilitation center

o

Burns unit

o

Adult ICU’s

o

Old age homes

o

Neuropsychiatric units

o

AREA WHERE ROGERIAN MODEL IS NOT APPLICABLE

o

Operation theaters

Purpose of nursing practice •

To promote well-being for all persons, wherever they are

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To assist both the client and nurse to increase their awareness of their own rhythm

Setting for practice •

From community to hospital to outer space

Legitimate participants •

People of all ages both as individual human energy fields and group energy fields

Nursing process- Health patterning practice method •

Assessment

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Voluntary mutual patterning

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Evaluation

For the nurse •

Pattern appraisal

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Mutual patterning of human and environmental fields

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Evaluation

For the patient •

Self reflection

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Patterning activities

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Personal appraisal

Nursing process Assessment •

•

•

Areas of assessment •

Simultaneous states of the individual and the environment

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Total pattern of events at any given point in space –time

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Rhythms of life process

Supplementary data •

Categorical disease entities

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Subsystem pathology

Pattern appraisal It is a comprehensive assessment of: •

Human field patterns of communication, exchange, rhythms, dissonance

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Environmental fields pattern of communication, rhythms, dissonance, harmony

Intuitive reflection of self Validation of the appraisal •

Validate with self

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Validate with the client

Mutual patterning of human and environmental field o

Sharing knowledge

o

Offering choices

o

Empowering the client

o

Fostering patterning

o

Evaluation

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Repeat pattern appraisal

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Identify dissonance and harmony

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Validate appraisal with the client

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Self reflection for the client

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Pattern appraisal include appraisal of multiple lifestyle rhythms such as: •

Nutrition

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Work/leisure activities

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Exercise

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Sleep / wake cycles

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Relationships

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Discomfort or pain

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Fear /hopes

Patterning activities for the client Meditation Imagery Journaling Modifying the surroundings Clinical case study of Radha using Rogerian conceptual Model Radha is a 22years old female admitted in a psychiatry unit with severe depression secondary to diagnosis of ovarian malignancy She becomes tearful during history taking Radha is accompanied with her husband and 1year old child Her husband appeared anxious but supportive and attentive …………he is working as an accountant in their native place Radha was diagnosed with ovarian cancer 2 months back and underwent bilateral salphingio oopherectomy and hysterectomy……… 30days ago She is undergoing chemotherapy due to its Metastatic pattern……. From past 3 weeks Radha started sitting lonely, decreased ADL, repeated crying spells, decreased talks, neglects hygiene, muttering to self, decreased sleep , appetite, neglecting her child care, complaints of severe pain in the body,………….3 days back attempted suicide by consuming rat poison. Current assessment findings …….her general appearance is a teary eyed young woman ,ill-kempt, clinging to her husband ,looking perplexed, not talking…..poor nutritional intake, when asked about her illness….cries inconsolably …on repeated asking expressed sadness of mood Nursing care of Radha with Rogers model •

With rogerian model, the process of caring Radha begins with pattern appraisal

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Nursing care involve pattern appraisal, mutual patterning, and evaluation Pattern appraisal

•

This visible rhythmical pattern is a manifestation of evolution towards dissonance

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Radha has pattern manifestation of dissonance……..depression with suicidal ideation, ovarian malignancy, pain

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Radha has a low educational background

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A pattern activity of healing is noted through reports of a positive operative course

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Patterning has to be directed towards reduction in perceived dissonance with her personal and environmental field

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Pain is a manifestation of perceived dissonance

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Decreased environmental energy transfer is visible by decreased talking and crying

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Radha has manifestation of fear…….her self knowledge links her illness to her personal belief of being punished for her past sins

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Appraisal is needed in her sleep patterns, nutrition and her perception of self

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Appraisal can be grouped into exchanging patterns, communication patterns, and relating patterns

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Time between nurse and Radha is needed to foster her healing

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During the process nurse must rely on personal intuition and insight regarding the emerging pattern

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All this pattern forms the unitary pattern of Radha Mutual patterning

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The process is mutual between the nurse and Radha

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The surgery performed, medication she is receiving are patterning modalities

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Patterning activities planned by the nurse for Radha ……..therapeutic touch, humor , meditation, imagery

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Radha needs to be assessed fully regarding her ability to understand and agree with different patterning modalities

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Therapeutic touch can be introduced to Radha

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Touch is introduced and incorporated into the management of pain, helps in energy transmission for healing and …….helps in developing trust in the nurse

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Teach her how to center the energy and channel her energy to the area of pain

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Use humor for increasing socialization and developing self confidence and developing worthiness

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Human environmental patterning needs to involve the other individual who share her environment including husband and son

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Options are introduced relating to increase communication and hygiene patterns

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The entire family is involved in power as knowing participation in change Evaluation

•

The evaluation process centers on the perceptions of dissonance that exist after the mutual pattern activities

•

The appraisal process is repeated

•

Manifestation of worry, pain, fear, sadness of moos has to be appraised with family members

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A summary of the dissonance and/or harmony that is perceived is then shared with Radha, and mutual patterning is modified or instituted ad indicated based on the evaluation

Summary •

Biographical sketch of Martha Rogers

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Overview of Rogerian concepts

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Rogerian terminologies

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Rogerian theories

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Nursing concepts, nursing process

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Perspectives of nursing education, administration, nursing practice

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Contribution to nursing knowledge

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Clinical example

References 1. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange. 2. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins. 3. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott. 4. Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott. 5. Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

THEORIES BASED ON INTERACTIVE PROCESS IMOGENE KING: THEORY OF GOAL ATTAINMENT Major Concepts and Definitions Interaction · A process of perception and communication · Between person and environment · Between person and person · Represented by verbal and nonverbal behaviors · Goal-directed · Each individual brings different knowledge , needs, goals, past experiences and perceptions, which influence interaction Communication · Information from person to person · Directly or indirectly · Information component of interaction Perception · Each person’s representation of reality Transaction · Purposeful interaction leading to goal attainment Role · A set of behaviours expected of person’s occupying a position in a social system · Rules that define rights and obligations in a position Stress · Dynamic state · Human being interacts with the environment Growth and development · Continuous changes in individuals · At cellular, molecular and behavioural levels of activities · Helps individuals move towards maturity Time · Sequence of events · Moving onwards to the future Space · Existing in all directions · Same everywhere · Immediate environment (nurse and client interaction)

MAJOR ASSUMPTIONS Nursing · Observable behaviour · In health care system in society · Goal – to help individuals maintain health · Interpersonal process of action; reaction, interaction and transaction Person · Social beings · Sentient beings · Rational beings · Perceiving beings · Controlling beings · Purposeful beings · Action – oriented beings · Time – oriented beings Health · Dynamic state in the life cycle · Continuous adaptation to stress · To achieve maximum potential for daily living · Function of nurse, patient, physicians, family and other interactions Environment · Open system · Constantly changing · Influences adjustment to life and health Personal system Concepts • Perception •

Self

•

Body image

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Growth and development

•

Time

•

Space

Interpersonal system Concepts • Interaction •

Transaction

•

Communication

•

Role

•

Stress

Social system Concepts • Organization •

Authority

•

Power

•

Status

•

Decision making

ASSUMPTIONS • Perceptions, goals, needs and values of the nurses and client influence interaction process • Individuals have the right to knowledge about themselves and to participate in decisions that influence their life, health and community services • Health professionals have the responsibility that helps individuals to make informed decisions about their health care • Individuals have the right to accept or reject health care •

Goals of health professionals and recipients of health care may not be congruent

II. SISTER CALLISTA ROY: ADAPTATION MODEL Introduction · Begins with man · Man as a biopsychosocial being · In constant interaction with his environment Focus of nursing · Man’s position on the health – illness continuum · Influenced by ability to adapt to confronted stimuli MAJOR CONCEPTS AND DEFINITIONS System · a set of units so related or connected as to form a unit · characterised by inputs, out puts, control and feedback process. Adaptational level · a constantly changing point, made up of focal, contextual and residual stimuli · represent the persons own standard of the range of stimuli, to which one can respond with the ordinary adaptive response Adaptation problems: · the occurrence of situations of inadequate responses to need deficits or excesses Focal stimulus: · stimulus most immediately confronting the person · must make an adaptive response · factor that precipitates behaviour Contextual stimuli · all other stimuli present · contribute to behaviour caused by the focal stimuli Residual stimuli · ·

factors that may be affecting behaviour effect not validated

Regulator · subsystem coping mechanism · responds automatically through neural-chemical-endocrine processes Cognator · subsystem coping mechanism · cognitive – emotive process · responds through · perception, information · processing, learning · judgment and emotion Adaptive (effector) modes · classification of ways of coping · manifests regulator and cognator activity · physiologic, self concept, role function and interdependence Adaptive responses · Promote integrity of the person in terms of the goals of survival, growth, reproduction and mastery. Ineffective responses: · Does not contribute to adaptive goals Physiological mode · involves body’s basic needs and ways of dealing with adaptation in relation to Fluid and electrolytes Exercise and rest Elimination Nutrition Circulation Oxygen · regulation includes: The senses Temperature Endocrine regulation Self – concept mode: · composite of belief and feeling · formed from perceptions · directs one’s behaviour · components are : · the physical self · the personal self Role performance mode: * performance of duties * based on given positions in society Interdependence mode: * one’s relation with significant others

* support system * maintains psychic integrity * meets needs for nurturance and affection MAJOR ASSUMPTIONS • from system theory •

from Helson’s theory

•

from humanism

ASSUMPTIONS FROM SYSTEMS THEORY • a system is a set of units so related or connected as to form a unit or whole • •

a system is a whole that functions as a whole by virtue of the interdependence of its parts systems have inputs, outputs and control and feedback processes

•

input, in the form of a standard or feedback (information)

•

living systems are more complex than mechanical systems and have standards and feedback to direct their functioning as a whole. ASSUMPTIONS FROM HELSON’S THEORY • human behaviour represents adaptation to environmental and organismic forces • adaptive behaviour is a function of the stimulus and adaptation level, that is, the pooled effect of the focal, contextual and residual stimuli • adaptation is a process of responding positively to environmental changes •

responses reflect the state of the organism as well as the properties of stimuli and hence are regarded as active processes. ASSUMPTIONS FROM HUMANISM • Persons have their own creative power • •

A persons behaviour is purposeful and not merely a chain of cause and effect Person is holistic

•

A person’s opinions and view points are of value

•

The interpersonal relationship is significant.

ELEMENTS Nursing • A science and practice discipline •

A theoretical system of knowledge

•

Prescribes a process of analysis and action

•

Related to the care of the ill or potentially ill person

Person • A biopsychosocial being •

A living, complex, adaptive system

•

With internal processes (the cognator and regulator)

•

Acting to maintain adaptation to the four modes

Health • A state and a process of being and becoming an integrated and whole person

Environment 1. All the conditions, circumstances and influences surrounding and affecting the development and behaviour of persons or groups References • • • • • •

Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia, 2002. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton and Lange. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williamsand wilkins. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and Progress 3rd ed. Philadelphia, Lippincott. Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing –Concepts Process and Practice 3rd ed. London Mosby Year Book. Orem’s Theory Introduction One of America’s foremost nursing theorists. Dorothea Orem earned her Bachelor of science in nursing education in 1939 and Master of science in nursing in 1945 During her professional career ,she worked as a staff nurse ,private duty nurse ,nurse educator and administrator and nurse consultant Received honorary Doctor of Science degree in 1976 Dorothea Orem as a member of a curriculum subcommittee at Catholic University, recognized the need to continue in developing a conceptualization of nursing. Published first formal articulation of her ideas in Nursing: Concepts of Practice in 1971.second in 1980,and finally in 1995 Development of Theory 1949-1957 Orem worked for the Division of Hospital and Institutional Services of the Indiana State Board of Health. Her goal was to upgrade the quality of nursing in general hospitals throughout the state. During this time she developed her definition of nursing practice. 1958-1960 US Department of Health, Education and Welfare where she help publish "Guidelines for Developing Curricula for the Education of Practical Nurses" in 1959. 1959 Orem subsequently served as acting dean of the school of Nursing and as an assistant professor of nursing education at CUA. She continued to develop her concept of nursing and self care during this time. Orem’s Nursing: Concept of Practice was first published in 1971 and subsequently in 1980,1985, 1991, 1995, and 2001.

Continues to develop her theory after her retirement in 1984 Definitions of domain concepts Nursing – is art, a helping service, and a technology Actions deliberately selected and performed by nurses to help individuals or groups under their care to maintain or change conditions in themselves or their environments Encompasses the patient’s perspective of health condition ,the physician’s perspective , and the nursing perspective Goal of nursing – to render the patient or members of his family capable of meeting the patient’s self care needs To maintain a state of health To regain normal or near normal state of health in the event of disease or injury To stabilize ,control ,or minimize the effects of chronic poor health or disability Health – health and healthy are terms used to describe living things … it is when they are structurally and functionally whole or sound … wholeness or integrity. .includes that which makes a person human,…operating in conjunction with physiological and psychophysiological mechanisms and a material structure and in relation to and interacting with other human beings Environment – environment components are environmental factors ,environmental elements, conditions ,and developmental environment Human being – has the capacity to reflect ,symbolize and use symbols Conceptualized as a total being with universal ,developmental needs and capable of continuous self care A unity that can function biologically, symbolically and socially Nursing client- a human being who has "health related /health derived limitations that render him incapable of continuous self care or dependent care or limitations that result in ineffective / incomplete care. A human being is the focus of nursing only when a self –care requisites exceeds self care capabilities Nursing problem – deficits in universal, developmental, and health derived or health related conditions Nursing process- a system to determine (1)why a person is under care (2)a plan for care ,(3)the implementation of care Nursing therapeutics– deliberate ,systematic and purposeful action Orem’s General Theory of Nursing Orem’s general theory of nursing in three related parts:Theory of self care Theory of self care deficit Theory of nursing systems Theory of Self Care Includes :--

Self care – practice of activities that individual initiates and perform on their own behalf in maintaining life ,health and well being Self care agency – is a human ability which is "the ability for engaging in self care" -- Conditioned by age developmental state, life experience sociocultural orientation health and available resources Therapeutic self care demand – "totality of self care actions to be performed for some duration in order to meet self care requisites by using valid methods and related sets of operations and actions" Self care requisites-action directed towards provision of self care 3 categories of self care requisites are:-Universal Developmental Health deviation Universal self care requisites Associated with life processes and the maintenance of the integrity of human structure and functioning Common to all , ADL Identifies these requisites as: Maintenance of sufficient intake of air ,water, food Provision of care assoc with elimination process Balance between activity and rest, between solitude and social interaction Prevention of hazards to human life well being and Promotion of human functioning Developmental self care requisites Associated with developmental processes/ derived from a condition…. Or associated with an event E.g. adjusting to a new job adjusting to body changes Health deviation self care Required in conditions of illness ,injury, or disease .these include:-o o o o o

Seeking and securing appropriate medical assistance Being aware of and attending to the effects and results of pathologic conditions Effectively carrying out medically prescribed measures Modifying self concepts in accepting oneself as being in a particular state of health and in specific forms of health care Learning to live with effects of pathologic conditions

Theory of self care deficit Specifies when nursing is needed

Nursing is required when an adult (or in the case of a dependent ,the parent) is incapable or limited in the provision of continuous effective self care Orem identifies 5 methods of helping:-Acting for and doing for others Guiding others Supporting another Providing an environment promoting personal development in relation to meet future demands Teaching another Theory of Nursing Systems Describes how the patient’s self care needs will be met by the nurse , the patient, or both Identifies 3 classifications of nursing system to meet the self care requisites of the patient:Wholly compensatory system Partly compensatory system Supportive – educative system Design and elements of nursing system define Scope of nursing responsibility in health care situations General and specific roles of nurses and patients Reasons for nurses’ relationship with patients and The kinds of actions to be performed and the performance patterns and nurses’ and patients’ actions in regulating patients’ self care agency and in meeting their self care demand Orem recognized that specialized technologies are usually developed by members of the health profession A technology is systematized information about a process or a method for affecting some desired result through deliberate practical endeavor ,with or without use of materials or instruments Categories of technologies Social or interpersonal Communication adjusted to age, health status Maintaining interpersonal ,intragroup or intergroup relations for coordination of efforts Maintaining therapeutic relationship in light of psychosocial modes of functioning in health and disease Giving human assistance adapted to human needs ,action abilities and limitations Regulatory technologies Maintaining and promoting life processes Regulating psycho physiological modes of functioning in health and disease

Promoting human growth and development Regulating position and movement in space Orem’s Theory and Nursing Process Orem’s approach to the nursing process presents a method to determine the self care deficits and then to define the roles of person or nurse to meet the self care demands. The steps within the approach are considered to be the technical component of the nursing process. Orem emphasizes that the technological component "must be coordinated with interpersonal and social processes within nursing situations Comparison of Orem’s Nursing Process and the Nursing Process Nursing Process Assessment Nursing diagnosis Plans with scientific rationale Implementation evaluation Orem’s Nursing. Process Diagnosis and prescription ;determine why nursing is needed. analyze and interpret –make judgment regarding care Design of a nursing system and plan for delivery of care Production and management of nursing systems Step 1-collect data in six areas:The person’s health status The physician’s perspective of the person’s health status The person’s perspective of his or her health The health goals within the context of life history ,life style, and health status The person’s requirements for self care The person’s capacity to perform self care Step 2 Nurse designs a system that is wholly or partly compensatory or supportive-educative. The 2 actions are:Bringing out a good organization of the components of patients’ therapeutic self care demands Selection of combination of ways of helping that will be effective and efficient in compensating for/ overcoming patient’s self care deficits Step 3 Nurse assists the patient or family in self care matters to achieve identified and described health and health related results ..collecting evidence in evaluating results achieved against results specified in the nursing system design

Actions are directed by etiology component of nursing diagnosis evaluation Application of Orem’s theory to nursing process Personal factors

Universal self care

29 yr.

32pack /yr

Female

Water-no restrictions

Early adulthood transition

Food –nil Wt89lb Wt loss-19%

Developmental Health self care deviatio n Teenage pregnancy-2 OC-10 yrs Husband emotionally away

nauseated 8th grade Teenage pregnancy No work Married Child-2

Lives at mother’s home. Environmen t unclean Limited resources

Urinary retention Intermittent self catheterizatio n Pain

Medical problem & plan

Self care deficits

Surgery on reproductive organs

Difference between knowledge base & lifestyle

Seeks medical attention for overt s/s Aware of disease No evidence

No BSE Infrequent physical examination

ability to manage effects

No HRT Poor health

Tearful

EDU deprivation

Husband abusive

Oppressive living conditions

Dissatisfied with home

Will receive RT ,perform intermittent catheterizatio n

RT

Therapeutic self care demand

Adequacy of self care agency

Nursing diagnosis

Methods of helping

Air Maintain effective respiration Water No problem Food maintain sufficient intake

Inadequate Potential for impaired respiratory status P F fluid imbalance Adequate

Actual nutritional deficit r/t ausea

Inadequate

Guiding & directing

Teaching Providing physical support

Personal development Hazards

Inadequate P/F injury

Prevent spouse abuse Promotion of normalcy

Guiding & directing Guiding & directing

Inadequate A/d in environment Shared housing

Maintain developmental environment Support ed normalcy in environment Prevent /manage dev threat

Inadequate Actual delay in normaldev. R/T early parenthood

Inadequate

Guiding & directing Providing psy support

Level of education Providing physical, psy support Dev deficit r/t loss of reproductive organs

Maintenance of health status

Inadequate

Management of disease process

Inadequate

Adherence to med regimen

Inadequate

Awareness of potential problems

Inadequate

Adjust to loss of reproductive ability & dev healthy view of illness

Inadequate

Adjust life style to cope with change

Inadequate

P/F contd. alterations in health status P/F UTI

P/F ¯ adherence in self catheterization & OPD RT

Guiding & directing, teaching Guiding & directing, teaching

teaching

teaching

Actual deficit in awareness of advisability of HRT & RT effects

Actual threat to self image

Providing psy support

Actual self deficit in planning for future needs

Guiding & directing

Orem’s work and the characteristics of a theory Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon Theories must be logical in nature Theories must be relatively simple yet generalizable Theories are the basis for hypothesis that can be tested Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them Theories can be used by the practitioners to guide and improve their practice Theories must be consistent with other validated theories ,laws and principles Theory Testing Orem’s theory has been used as the basis for the development of research instruments to assist researchers in using the theory A self care questionnaire was developed and tested by Moore(1995) for the special purpose of measuring the self care practice of children and adolescents

The theory has been used as a conceptual framework in assoc. degree programs (Fenner 1979) also in many nursing schools Strengths Provides a comprehensive base to nursing practice It has utility for professional nursing in the areas of nursing practice nursing curricula ,nursing education administration ,and nursing research Specifies when nursing is needed Also includes continuing education as part of the professional component of nursing education Her self care approach is contemporary with the concepts of health promotion and health maintenance Expanded her focus of individual self care to include multiperson units Limitations In general system theory a system is viewed as a single whole thing while Orem defines a system as a single whole ,thing Health is often viewed as dynamic and ever changing .Orem’s visual presentation of the boxed nursing systems implies three static conditions of health Appears that the theory is illness oriented rather with no indication of its use in wellness settings Summary Orem’s general theory of nursing is composed of three constructs .Throughout her work ,she interprets the concepts of human beings, health, nursing and society .and has defined 3 steps of nursing process It has a broad scope in clinical practice and to lesser extent in research ,education and administration References • • • • • • • • •

Orem, D.E. (1991). Nursing: Concepts of practice (4th ed.). St. Louis, MO: Mosby-Year Book Inc. Taylor, S.G. (2006). Dorthea E. Orem: Self-care deficit theory of nursing. In A.M. Tomey, A. & Alligood, M. (2002). Significance of theory for nursing as a discipline and profession. Nursing Theorists and their work. Mosby, St. Louis, Missouri, United States of America. Whelan, E. G. (1984). Analysis and application of Dorothea Orem’s Self-care Practuce Model. Retrieved October 31, 2006. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott. Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott. Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

THE ROY'S ADAPTATION MODEL Introduction Sr.Callista Roy, a prominent nurse theorist, writer, lecturer, researcher and teacher Professor and Nurse Theorist at the Boston College of Nursing in Chestnut Hill Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and Mrs. Fabien Roy she earned a Bachelor of Arts with a major in nursing from Mount St. Mary's College, Los Angeles in 1963. a master's degree program in pediatric nursing at the University of California ,Los Angeles in 1966. She also earned a master’s and PhD in Sociology in 1973 and 1977 ,respectively. Sr. Callista had the significant opportunity of working with Dorothy E. Johnson Johnson's work with focusing knowledge for the discipline of nursing convinced Sr. Callista of the importance of describing the nature of nursing as a service to society and prompted her to begin developing her model with the goal of nursing being to promote adaptation. She joined the faculty of Mount St. Mary's College in 1966, teaching both pediatric and maternity nursing. She organized course content according to a view of person and family as adaptive systems. She introduced her ideas about ‘Adaptation Nursing’ as the basis for an integrated nursing curriculum. Goal of nursing to direct nursing education, practice and research Model as a basis of curriculum impetus for growth--Mount St. Mary’s College 1970-The model was implemented in Mount St. Mary’s school 1971- she was made chair of the nursing department at the college. Influencing Factors •

Family

•

Education

•

Religious Background

•

Mentors

•

Clinical Experience

Theory description •

The central questions of Roy’s theory are: o

Who is the focus of nursing care?

o

What is the target of nursing care?

o

When is nursing care indicated?

•

Roy’s first ideas appeared in a graduate paper written at UCLA in 1964.

•

Published these ideas in "Nursing outlook" in 1970

•

Subsequently different components of her framework crystallized during 1970s, ’80s, and ’90s

•

Over the years she identified assumptions on which her theory is based.

Explicit assumptions (Roy 1989; Roy and Andrews 1991) •

The person is a bio-psycho-social being.

•

The person is in constant interaction with a changing environment.

•

To cope with a changing world, person uses both innate and acquired mechanisms which are biological, psychological and social in origin.

•

Health and illness are inevitable dimensions of the person’s life.

•

To respond positively to environmental changes ,the person must adapt.

•

The person’s adaptation is a function of the stimulus he is exposed to and his adaptation level

•

The person’s adaptation level is such that it comprises a zone indicating the range of stimulation that will lead to a positive response.

•

The person has 4 modes of adaptation: physiologic needs, self- concept, role function and inter-dependence.

•

"Nursing accepts the humanistic approach of valuing other persons’ opinions, and view points" Interpersonal relations are an integral part of nursing

•

There is a dynamic objective for existence with ultimate goal of achieving dignity and integrity

Implicit assumptions •

A person can be reduced to parts for study and care.

•

Nursing is based on causality.

•

Patient’s values and opinions are to be considered and respected.

•

A state of adaptation frees an individual’s energy to respond to other stimuli.

Roy Adaptation Model Concepts: Early and Revised •

Adaptation -- goal of nursing

•

Person -- adaptive system

•

Environment -- stimuli

•

Health -- outcome of adaptation

•

Nursing -- promoting adaptation and health

Concepts-Adaptation •

Responding positively to environmental changes

•

The process and outcome of individuals and groups who use conscious awareness, self reflection and choice to create human and environmental integration Concepts-Person

•

Bio-psycho-social being in constant interaction with a changing environment

•

Uses innate and acquired mechanisms to adapt

•

An adaptive system described as a whole comprised of parts

•

Functions as a unity for some purpose

•

Includes people as individuals or in groups-families, organizations, communities, and society as a whole Concepts-Environment

•

Focal - internal or external and immediately confronting the person

•

Contextual- all stimuli present in the situation that contribute to effect of focal stimulus

•

Residual-a factor whose effects in the current situation are unclear

•

All conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups with particular consideration of mutuality of person and earth resources, including focal, contextual and residual stimuli Concepts-Health

•

Inevitable dimension of person's life

•

Represented by a health-illness continuum

•

A state and a process of being and becoming integrated and whole Concepts-Nursing

•

To promote adaptation in the four adaptive modes

•

To promote adaptation for individuals and groups in the four adaptive modes, thus contributing to health, quality of life, and dying with dignity by assessing behaviors and factors that influence adaptive abilities and by intervening to enhance environmental interactions Concepts-Subsystems

•

Cognator subsystem — A major coping process involving 4 cognitive-emotive channels: perceptual and information processing, learning, judgment and emotion.

•

Regulator subsystem — a basic type of adaptive process that responds automatically through neural, chemical, and endocrine coping channels Relationships

•

Derived Four Adaptive Modes

•

500 Samples of Patient Behavior

•

What was the patient doing?

•

What did the patient look like when needing nursing care? Four Adaptive Modes

•

Physiologic Needs

•

Self Concept

•

Role Function

•

Interdependence Four Adaptive Mode Categories

•

Tested in practice for 10 years

•

Criteria of significance, usefulness, and completeness were met Sample Proposition and Hypothesis for Practice

•

Self Concept Mode: Increased quality of social experience leads to increased feelings of adequacy

•

Providing support for new mothers can lead to positive parenting

Theory Development Derived Theory •

91 Propositions

•

Described relationships between and among regulator and cognator and four adaptive modes

•

12 Generic propositions Questions Raised by 21st Century Changes

•

How can ethics and public policy keep pace with developments in science?

•

How can nurses focus on human needs not machines?

•

How can nurses contribute to creating meaning and purpose in a global society?

Scientific Assumptions for the 21st Century •

Systems of matter and energy progress to higher levels of complex self organization

•

Consciousness and meaning are constitutive of person and environment integration

•

Awareness of self and environment is rooted in thinking and feeling

•

Human decisions are accountable for the integration of creative processes.

•

Thinking and feeling mediate human action

•

System relationships include acceptance, protection, and fostering of interdependence

•

Persons and the earth have common patterns and integral relations

•

Person and environment transformations are created in human consciousness

•

Integration of human and environment meanings results in adaptation

Philosophical Assumptions •

Persons have mutual relationships with the world and God

•

Human meaning is rooted in an omega point convergence of the universe

•

God is intimately revealed in the diversity of creation and is the common destiny of creation

•

Persons use human creative abilities of awareness, enlightenment, and faith

•

Persons are accountable for the processes of deriving, sustaining, and transforming the universe

Adaptation and Groups •

Includes relating persons, partners, families, organizations, communities, nations, and society as a whole

Adaptive Modes Persons •

Physiologic

•

Self Concept

•

Role Function

•

Interdependence Groups

•

Physical

•

Group Identity

•

Role Function

•

Interdependence Role Function Mode

•

Underlying Need of Social integrity

•

The need to know who one is in relation to others so that one can act

•

The need for role clarity of all participants in group Adaptation Level

•

A zone within which stimulation will lead to a positive or adaptive response

•

Adaptive mode processes described on three levels:

•

Integrated

•

Compensatory

•

Compromised Integrated Life Processes

•

Adaptation level where the structures and functions of the life processes work to meet needs

•

Examples of Integrated Adaptation

•

Stable process of breathing and ventilation

•

Effective processes for moral-ethical-spiritual growth Compensatory Processes

•

Adaptation level where the cognator and regulator are activated by a challenge to the life processes

•

Compensatory Adaptation Examples:

•

Grieving as a growth process, higher levels of adaptation and transcendence

•

Role transition, growth in a new role Compromised Processes

•

Adaptation level resulting from inadequate integrated and compensatory life processes

•

Adaptation problem

•

Compromised Adaptation Examples

•

Hypoxia

•

Unresolved Loss

•

Stigma

•

Abusive Relationships

The nursing process •

RAM offers guidelines to nurse in developing the nursing process.

•

The elements : •

First level assessment

•

Second level assessment

•

Diagnosis

•

Goal setting

•

Intervention

•

evaluation

Usefulness of Adaptation Model •

Scientific knowledge for practice

•

Clinical assessment and intervention

•

Research variables

•

To guide nursing practice

•

To organize nursing education

•

Curricular frame work for various nursing colleges

Characteristics of the theory •

Theories can interrelates concepts in such a way as to present a new view of looking at a particular phenomenon.

•

Theories must be logical in nature

•

Theories should be relatively simple yet generalizable

•

Theories can be the basis for the hypotheses that can be tested

•

Theories contribute to and assist in increasing the general body of knowledge of a discipline through the research implemented to validate them

•

Theories can be utilized by the practitioners to guide and improve their practice

•

Theories must be consistent with other validated theories, laws and principles but will leave open unanswered questions that need to be investigated

Testability •

RAM is testable

•

BBARNS (1999) reported that 163 studies have been conducted using this model.

•

RAM is complete and comprehensive

•

It explains the reality of client, so nursing interventions can be specifically targeted.

Research studies using RAM •

Middle range theories have been derived from RAM

•

1998-Ducharme et al described a longitudinal model of psychosocial determinants of adaptation

•

1998-Levesque et al presented a MRT of psychological adaptation

•

1999-A MRNT , the urine control theory by Jirovec et al

•

Dunn, H.C. and Dunn, D. G. (1997). The Roy Adaptation Model and its application to clinical nursing practice. Journal of Ophthalmic Nursing and Technology. 6(2), 74-78.

•

Samarel, N., Fawcett, J., Krippendorf, K., Piacentino, J.C., Eliasof, B., Hughes, P., Kowitski, C., and Ziegler, E. (1998). Women's perception of group support and adaptation to breast cancer. Journal of Advanced Nursing. 28(6), 12591268.

•

Chiou, C. (2000). A meta-analysis of the interrelationships between the modes in Roy's adaptation model. Nursing Science Quarterly. 13(3), 252-258

•

Yeh, C. H. (2001). Adaptation in children with cancer: research with Roy's model. Nursing Science Quarterly. 14, 141-148.

•

Zhan, L. (2000). Cognitive adaptation and self-consistency in hearingimpaired older persons: testing Roy's adaptation model. Nursing Science Quarterly. 13(2), 158-165.

Summary 1. 5 elements -person, goal of nursing, nursing activities, health and environment •

Persons are viewed as living adaptive systems whose behaviours may be classified as adaptive responses or ineffective responses.

•

These behaviors are derived from regulator and cognator mechanisms.

•

These mechanisms work with in 4 adaptive modes.

•

The goal of nursing is to promote adaptive responses in relation to 4 adaptive modes, using information about person’s adaptation level, and various stimuli.

•

Nursing activities involve manipulation of these stimuli to promote adaptive responses.

•

Health is a process of becoming integrated and able to meet goals of survival, growth, reproduction, and mastery.

•

The environment consists of person’s internal and external stimuli.

References •

George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange.

•

Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.

•

Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

•

Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

•

Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

•

Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-15

•

Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):225

ORLANDO'S NURSING PROCESS THEORY INTRODUCTION Ida Jean Orlando, a first-generation American of Italian descent was born in 1926. She received her nursing diploma from New York Medical College, her BS in public health nursing from St. John's University, NY, and her MA in mental health nursing from Columbia University, New York. Orlando was an Associate Professor at Yale School of Nursing where she was Director of the Graduate Program in Mental Health Psychiatric Nursing. While at Yale she was project investigator of a National Institute of Mental Health grant entitled: Integration of Mental Health Concepts in a Basic Nursing Curriculum. It was from this research that she developed her theory which was published in her 1961 book, The Dynamic Nurse-Patient Relationship. She furthered the development of her theory when at McLean Hospital in Belmont, MA as Director of a Research Project: Two Systems of Nursing in a Psychiatric Hospital. The results of this research are contained in her 1972 book titled: The Discipline and Teaching of Nursing Processes Orlando held various positions in the Boston area, was a board member of Harvard Community Health Plan, and served as both a national and international consultant. She is a frequent lecturer and conducted numerous seminars on nursing process. Orlando's theory was developed in the late 1950s from observations she recorded between a nurse and patient. Despite her efforts, she was only able to categorize the records as "good" or "bad" nursing.

It then dawned on her that both the formulations for "good" and "bad" nursing were contained in the records. From these observations she formulated the deliberative nursing process Questions What prompts nursing actions? What are the properties of dynamic nurse patient relationships that may lead to effective care? Answer Nurses were prompted in their actions for reasons other than the patients immediate experiences and needs INTRODUCTION TO THEORY The role of the nurse is to find out and meet the patient's immediate need for help. The patient's presenting behavior may be a plea for help, however, the help needed may not be what it appears to be. Therefore, nurses need to use their perception, thoughts about the perception, or the feeling engendered from their thoughts to explore with patients the meaning of their behavior. This process helps nurse find out the nature of the distress and what help the patient needs. MAJOR DIMENSIONS OF THE THEORY Function of professional nursing - organizing principle Presenting behavior - problematic situation Immediate reaction - internal response Nursing process discipline – investigation Improvement - resolution FUNCTIONS OF PROFESSIONAL NURSING – ORGANIZING PRINCIPLE Finding out and meeting the patients immediate needs for help Nursing….is responsive to individuals who suffer or anticipate a sense of helplessness, it is focused on the process of care in an immediate experience, it is concerned with providing direct assistance to individuals in whatever setting they are found for the purpose of avoiding, relieving, diminishing or curing the individuals sense of helplessness The purpose of nursing is to supply the help a patient requires for his needs to be met Nursing thought - Does the patient have an immediate need for help or not? If the patient has an immediate need for help and the nurse finds out and meets that need ,the function of professional nursing is achieved PRESENTING BEHAVIOR – PROBLEMATIC SITUATION To find out the immediate need for help the nurse must first recognize the situation as problematic

The presenting behavior of the patient, regardless of the form in which it appears, may represent a plea for help The presenting behavior of the patient, the stimulus, causes an automatic internal response in the nurse, and the nurses behavior causes a response in the patient IMMEDIATE REACTION –INTERNAL RESPONSE Person perceives with any one of his five sense organs an object or objects The perceptions stimulate automatic thought Each thought stimulates an automatic feeling Then the person acts The first three items taken together are defined as the person’s immediate reaction Reflects how the nurse experiences her or his participation in the nurse patient situation NURSING PROCESS DISCIPLINE - INVESTIGATION Any observation shared and explored with the patient is immediately useful in ascertaining and meeting his need or finding out that he is not in need at that time The nurse does not assume that any aspect of her reaction to the patient is correct, helpful or appropriate until she checks the validity of it in exploration with the patient The nurse initiates a process of exploration to ascertain how the patient is affected by what she says or does Automatic reactions are not effective because the nurses action is decided upon for reasons other than the meaning of the patients behavior or the patients immediate need for help When the nurse does not explore with the patient her reaction it seems reasonably certain that clear communication between them stops IMPROVEMENT - RESOLUTION It is not the nurses activity that is evaluated but rather its result : whether the activity serves to help the patient communicate her or his need for help and how it is met In each contact the nurse repeats a process of learning how to help the individual patient. Her own individuality and that of the patient requires that she go through this each time she is called upon to render service to those who need her ASSUMPTIONS When patients cannot cope with their needs without help, they become distressed with feelings of helplessness Nursing , in its professional character , does add to the distress of the patient Patients are unique and individual in their responses

Nursing offers mothering and nursing analogous to an adult mothering and nurturing of a child Nursing deals with people, environment and health Patient need help in communicating needs, they are uncomfortable and ambivalent about dependency needs Human beings are able to be secretive or explicit about their needs, perceptions, thoughts and feelings The nurse – patient situation is dynamic, actions and reactions are influenced by both nurse and patient Human beings attach meanings to situations and actions that are not apparent to others Patients entry into nursing care is through medicine The patient cannot state the nature and meaning of his distress for his need without the nurses help or without her first having established a helpful relationship with him Any observation shared and observed with the patient is immediately useful in ascertaining and meeting his need or finding out that he is not in need at that time Nurses are concerned with needs that patients cannot meet on their own DOMAIN CONCEPTS Nursing – is responsive to individuals who suffer or anticipate a sense of helplessness Process of care in an immediate experience….. for avoiding, relieving, diminishing or curing the individuals sense of helplessness Finding out meeting the patients immediate need for help Goal of nursing – increased sense of well being, increase in ability, adequacy in better care of self and improvement in patients behavior Health – sense of adequacy or well being . Fulfilled needs. Sense of comfort Environment – not defined directly but implicitly in the immediate context for a patient Human being – developmental beings with needs, individuals have their own subjective perceptions and feelings that may not be observable directly Nursing client – patients who are under medical care and who cannot deal with their needs or who cannot carry out medical treatment alone Nursing problem – distress due to unmet needs due to physical limitations, adverse reactions to the setting or experiences which prevent the patient from communicating his needs Nursing process – the interaction of 1)the behavior of the patient, 2) the reaction of the nurse and 3)the nursing actions which are assigned for the patients benefit Nurse – patient relations – central in theory and not differentiated from nursing therapeutics or nursing process

Nursing therapeutics – Direct function : initiates a process of helping the patient express the specific meaning of his behavior in order to ascertain his distress and helps the patient explore the distress in order to ascertain the help he requires so that his distress may be relieved. Indirect function – calling for help of others , whatever help the patient may require for his need to be met Nursing therapeutics - Disciplined and professional activities – automatic activities plus matching of verbal and nonverbal responses, validation of perceptions, matching of thoughts and feelings with action Automatic activities – perception by five senses, automatic thoughts, automatic feeling, action THEORY ANALYSIS PARADIGMATIC ORIGINS Paplau’s focus of interpersonal relationships in nursing Paplau acknowledged the influence of Harry Stack Sullivan on the development of her ideas Symbolic interactionism – Chicago school Use of field methodology John Dewey’s theory of inquiry ORLANDO'S WORK AND CHARACTERISTICS OF A THEORY Theories can interrelate concepts in such a way in such a way as to create a different way of looking at a particular phenomenon Theories must be logical in nature Theories should be relatively simple yet generalizable Theories can be the bases for hypotheses that can be tested Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them Theories can be utililized by practitioners to guide and improve their practice Theories must be consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated INTERNAL DIMENSIONS •

Analyzed 2000 nurse – patient interactions to identify the properties, dimensions and goals of interactions

•

Use of field approach

•

Focus on describing psychosocial aspects of nurse - patient interaction

•

Used a mixture of operational and problematic methods of theory development

•

Focus on how to deliver care not on what care to be given

•

Nursing process theory of low to medium level abstraction

STRENGTHS

•

Use of her theory assures that patient will be treated as individuals and that they will have active and constant input into their own care

•

Prevents inaccurate diagnosis or ineffective plans because the nurse has to constantly explore her reactions with the patient

•

Assertion of nursing’s independence as a profession and her belief that this independence must be based on a sound theoretical frame work

•

Guides the nurse to evaluate her care in terms of objectively observable patient outcomes

•

Make evaluation a less time consuming and more deliberate function, the results of which would be documented in patients charts

•

Nursing can pursue Orlando's work for retesting and further developing her work

THEORY CRITIQUE •

Lack of operational definitions for concepts – limits development of research hypothesis

•

Theory is more congruent in guiding nurse – patient interactions for assessing needs and in providing nursing therapeutics deemed necessary to patient care

•

Focus on short term care, particularly aware and conscious individuals and on the virtual absence of reference group or family members

LIMITATIONS •

Highly interactive nature Orlando's theory makes it hard to include the highly technical and physical care that nurses give in certain settings

•

Her theory struggles with the authority derived from the function of profession and that of the employing institution’s commitment to the public

EXTERNAL COMPONENTS •

Value of nursing shifted from task oriented to patient oriented nursing process

•

Theory is culturally bound

•

Misinterpretation of continuous validation as lack of knowledge and expertise

•

The uniqueness of individuals assumed by the theory could counteract automatic responses of nurses

COMPARISON WITH NURSING PROCESS THEORY TESTING •

Validation of perceptions, thoughts and feelings is essential for enhancing the congruence between patient’s needs and the care given

•

Results indicate unique nursing process is more effective than other approaches in dealing with pain, in reducing stress, in understanding patient’s needs, in relieving distress to experienced by patients during the process of admission to a hospital

•

Used in describing the responsibilities of nursing students to distressed patients

•

A number of studies focused on explicating the properties and components of nurse – patient interactions

•

Perceptions was used as a frame work to describe needs of grieving spouses

•

Gillis supported Orlando’s differentiation between presenting problems as perceived by the nurse and those as perceived and validated by patients

•

Used as a framework to research nursing administration USES OF THEORY

•

•

Use in Education •

Midwestern State University in Wichita Falls, Texas, is using Orlando's theory for teaching entering nursing students.

•

South Dakota State University in Brookings, SD has been using Haggerty’s (1985) description of the communication based on Orlando’s theory for entering nursing students as well as reenforcing it in their junior year

Uses in Administration o

•

•

Schmieding successfully used Orlando's theory in two major hospitals for both practice and administration (Lincoln General Hospital, Lincoln, NE and Boston City Hospital, Boston, MA).. Implementation of Orlando’s theory produced substantial benefits. Its use increased effectiveness in meeting patient needs; improved decision-making skills among staff nurses, including determining what constituted nursing versus non-nursing functions; negotiated more effectively in resolving conflict among staff nurses and between staff and physicians; and influenced a more positive nursing identity and unity among staff.

Use in Research o

In an Veterans Administration (VA) ambulatory psychiatric practice in Providence, RI Shea, McBride, Gavin, and Bauer (1987) used Orlando’s theoretical model with patients (N = 76) having a bipolar disorder. Their research results indicate that there were: higher patient retention, reduction of emergency services, decreased hospital stay, and increased satisfaction.

•

In a pilot study, Potter and Bockenhauer (2000) found positive results after implementing Orlando’s theory. These included: positive, patient-centered outcomes, a model for staff to use to approach patients, and a decrease in patient’s immediate distress.

Use in Clinical Practice o

Nursing care plan

o

Case studies

o

Progressive patient care settings

Nursing process •

Assessment

•

Diagnosis

•

Planning

•

Implementation

•

Evaluation

SUMMARY •

Theorist – IDA JEAN ORLANDO

•

Development of theory

•

Dimensions of theory

•

Assumptions

•

Concepts

•

Theory analysis

•

Characteristics of a theory

•

Paradigmatic origins

•

Strengths and limitations

•

Internal and external components

•

Comparison with nursing process

•

Theory testing and uses of theory

CONCLUSION TO THEORY 1. Orlando's theory remains one the of the most effective practice theories available. 2. The use of her theory keeps the nurse's focus on the patient. 3. The strength of the theory is that it is clear, concise, and easy to use. 4. While providing the overall framework for nursing, the use of her theory does not exclude nurses from using other theories while caring for the patient. REFERENCES •

George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange.

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Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.

•

Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

•

Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

•

Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

•

Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-15

•

Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):225

APPLICATION OF IMOGENE KING’S THEORY OF GOAL ATTAINMENT Objectives 1. to assess the patient condition by the various methods explained by the nursing theory 2. to identify the needs of the patient 3. to demonstrate an effective communication and interaction with the patient. 4. to select a theory for the application according to the need of the patient 5. to apply the theory to solve the identified problems of the patient 6. to evaluate the extent to which the process was fruitful. Introduction King’s theory offers insight into nurses’ interactions with individuals and groups within the environment. It highlights the importance of client’s participation in decision that influences care and focuses on both the process of nurse-client interaction and the outcomes of care. Mr.Sy (74 years) was admitted in L3 ward of ...Hospital, for a herniorrhaphy on ... for his left indirect inguinal hernia and was expecting discharge from hospital... the theory of goal attainment was used in his nursing process. Major Concepts and Definitions 1.

Interaction A process of perception and communication Between person and environment

Between person and person Represented by verbal and nonverbal behaviours Goal-directed Each individual brings different knowledge , needs, goals, past experiences and perceptions, which influence interaction 2. Communication Information from person to person Directly or indirectly Information component of interaction 3. Perception Each person’s representation of reality 4. Transaction Purposeful interaction leading to goal attainment 5. Role A set of behaviours expected of person’s occupying a position in a social system Rules that define rights and obligations in a position 6. Stress Dynamic state Human being interacts with the environment 7. Growth and development Continuous changes in individuals At cellular, molecular and behavioural levels of activities Helps individuals move towards maturity 8. Time Sequence of events Moving onwards to the future 9. Space Existing in all directions Same everywhere Immediate environment (nurse and client interaction) MAJOR ASSUMPTIONS Nursing Observable behaviour In health care system in society Goal – to help individuals maintain health Interpersonal process of action; reaction, interaction and transaction Person 1. Social beings 2. Sentient beings 3. Rational beings 4. Perceiving beings 5. Controlling beings 6. Purposeful beings 7. Action – oriented beings

8. Time – oriented beings Health Dynamic state in the life cycle Continuous adaptation to stress To achieve maximum potential for daily living Function of nurse, patient, physicians, family and other interactions Environment Open system Constantly changing Influences adjustment to life and health Dynamic Interacting Systems Personal system Concepts Perception Self Body image Growth and development Time Space Interpersonal system Concepts 1. Interaction, 2. Transaction 3. Communication 4. Role 5. Stress Social system Concepts 1. Organization 2. Authority 3. Power 4. Status, 5. Decision making ASSUMPTIONS Perceptions, goals, needs and values of the nurses and client influence interaction process Individuals have the right to knowledge about themselves and to participate in decisions that influence their life, health and community services Health professionals have the responsibility that helps individuals to make informed decisions about their health care Individuals have the right to accept or reject health care Goals of health professionals and recipients of health care may not be congruent Propositions of King’s Theory From the theory of goal attainment king developed predictive propositions, which includes: If perceptual interaction accuracy is present in nurse-client interactions, transaction will occur If nurse and client make transaction, goal will be attained If goal are attained, satisfaction will occur Proposition cont… If transactions are made in nurse-client interactions, growth & development will be enhanced

If role expectations and role performance as perceived by nurse & client are congruent, transaction will occur If role conflict is experienced by nurse or client or both, stress in nurseclient interaction will occur If nurse with special knowledge skill communicate appropriate information to client, mutual goal setting and goal attainment will occur. Theory of Goal Attainment and Nursing Process Assumptions Basic assumption of goal attainment theory is that nurse and client communicate information, set goal mutually and then act to attain those goals, is also the basic assumption of nursing process. Assessment King indicates that assessment occur during interaction. The nurse brings special knowledge and skills whereas client brings knowledge of self and perception of problems of concern, to this interaction. During assessment nurse collects data regarding client (his/her growth & development, perception of self and current health status, roles etc.) Perception is the base for collection and interpretation of data. Communication is required to verify accuracy of perception, for interaction and transaction. The first process in nursing process is nurse meets the patient and communicates and interacts with him. Assessment is conducted by gathering data about the patient based on relevant concepts. Mr. Sy is 74yrs married, got admitted in L3 ward of ...Hospital on 27/03/08 with a diagnosis of indirect inguinal hernia underwent herniorraphy with prolene mesh done on 30/03/08. The following areas were addressed to for gathering data. What is the patient’s perception of the situation?

Patient says ” I have undergone surgery for hernia”. “ The wound is getting healed, I have no other problem” “I have pain in the area of surgery when moving” “I’m taking medicines for hypertension for the last 7 years from here” “I have vision problem to my left eye. I had undergone a surgery for my right eye about 10 years back”.

What are my perceptions of the situation?

Patient underwent herniorahaphy operation on 30th March for indirect inguinal hernia which he kept untreated for 35 years. Patient has health maintenance related problems. Patient is at risk of developing infection. Patient has pain related to surgical incision. Patient may develop hypertension related complications in future.

What other information do I need to assist this patient to achieve health?

History Identification details Mr. Sy is 74yrs married, male, studied up to 7th

Std is doing Business, a practicing Muslim, got admitted in L3 ward of ...Hospital on 27/03/08 with a diagnosis of indirect inguinal hernia underwent herniorraphy with prolene mesh done on 30/03/08. Present History of Illness Abdominal swelling for 35 years with difficulty in activities and occasional abdominal pain. He has hypertension for seven years. The swelling remained stable with uncomplicated progress, getting increasing size when standing for long and reducible on applying pressure No h/o severe pain but increasing size for the last few years Relived after pressing the swelling back to position and on taking rest and applying pressure Past health history Patient underwent cataract surgery about 10 years back On treatment for hypertension No other significant illness Family History Patient’s next elder brother and next younger brother had inguinal hernia and were operated Elder brother underwent 3 surgeries for hernia Socioeconomic Status High economic status >Rs.20000/- per month Life Style Non vegetarian No habit of smoking or alcoholism. Aware about health care facilities Physical examination Alert, conscious and oriented Moderately built, adequate nourishment, with BMI of 22 Vital signs – normal except BP 140/90 mmHg General head-to-foot examination reveals normal finding except for the vision difficulty of the right eye and healing surgical wound on th left inguinal region. Subjective problems Pain at the surgical wound site Lack of bowel movement for 2 days Review of relevant systems GI system Inspection: Healing wound, No infection, No redness, No swelling

Auscultation: Normal bowel sounds Palpation No pain at the site, Normal abdominal organs Percussion: No dull sound suggesting fluid collection or ascitis Genito-Urinary system Inspection: Testicles in position, No infection, No swelling or enlargement Palpation No c/o pain,No prostate enlargement Percussion No fluid collection in scrotum Auscultation Normal Bowel sounds Laboratory Investigations FBS - 91 mg/dl Na(130-143mEq/dl) - 134 mEq / dl K+ (3.5-5 mg/dl) - 3.5 mEq / dl Urea(8-35mg/dl)-29 mg / dl Cr (0.6-1.6 mg/ dl)- <1 mg/ dl Other investigations Electro cardio gram Ant. Fascicular block Left atrial enlargement Normal axis What does this information means to this situation?

years

Patient neglected a health problem for 35 Patient has acute pain at the site of surgical

wound Patient has family history of inguinal hernia and risk for recurrence Patient has a risk for recurrence due to constipation. Patient has risk for infection due to inadequate knowledge and age. Patient is at risk of developing complications of hypertension Patient requires education regarding health maintenance What conclusion (judgement) does this patient make?

Patient requires management for his pain Patient understands the need taking care of health risks and agrees to work on these aspects

What conclusions (judgement) do I make?

Based on the assessment following nursing diagnoses were formulated, i.e. the clinical

Nursing diagnosis The data collected by assessment are used to make nursing diagnosis in nursing process. Acc. to King in process of attaining goal, the nurse identifies the problems, concerns and disturbances about which person seek help.

judgement about the patient’s actual and potential problems. • Acute pain related to surgical incision •

Risk for infection related to surgical incision

•

Risk for constipation related to bed rest, pain medication and NPO or soft diet Deficient knowledge regarding the treatment and home care Ineffective health maintenance

• •

Planning After diagnosis, planning for interventions to solve those problems is done. In goal attainment planning is represented by setting goals and making decisions about and being agreed on the means to achieve goals. This part of transaction and client’s participation is encouraged in making decision on the means to achieve the goals. Identifying the goals and planning to achieve these goals(this step is congruent with planning in the traditional nursing process) What goals do I think will serve the patient’s best interest?

1. The client will experience improved comfort, as evidenced by: a decrease in the rating of the pain, the ability to rest and sleep comfortably 2. The client will be free of infection as evidenced by normal temperature, normal vital signs. 3. The client will have improved bowel elimination, as evidenced by: Elimination of stool without straining 4. Client will acquire adequate knowledge regarding the treatment and home care. 5. Client will attend to health problems promptly

What are the patient’s goals?

Patient’s goals are: Freedom from pain Rapid healing Adequate bowel movement Acquiring adequate knowledge regarding his health problems

Are the patient’s goals and professional goals are congruent?

Yes

What are the priority goals?

Relief of pain Freedom from infection Adequate bowel movement Improvement knowledge aspect of health conditions Prompt attendance to health problems

What does the patient perceives as the best way to achieve goals?

Working with the health professionals Gaining knowledge Disclosing adequate information regarding

health problems Is the patient willing to work towards the goals?

Yes

What do I perceive to be the best way to achieve the goals?

Goal 1: Assess the characteristics of pain Administration of prescribed medicine Monitor the responses to drug therapy Provide calm, efficient manner that reassures the client and minimizes anxiety Provide a comfortable position as per client’s requests. Goal 2: Monitor vital signs Administer antibiotics as advised Use aseptic techniques while changing dressing Kept the surgical wound site clean Report surgeon regarding early signs of infection Goal 3: Ensure that the client has adequate bulk in diet and adequate fluid intake Instruct the client on prevention of straining and avoiding valsalva manoeuvre Consult treating physician regarding medications. Goal 4: Explain the treatment measures to the patient and their benefits in a simple understandable language. Explain demonstrate about the home care. Clarify the doubts of the patient as the patient may present with some matters of importance. Repeat the information whenever necessary to reinforce learning. Goal 5: Health education given about the following. Restriction of heavy weight lifting (more than 20kg) for 6 months Further management which may be necessary Diet control for his hypertension Rehabilitation measures to promote better living For regular examination of the site for recurrence of hernia

Are the goals short-term or long term?

Goals are both short-term and long term

What modifications required based on

Pain is tolerable to the patient and requires no SOS medication

mutuality?

Constipation is not that severe enough to take medication Other interventions are mutually acceptable.

Implementations 1. In nursing process implementation involves the actual activities to achieve the goals. 2. This step results in transactions being made. 3. Transactions occur as a result of perceiving the other person and the situation, making judgments about those perceptions, and taking some actions in response. 4. Reactions to action lead to transactions that reflect a shared view and commitment 5. This step reflects implementation in the traditional nursing process. Am I doing what the patient and I have agreed upon?

Yes

How am I carrying out the actions?

On a mutually acceptable manner in accordance with the goals set.

When do I carry out the action?

According to priority, a few interventions require immediate attention. Other interventions are carried out during the period of hospitalization till 5th April.

Why am I carrying out the action?

Patient’s condition demands nursing car.

Is it reasonable to think that the identified goals will be reached by carrying out the action?

Yes

Evaluation It involves to finding out weather goals are achieved or not. In King’s description evaluation speaks about attainment of goal and effectiveness of nursing care. Are my actions helping the patient achieve mutually defined goals?

Yes

How well are goals being met?

Short-term goals are met before discharge from hospital Long-term goals are expected to be met, because the patient is motivated to continue home care.

What actions are not working? What is patient’s response to my actions?

Patient is satisfied with my actions

Are other factors hindering goal achievement?

Patient’s age is a hindering factor in goal achievement regarding health maintenance.

How should the plan be changed to achieve goals?

Health teaching can be modified according to developmental stage. Involvement of family member in care of the patient.

References

• • • •

Phipps J Wilma, Sands K Judith. Medical Surgical Nursing: concepts & clinical practice.6th edition. Philadelphia. Mosby publications. 1996. Black M. Joice, Hawks Hokanson Jane. Medical Surgical Nursing: Clinical Management for positive outcomes. St Lois, Missouri. 2005. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002 Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia, 2002.

APPLICATION OF OREM'S SELF-CARE DEFICIT THEORY IN NURSING PRACTICE INTRODUCTION •

The history of professional nursing begins with Florence nightingale.

•

Later in last century nursing began with a strong emphasis on practice.

•

Following that came the curriculum era which addressed the questions about what the nursing students should study in order to achieve the required standard of nursing.

•

As more and more nurses began to pursue higher degrees in nursing, there emerged the research era.

•

Later graduate education and masters education was given much importance.

•

The development of the theory era was a natural outgrowth of the research era.

•

With an increased number of researches it became obvious that the research without theory produced isolated information; however research and theory produced the nursing sciences.

•

Within the contemporary phase there is an emphasis on theory use and theory based nursing practice and lead to the continued development of the theories.

OBJECTIVES 

to assess the patient condition by the various methods explained by the nursing theory



to identify the needs of the patient



to demonstrate an effective communication and interaction with the patient.



to select a theory for the application according to the need of the patient



to apply the theory to solve the identified problems of the patient



to evaluate the extent to which the process was fruitful. Areas

Patient details



Name

•

Mrs. X



Age

•

56 years



Sex

•

Female



Education

•

No formal education



Occupation

•

House hold



Marital status

•

Married



Religion

Hindu



Diagnosis

•

Theory applied

•

Rheumatoid arthritis



•

Orem’s theory of self care deficit.

OREM’S THEORY OF SELF CARE DEFICIT •

The self care deficit theory proposed by Orem is a combination of three theories, i.e. theory of self care, theory of self care deficit and the theory of nursing systems.

•

In the theory of self care, she explains self care as the activities carried out by the individual to maintain their own health.

•

The self care agency is the acquired ability to perform the self care and this will be affected by the basic conditioning factors such as age, gender, health care system, family system etc.

•

Therapeutic self-care demand is the totality of the self care measures required.

•

The self care is carried out to fulfill the self-care requisites.

•

There are mainly 3 types of self care requisites such as universal, developmental and health deviation self care requisites.

•

Whenever there is an inadequacy of any of these self care requisite, the person will be in need of self care or will have a deficit in self care. •

The deficit is identified by the nurse through the thorough assessment of the patient.

•

Once the need is identified, the nurse has to select required nursing systems to provide care: wholly compensatory, partly compensatory or supportive and educative system.

•

The care will be provided according to the degree of deficit the patient is presenting with.

•

Once the care is provided, the nursing activities and the use of the nursing systems are to be evaluated to get an idea about whether the mutually planned goals are met or not.

•

Thus the theory could be successfully applied into the nursing practice.

For Mrs. X…. 1. She came to the hospital with complaints of pain over all the joints, stiffness which is more in the morning and reduces by the activities. 2. She has these complaints since 5 years and has taken treatment from local hospital.

3. The symptoms were not reducing and came to --MC, Hospital for further management. 4. Patient was able to do the ADL by herself but the way she performed and the posture she used was making her prone to develop the complications of the disease. 5. She also was malnourished and was not having awareness about the deficiencies and effects. DATA COLLECTION ACCORDING TO OREM’S THEORY OF SELF CARE DEFICIT 1. BASIC CONDITIONING FACTORS Age

56 year

Gender

Female

Health state

Disability due to health condition, therapeutic self care demand

Development state

Ego integrity vs despair

Sociocultural orientation

No formal education, Indian, Hindu

Health care system

Institutional health care

Family system

Married, husband working

Patterns of living

At home with partner

Environment

Rural area, items for ADL not in easy reach, no special precautions to prevent injuries

resources

Husband, daughter, sister’s son

2. UNIVERSAL SELF-CARE REQUISITES: Air

Breaths without difficulty, no pallor cyanosis

Water

Fluid intake is sufficient. Edema present over ankles. Turgor normal for the age

Food

Hb – 9.6gm%, BMI = 14.Food intake is not adequate or the diet is not nutritious.

Elimination

Voids and eliminates bowel without difficulty.

Activity/ rest

Frequent rest is required due to pain. Pain not completely relieved, Activity level ha s come down. Deformity of the joint secondary to the disease process and use of the joints.

Social interaction Communicates well with neighbors and calls the daughter by phone Need for medical care is communicated to the daughter. Prevention of hazards

Need instruction on care of joints and prevention of falls. Need instruction on improvement of nutritional status. Prefer to walk bare foot.

Promotion of normalcy

Has good relation with daughter

3. DEVELOPMENTAL SELF-CARE REQUISITES: Maintenance of developmental environment Prevention/management of the conditions threatening the normal development

Able to feed self , Difficult to perform the dressing, toileting etc Feels that the problems are due to her own behaviours and discusses the problems with husband and daughter.

4. HEALTH DEVIATION SELF CARE REQUISITES Adherence to medical regimen

Reports the problems to the physician when in the hospital. Cooperates with the medication, Not much aware about the use and side effects of medicines

Awareness of potential problem associated with the regimen

Not aware about the actual disease process.

Modification of self image to incorporates changes in health status

Has adapted to limitation in mobility.

Adjustment of lifestyle to accommodate changes in the health status and medical regimen.

Adjusted with the deformities.

Not compliant with the diet and prevention of hazards. Not aware about the side effects of the medications

The adoption of new ways for activities leads to deformities and progression of the disease.

Pain tolerance not achieved

5. MEDICAL PROBLEM AND PLAN: Physician’s perspective of the condition: Diagnosed with rheumatoid arthritis and is on the following medications: T. Valus SR OD T. Pan 40 mg OD T. Tramazac 50 mg OD T. Recofix Forte BD

T. Shelcal BD Syp. Heamup 2tsp TID Medical Diagnosis: Rheumatoid arthritis Medical Treatment: Medication and physical therapy. AREAS AND PRIORITY ACCORDING TO OREM’S THEORY OF SELF-CARE DEFICIT: IMPORTANT FOR PRIORITIZING THE NURSING DIAGNOSIS. a. Air b. Water c. Food d. Elimination e. Activity/ Rest f.

Solitude/ Interaction

g. Prevention of hazards h. Promotion of normalcy i. j.

Maintain a developmental environment. Prevent or manage the developmental threats

k. Maintenance of health status l.

Awareness and management of the disease process.

m. Adherence to the medical regimen n. Awareness of potential problem. o.

modify self image

p. Adjust life style to accommodate health status changes and MR Nursing care plan according to Orem’s theory of self care deficit Nursing diagnosis

Outcome and plan

( diagnostic operations )

(Prescriptive operations)

Based on self care deficits

1. Outcome 2. Nursing goal and objectives 3. Design of nursing system 4. Appropriate method of helping

Implementation

Evaluation

(control operations)

(regulatory operations )

Nurse- patient actions to

1. Effectiveness of the nurse patient action to

-

Promote patient as self care agent

-

Meet self care needs

-

-Promote patient as self care agent -

Meet self care needs

- Decrease the Decrease the self care self care deficit. deficit. 2. Effectiveness of the selected nursing system to meet the needs.

Thus in the patient Mrs. X the areas that need assistance were… •

Air

•

Water

•

Food

•

Elimination

•

Activity/ Rest(2)

•

Solitude/ Interaction

•

Prevention of hazards(2)

•

Promotion of normalcy

•

Maintain a developmental environment.

•

Prevent or manage the developmental threats

•

Maintenance of health status

•

Awareness and management of the disease process.

•

Adherence to the medical regimen

•

Awareness of potential problem.

• •

modify self image Adjust life style to accommodate health status changes and medical regimen

APPLYING THE OREM’S THEORY OF SELF-CARE DEFICIT, A NURSING CARE PLAN FOR MRS. X COULD BE PREPARED AS FOLLOWS … Therapeutic self care demand: deficient area: food Adequacy of self care agency: Inadequate NURSING DIAGNOSIS Inability to maintain the ideal nutrition related to inadequate intake and knowledge deficit OUTCOMES AND PLAN a. Outcome: improved nutrition Maintenance of a balanced diet with adequate iron supplementation. b. Nursing Goals and objectives Goal: to achieve optimal levels of nutrition. Objectives: Mrs. X will: - state the importance of maintaining a balanced diet. - List the food items rich in iron , that are available in the locality. c. Design of the nursing system: supportive educative d. Method of helping: guidance support Teaching Providing developmental environment

IMPLEMENTATION Mutually planned and identified the objectives and the patient were made to understand about the required changes in the behaviour to have the requisites met. EVALUATION Mrs. X understood the importance of maintaining an optimum nutrition. She told that she will select the iron rich diet for her food. She listed the foods that are rich in iron and that are locally available. The self care deficit in terms of food will be decreased with the initiation of the nutritional intake. The supportive educative system was useful for Mrs. X -------------------------------------------------------------------------Therapeutic self care demand: deficient area: Activity Adequacy of self care agency: Inadequate NURSING DIAGNOSIS Self-care deficit: dressing, toileting related to restricted joint movement, secondary to the inflammatory process in the joints. OUTCOMES AND PLAN a. Outcome: - improved self-care - maintain the ability to perform the toileting and dressing with modification as required. b. Nursing Goals and objectives Goal: to achieve optimal levels of ability for self care. Objectives: Mrs. X will: -perform the dressing activities within limitations -utilize the alternative measures available for improving the toileting -perform the other activities of daily living with minimal assistance. c. Design of the nursing system: Partly compensatory d. Method of helping: Guidance: Assess the various hindering factors for self care and how to tackle them. Support: Provide all the articles needed for self care, near to the patient and ask the family members also to give the articles near to her. Provide passive exercises and make to perform active exercises so as to promote the mobility of the joint. Make the patient use commodes or stools to perform toileting and insist on avoidance of squatting position Provide assistance whenever needed for the self care activities Provide encouragement and positive reinforcement for minor improvement in the activity level. Initiate the pain relieving measures always before the patient go for any of the activities of daily living

Make the patient to use loose fitting clothes which will be easy to wear and remove. Teaching: Teach the family members the limitation in the activity level the patient has and the cooperation required Promoting a developmental environment: Teach the family and help them to practice how to help the patient according to her needs IMPLEMENTATION Mutually planned and identified the objectives and the patient was made to understand about the required changes in the behaviour to have the requisites met. EVALUATION Patient was performing some of the activities and she practiced toileting using a commode in the hospital. She verbalized an improved comfort and self care ability. She performed the dressing activities with minimal assistance Patient verbalized that she will perform the activities as instructed to get her ADL done. The partly compensatory system was useful for Mrs. X ---------------------------------------------------------------------Therapeutic self care demand: deficient area: Pain control Adequacy of self care agency: Inadequate NURSING DIAGNOSIS •

Ineffective pain control related to lack of utilization of pain relief measures

OUTCOMES AND PLAN a. Outcome: •

- improved pain self control

•

- achieve and maintain a reduction in the pain.

b. Nursing Goals and objectives Goal: to achieve reduction in the pain. Objectives: Mrs. X will: describe the total plan of pharmacological and non pharmacological pain relief demonstrate a reduction in the pain behaviours verbalize a reduction in the pain scale score from 7 – 4 c. Design of the nursing system: supportive educative d. method of helping: Guidance: Explore the past experience of pain and methods used to manage them. Ask the client to report the intensity, location, severity, associated and aggravating factors. Support: Provide rest to the joints and avoid excessive manipulations

provide hot and cold application to have better mobility. Encourage exercises to the joints by immersing in the warm water. Administer T. Ultracet and Tab Diclofecac as prescribed. Provide diversion and psychological support to the patient Teaching: Teach the non – pharmacological method to the patient once the pain is a little reduced. Providing the developmental environment: Discuss with the patient the necessity to maintain a pain diary with all information regarding episodes of pain and refer to that periodically Enquire from the health team, the need for opioid analgesics or other analgesics and get a prescription for the patient. IMPLEMENTATION ----------------------------------------------------------------------------EVALUATION Patient still has pain over the joints and she agreed that she will use the measures for pain relief that is told to her. The pain scale score was 6 after the measures were provided to the patient. She demonstrated slight reduction in the pain behaviours. The supportive educative system was useful for Mrs. X -------------------------------------------------------------Therapeutic self care demand: deficient area: prevention of hazards. Adequacy of self care agency: Inadequate NURSING DIAGNOSIS Potential for fall and fractures related to rheumatoid arthritis. OUTCOMES AND PLAN a. Outcome: Absence of falls and injury to the patient b. Nursing Goals and objectives Goal: prevent the falls and injury and to maintain a good body mechanics. objectives: Mrs. X will: -remain free from injury as evidenced by: -absence of signs and symptoms of fall or injury - explaining the methods to prevent the injury. c. Design of the nursing system: supportive educative d. method of helping: Support Never leave the client alone in the unit Assess the patients gait, activities and the mental status for any confusion or disorientation Encourage the patient to use supportive devices as required.

Provide a safe environment in the hospital by avoiding sharp objects or wooden objects on the way and slippery floor. Involve the family members in providing and maintaining a safe environment in the home Involve the family members to provide support to the patient whenever necessary Plan a balanced diet for the patient with a mutual interaction IMPLEMENTATION -----------------------------------------------------------------EVALUATION Patient remained free from injury as evidenced by absence of signs and symptoms. Patient explained the various measures that they will take to prevent the injury. The supportive educative system was useful for Mrs. X -----------------------------------------------------------------Therapeutic self care demand: deficient area: prevention of hazards. Adequacy of self care agency: Inadequate NURSING DIAGNOSIS: Potential for impaired skin integrity related to edema secondary to renal cysts. OUTCOMES AND PLAN: a. Outcome: Maintenance of normal skin integrity. b. nursing Goals and objectives Goal: Maintain the skin integrity and take measures to prevent skin impairment. Objectives: Mrs. X will: 1. maintain a normal skin integrity 2. list the measures to prevent the loss of skin integrity 3.

identify the measures to relieve edema.

c. Design of the nursing system: supportive educative d. method of helping: Support: Assess the skin regularly for any excoriation or loss of integrity or colour changes. Keep the skin clean always Avoid stress or pressure over the area of edema by providing extra cushions or padding Monitor the lab values as well as the patient for any signs and symptoms of renal failure. Encourage the patient to use slippers while walking and that should not be tight fitting. Assess the edema for its degree, pitting or non pitting and continue the assessment daily.

Provide a leg end elevated position or elevation of the leg on a pillow if no cardiac abnormalities are identified. Explain the patient the need for taking care of the edematous parts Explain the patient to report the symptoms like decreased urine output, palpitations, increased edema etc. to the health team IMPLEMENTATION ------------------------------------------------------------------EVALUATION Patient remained free from impaired skin integrity She listed the measures to prevent the loss of skin integrity She identified the measures to relieve edema. The supportive educative system was useful for Mrs. x ----------------------------------------------------------------Therapeutic self care demand: deficient area: awareness of the disease process and management Adequacy of self care agency: Inadequate NURSING DIAGNOSIS Potential for complications related to rheumatoid arthritis secondary to knowledge deficit. OUTCOMES AND PLAN a. Outcome: Absence of complications and improved awareness about the disease process. b. nursing Goals and objectives Goal: Improve the knowledge of the patient about the disease process and the complications. Objectives: Mrs. X will: -verbalize the various complication and their preventions -verbalize the changes occurring with the disease process and the treatment available -describe the actions and side effects of the medications which she is using c. Design of the nursing system: supportive educative d. Methods of helping: •

Guidance

•

Teaching

•

Promoting a developmental environment

IMPLEMENTATION ------------------------------------------------------------EVALUATION Patient got adequate information regarding the disease

She verbalized what she understood about the disease and its management. Patient has cleared her doubts regarding the medication actions and the side effect The supportive educative system was useful for Mrs. X EVALUATION OF THE APPLICATION OF SELF CARE DEFICIT THEORY The theory of self-care deficit when applied could identify the self care requisites of Mrs. X from various aspects. This was helpful to provide care in a comprehensive manner. Patient was very cooperative. the application of this theory revealed how well the supportive and educative and partly compensatory system could be used for solving the problems in a patient with rheumatoid arthritis. REFERENCES 1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed. Missouri: Elsevier Mosby Publications; 2002. 2. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002 3. George JB .Nursing Theories: The Base for Professional Nursing Practice .5th ed. New Jersey :Prentice Hall;2002.

HEALTH PROMOTION MODEL INTRODUCTION The health promotion model (HPM) proposed by Nola J Pender (1982; revised, 1996) was designed to be a “complementary counterpart to models of health protection.” It defines health as a positive dynamic state not merely the absence of disease. Health promotion is directed at increasing a client’s level of wellbeing. The health promotion model describes the multi dimensional nature of persons as they interact within their environment to pursue health. The model focuses on following three areas: Individual characteristics and experiences Behavior-specific cognitions and affect Behavioral outcomes

The health promotion model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The set of variables for behavioral specific knowledge and affect have important motivational significance. These variables can be modified through nursing actions. Health promoting behavior is the desired behavioral outcome and is the end point in the HPM. Health promoting behaviors should result in improved health, enhanced functional ability and better quality of life at all stages of development. The final behavioral demand is also influenced by the immediate competing demand and preferences, which can derail an intended health promoting actions.

ASSUMPTIONS OF THE HEALTH PROMOTION MODEL The HPM is based on the following assumptions, which reflect both nursing and behavioral science perspectives: 1.

Persons seek to create conditions of living through which they can express their unique human health potential.

2.

Persons have the capacity for reflective self-awareness, including assessment of their own competencies.

3.

Persons value growth in directions viewed as positive and attempts to achieve a personally acceptable balance between change and stability.

4.

Individuals seek to actively regulate their own behavior.

5.

Individuals in all their biopsychosocial complexity interact with the environment, progressively transforming the environment and being transformed over time.

6.

Health professionals constitute a part of the interpersonal environment, which exerts influence on persons throughout their lifespan.

7.

Self-initiated reconfiguration of person-environment interactive patterns is essential to behavior change.

THEORETICAL PROPOSITIONS OF THE HEALTH PROMOTION MODEL

Theoretical statements derived from the model provide a basis for investigative work on health behaviors. The HPM is based on the following theoretical propositions: 1.

Prior behavior and inherited and acquired characteristics influence beliefs, affect, and enactment of health-promoting behavior.

2.

Persons commit to engaging in behaviors from which they anticipate deriving personally valued benefits.

3.

Perceived barriers can constrain commitment to action, a mediator of behavior as well as actual behavior.

4.

Perceived competence or self-efficacy to execute a given behavior increases the likelihood of commitment to action and actual performance of the behavior.

5.

Greater perceived self-efficacy results in fewer perceived barriers to a specific health behavior.

6.

Positive affect toward a behavior results in greater perceived self-efficacy, which can in turn, result in increased positive affect.

7.

When positive emotions or affect are associated with a behavior, the probability of commitment and action is increased.

8.

Persons are more likely to commit to and engage in health-promoting behaviors when significant others model the behavior, expect the behavior to occur, and provide assistance and support to enable the behavior.

9.

Families, peers, and health care providers are important sources of interpersonal influence that can increase or decrease commitment to and engagement in health-promoting behavior.

10. Situational influences in the external environment can increase or decrease commitment to or participation in health-promoting behavior. 11. The greater the commitments to a specific plan of action, the more likely health-promoting behaviors are to be maintained over time. 12. Commitment to a plan of action is less likely to result in the desired behavior when competing demands over which persons have little control require immediate attention. 13. Commitment to a plan of action is less likely to result in the desired behavior when other actions are more attractive and thus preferred over the target behavior. 13. Persons can modify cognitions, affect, and the interpersonal and physical environment to create incentives for health actions. THE MAJOR CONCEPTS AND DEFINITIONS OF THE HEALTH PROMOTION MODEL Individual Characteristics and Experience v

PRIOR RELATED BEHAVIOR

Frequency of the similar behaviour in the past. Direct and indirect effects on the likelihood of engaging in health promoting behaviors. v

PERSONAL FACTORS

Personal factors categorized as biological, psychological and socio-cultural. These factors are predictive of a given behavior and shaped by the nature of the target behaviour being considered. Personal biological factors Include variable such as age gender body mass index pubertal status, aerobic capacity, strength, agility, or balance. Personal psychological factors Include variables such as self esteem self motivation personal competence perceived health status and definition of health. Personal socio-cultural factors Include variables such as race ethnicity, accuculturation, education and socioeconomic status. Behavioural Specific Cognition and Affect v

PERCEIVED BENEFITS OF ACTION

Anticipated positive out comes that will occur from health behaviour. v

PERCEIVED BARRIERS TO ACTION

Anticipated, imagined or real blocks and personal costs of understanding a given behaviour v

PERCEIVED SELF EFFICACY

Judgment of personal capability to organise and execute a health-promoting behaviour. Perceived self efficacy influences perceived barriers to action so higher efficacy result in lowered perceptions of barriers to the performance of the behavior. v

ACTIVITY RELATED AFFECT

Subjective positive or negative feeling that occur before, during and following behavior based on the stimulus properties of the behaviour itself. Activity-related affect influences perceived self-efficacy, which means the more positive the subjective feeling, the greater the feeling of efficacy. In turn, increased feelings of efficacy can generate further positive affect. v

INTERPERSONAL INFLUENCES

Cognition concerning behaviours, beliefs, or attitudes of the others. Interpersonal influences include: norms (expectations of significant others), social support (instrumental and emotional encouragement) and modelling (vicarious learning through observing others engaged in a particular behaviour). Primary sources of interpersonal influences are families, peers, and healthcare providers. v

SITUATIONAL INFLUENCES

Personal perceptions and cognitions of any given situation or context that can facilitate or impede behaviour. Include perceptions of options available, demand characteristics and aesthetic features of the environment in which given health promoting is proposed to take place. Situational influences may have direct or indirect influences on health behaviour. Behavioural Outcome v

COMMITMENT TO PLAN OF ACTION

The concept of intention and identification of a planned strategy leads to implementation of health behaviour. v

IMMEDIATE COMPETING DEMANDS AND PREFERENCES

Competing demands are those alternative behaviour over which individuals have low control because there are environmental contingencies such as work or family care responsibilities. Competing preferences are alternative behaviour over which individuals exert relatively high control, such as choice of ice cream or apple for a snack v

HEALTH PROMOTING BEHAVIOUR

Endpoint or action outcome directed toward attaining positive health outcome such as optimal well-being, personal fulfillment, and productive living. REFERENCES

1. Marriner TA, Raile AM. Nursing theorists and their work. 5th ed. Sakraida T.Nola J. Pender. The Health Promotion Model. St Louis: Mosby; 2005

2. Polit DF, Beck CT. Nursing research:Principles and methods. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2007

3. Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th ed. Philadelphia: Elsevier Mosby; 2006.

4. Potter PA, Perry AG. Fundamentals of nursing. 6th ed. St.Louis: Elsevier Mosby; 2006.

HEALTH BELIEF MODEL (HBM) INTRODUCTION HBM is a popular model in nursing, especially in issues focusing on patient compliance and preventive health care practices. the model postulates that health-seeking behaviour is influenced by a person’s perception of a threat posed by a health problem and the value associated with actions aimed at reducing the threat. HBM addresses the relationship between a person’s beliefs and behaviors. It provides a way to understanding and predicting how clients will behave in relation to their health and how they will comply with health care therapies.

THE MAJOR CONCEPTS AND DEFINITIONS OF THE HEALTH PROMOTION MODEL There are six major concepts in HBM:

1.

1.

Perceived Susceptibility

2.

Perceived severity

3.

Perceived benefits

4.

Perceived costs

5.

Motivation

6.

Enabling or modifying factors

Perceived Susceptibility: refers to a person’s perception that a health problem is personally relevant or that a diagnosis of illness is accurate.

2.

Perceived severity: even when one recognizes personal susceptibility, action will not occur unless the individual perceives the severity to be high enough to have serious organic or social complications.

3.

Perceived benefits: refers to the patient’s belief that a given treatment will cure the illness or help to prevent it.

4.

Perceived Costs: refers to the complexity, duration, and accessibility and accessibility of the treatment

5.

Motivation: includes the desire to comply with a treatment and the belief that people should do what

6.

Modifying factors: include personality variables, patient satisfaction, and socio-demographic factors.

REFERENCES 1. Marriner TA, Raile AM. Nursing theorists and their work. 5th ed. Sakraida T.Nola J. Pender. The Health Promotion Model. St Louis: Mosby; 2005 2. Polit DF, Beck CT. Nursing research:Principles and methods. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2007 3. Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th ed. Philadelphia: Elsevier Mosby; 2006. 4. Potter PA, Perry AG. Fundamentals of nursing. 6th ed. St.Louis: Elsevier Mosby; 2006. 5. Rosenstoch I. Historical origin of Health Belief model. Health Educ Monogr 2:334, 1974.

THEORIES USED IN COMMUNITY HEALTH NURSING Introduction The concept of community is defined as "a group of people who share some important feature of their lives and use some common agencies and institutions." The concept of health is defined as "a balanced state of well-being resulting from harmonious interactions of body, mind, and spirit." The term community health is defined by meeting the needs of a community by identifying problems and managing interactions within the community

Basic Elements The six basic elements of nursing practice incorporated in community health programs and services are (1) promotion of healthful living (2) prevention of health problems (3) treatment of disorders (4) rehabilitation (5) evaluation and (6) research. Major Roles The focus of nursing includes not only the individual, but also the family and the community, meeting these multiple needs requires multiple roles. The seven major roles of a community health nurse are (1) care provider, (2) educator, (3) advocate, (4) manager, (5) collaborator, (6) leader, and (7) researcher. Major Settings Settings for community health nursing can be grouped into six categories: (1) homes, (2) ambulatory care settings, (3) schools, (4) occupational health settings, (5) residential institutions, and (6) the community at large. Community health nursing practice is not limited to a specific area, but can be practiced anywhere. Theories and Models for community health nursing The commonly used theories are: 1. Nightingale’s theory of environment 2. Orem’s Self care model 3. Neumann’s health care system model 4. Roger’s model of the science and unitary man 5. Pender’s health promotion model 6. Roy’s adaptation model 7. Milio’s Framework of prevention 8. Salmon White’s Construct for Public health nursing 9. Block and Josten’s Ethical Theory of population focused nursing 10. Canadian Model Milio’s Framework of prevention Nancy Milio a nurse and leader in public health policy and public health education developed a framework for prevention that includes concepts of community-oriented, population focused care.(1976,1981).The basic treatise is that behavioral patterns of populations and individuals who make up populations are a result of habitual selection from limited choices. She challenged the common notion that a main determinant for unhealthful behavioral choice is lack of knowledge. Governmental and institutional policies, she said set the range of options for personal choice making. It neglected the role of community health nursing, examining the determinants of community health and attempting to influence those determinants through public policy.

Salmon White’s construct for public health nursing Mark Salmon White (1982) describes a public health as an organized societal effort to protect, promote and restore the health of people and public health nursing as focused on achieving and maintaining public health. He gave 3 practice priorities i.e.; prevention of disease and poor health, protection against disease and external agents and promotion of health. For these 3 general categories of nursing intervention have also been put forward, they are: 11. education directed toward voluntary change in the attitude and behaviour of the subjects 12. engineering directed at managing risk-related variables 13. enforcement directed at mandatory regulation to achieve better health. Scope of prevention spans individual, family, community and global care. Intervention target is in 4 categories 1.Human/Biological 2. Environmental 3. Medical/technological/organizational 4. Social Block and Josten’s Ethical Theory of population focused nursing Derryl Block and Lavohn Josten, public health educators proposed this based on intersecting fields of public health and nursing. They have given 3 essential elements of population focused nursing that stem from these 2 fields: 1. an obligation to population 2. the primacy of prevention 3. centrality of relationship- based care the first two are from public health and the third element from nursing. Hence it implies to nursing that relation-based care is very important in population focused care. Canadian Model for community The community health nurse works with individuals, families, groups, communities, populations, systems and/or society, but at all times the health of the person or community is the focus and motivation from which nursing actions flow. The standards of practice are applied to practice in all settings where people live, work, learn, worship and play. The philosophical base and foundational values and beliefs that characterize community health nursing - caring, the principles of primary health care, multiple ways of knowing, individual/community partnerships and empowerment - are embedded in the standards and are reflected in the development and application of the community health nursing process. The community health nursing process involves the traditional nursing process components of assessment, planning, intervention and evaluation but is enhanced by community health nurses in three dimensions: 1) individual/community participation in each component, 2) multiple ways of knowing, each of which is necessary to understand the complexity and diversity of nursing in the

community; knowledge and utilization of all these ways of knowing forms evidencebased practice consistent with these standards, and 3) the inherent influence of the broader environment on the individual/community that is the focus of care (e.g. the community will be affected by provincial/territorial policies, its own economic status and by the actions of its individual citizens). The standards of practice are founded on the values and beliefs of community health nurses, and utilization of the community health nursing process. The model illustrates the dynamic nature of community health nursing practice, embracing the present and projecting into the future. The values and beliefs (green or shaded) ground practice in the present yet guide the evolution of community health nursing practice over time. The community health nursing process provides the vehicle through which community health nurses work with people, and supports practice that exemplifies the standards of community health nursing. The standards of practice revolve around both the values and beliefs and the nursing process with the energies of community health nursing always being focused on improving the health of people in the community and facilitating change in systems or society in support of health. Community health nursing practice does not occur in isolation but rather within an environmental context, such as policies within their workplace and the legislative framework applicable to their work. References

1. Allender J.N; Spradely B.W. Community Health Nursing Concepts and practice. (8th edn) 2001.Lippincott,342-45.

1. Stanhope M; Lancaster J. Community Health Nursing Promoting health of Aggregates, Families and individuals.(4th edn) 2001.Mosby,265-80.

Application of Suchman’s Stages of illness Model Introduction Man is a social being. Social factors play important role in health. Social conditions and not only promote the possibility of illness and disability, they also enhance prospect for disease prevention and health maintenance. Health life style and the avoidance of high-risk behaviour, advance the individual’s potential for a longer and healthier life. The recognition of the fact that the health of an individual is more than biological phenomena has brought in to the forefront the significance of behavioural dimension of health.

Mr. AS, a 73 years old, Muslim, male patient admitted in ---ward of ---Hospital with a diagnosis of prostate cancer. Data regarding psychosocial aspects of his life and illness were collected through interview. He was cooperative and interactive with me for most part. But later he was found to be reluctant to talk ...as he was frequently expressing his financial troubles which could not be helped by anyone related to him. Cancer Prostate Prostate cancer is the fifth most common type of cancer in men and its incidence rises with advancing years. It occurs in 1 in 10 in the men living to the age of 70 years. Early clinical features are indistinguishable from those of BPH and the gland may feel normal on digital examination. The PSA may be elevated (>4 ng/ml). As the tumour grows locally it may produce bladder neck obstruction, obstruct the ureters and rapidly lead to renal impairment. In late disease rectal examination shows the prostate to be large, hard and irregular. Rectal ultrasound may show the spread of the cancer and this should also be used for directing needle or aspiration biopsy. Prostatic biopsy is important in giving prognostic information- prognosis being poorer with poorly differentiated tumours. Therapy depends on staging. Early disease is treated with local radiotherapy and more advanced disease by orchidectomy and hormone therapy with oestrogen. It has been suggested that all men over the age of 50 years should be screened by rectal examination, transrectal ultrasound and PSA measurement. General information Name

: Mr. AS

Age

: 73 years

Gender

: Male

Marital status

: Married

Place

: ---/ ----

Hosp. No.

: ------

Date of admission

: 1-4-08

Ward/Unit

: --------

Education

: No formal education

Culture & life-style Religion too.

: Islam, Muslim, believes in 'Durgas', and has gone

Food habits

: four time in a day : Non-vegetarian once in a day

Socioeconomic condition ·

Lower socioeconomic status

·

Occupation

·

Fisher man for 12 years

·

He was a beedi worker for 10 years

·

went to gulf and worked there for 4 years

·

Cook for 35 years

·

His son is in Gulf country, but earns only Rs.5000/month

·

His residence is about 80 km away from ----, to and fro journey costs rs.50/ person

Role in the family ·

Head of the family, earning member, and father

·

These role are affected due the illness “ everything is disturbed at home”

Social Support Network ·

Patient has poor social support network

·

There is no one to support him financially for treatment of his illness

· His daughter visited him twice in the hospital, no other person visited him or enquired him about his illness after coming in the hospital Patient complaints (on the first meeting) ·

Pain at the genital area (on catheterization)

·

Urine tube needs to be removed

·

No taste for anything he eats

·

No money in hand to pay the hospital bill

·

No sleep at night

Identification of patient needs

Collection, observing/ performing activities relating to caring

Interpretation and analysis

Needs arising from present illness and the consequent response to cope with

· “I have pain at genital region”

· Patient’s main complaints are pain, irritation at the site of urinary catheter, and sleep disturbance

· “I have problem of passing urine without control, that is why tube is inserted” · “I want to get this urine tube removed” · “Who will pay my hospital bill of Rs.50,000?” · Patient complains that he is not getting adequate sleep during night

· He was a cook, working most of his life in night time for marriage parties · Currently, he is hospitalised for cancer, prostate and is receiving radiotherapy for the last one month

· He sleeps during daytime Basic physical needs

· He is advised not to take bath till the end of radiotherapy to

· He says is a practicing Muslim

avoid skin excoriation at the site · He maintains adequate cleanliness · He visits toilet with assistance from his wife · He is catheterized for the last 2 months Needs related to life style

· He is a nonvegetarian · But he not getting any non-veg food in the hospital

Needs related to habits

· He does not take tea or coffee · He does not smoke or take drinks

Individual’s knowledge and experience of illness

· He is taking bath means it interferes with his religious practices · He is advised not to take bath because he may wet the irradiation area, but the cultural issues are not addressed. · His life style related needs hindered in this hospital environment

· As he has any regular habits of taking tea or coffee or drinking alcohol

Patient’s Knowledge of Present illness Patient explains his illness: · “I have pain and urine block for the last 6 months” · “My illness is serious” · “I have diabetes for the last one year” · “I underwent a surgery for urinary block and pain in ----4 months back” What the patient wants to know about the illness? “will this illness get cured” “I have come here because, doctors in ---- told me my illness can be cured only in Manipal”

· Patient has understanding of the illness as his illness is serious. · Patient underwent orchidectomy and TURP in -------- 4 months back and later referred to Manipal for further management · Patient wants to know whether his illness will get cured. · He says he has no money to spend her. · But his expenses are met by his daughter and one brother

Experience of illness

What has been his past experience with illness? Past Illness History · “Earlier I went to many local folk doctors, they only made all these illness” · “I have sugar illness for the last one year”

· Patient has consulted many folk doctors for minor illness and never satisfied with them.

· “ The doctor in Kundapura told me to check sugar, so I know I have sugar problem”

· He had minor troubles with urinary frequency for about 4 years

· “I have not had any major illness in my life other than this”

· So he consulted some folk people for some remedies ·

But never satisfied

Family History · No major illness in his knowledge Whether patient has accepted his illness · “I don’t have any habits, drinking, smoking or taking even coffee since childhood. I don’t know why I got this illness” Knowledge of formal and alternative therapies

· He has adequate information about formal and folk medicines

· Patient has accepted the illness as some thing which he does not deserve. ·

He puts it on fate

He had tried alternative medicines and found to have no benefit in his illness

· “I have gone to them, but no benefits” Knowledge at present and future course of action. What is the treatment plan Does the person knows about it

· Patient says he has one month duration of x-ray treatment · “nobody tells me what is my illness” · “I’m taking medicines regularly”

· Patient has only partial knowledge of his illness and treatment plans · He is illiterate, but nobody has explained him about his treatment plans

Coping with the illness and its outcome (Patient and family)

·

“What will we do?”

· “We have to suffer everything” · He looks depressed and tries to avoid visitors · “I don’t have money pay here, I don’t know what to do”

Analyse the individuals and family’s views on ·

health team

·

doctors

·

nurses

· “Doctor People come and asks how you are? (he explains sarcastically), nothing else” · “They do not want to know about my pain” · “sometimes, nurses come asks about me”

· Patient is not showing adaptive responses · He has depressive cognitions · He has financial problems

He is not satisfied with the psychological attention given to him by nurse or doctor His wife too has the same opinion Doctor has explained about the illness to his daughter about the diagnosis and prognosis

“Doctor has told something to my daughter” Distinguish between the meanings of the patient, doctor, nurse

Patient: “they are not asking me anything” Doctor: “he will not understand anything, it is explained to his daughter”

Patient wants to know about his illness, and course of treatment, but doctor is preoccupied with the patient’s educational status.

Nurse: “doctor has explained everything to him, we cannot tell anything to the patient”

Nursing staff is bothered whether they may convey wrong message to the patient. There is a communication gap exists among these people.

Observe the patient, doctor and nurse interaction

What patient says has reason. · Doctor has advised him RT for 1 month, so he feels there is nothing more to talk to the patient than

The mutual interaction among the treating team and patient is missing in this situation

enquiring any problems · Nurse is largely functionally oriented and interact with patient only in such occasions

Suchman’s Stages of illness Model

Application of Suchman's Model

Conclusion

Mr. AS has been suffering form Prostate cancer for the last 1 year. But his symptoms started about 4 years back. For about 3 years he tried folk remedies based on the advice of other people. He approached medical advice when his symptoms aggravated. He is currently undergoing radiotherapy for prostate cancer and medications for diabetes and other symptoms. This case study helps to understand the psychosocial aspects of illness development and application illness behaviour model in nursing practice. Reference •

Guptha MC, Mahajan B. Text book of Social Medicine, 3rd Edn. JayPee, ND,2003

•

Coe RM. Sociology of Medicine. McGraw-Hill Inc. New York, 1978.

APPLICATION OF BETTY NEUMAN'S SYSTEMS MODEL OBJECTIVES: •

to assess the patient condition by the various methods explained by the nursing theory

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to identify the needs of the patient

•

to demonstrate an effective communication and interaction with the patient.

•

to select a theory for the application according to the need of the patient

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to apply the theory to solve the identified problems of the patient

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to evaluate the extent to which the process was fruitful.

INTRODUCTION SYSTEM MODEL- BETTY NEUMAN A theory is a group of related concepts that propose action that guide practice. A nursing theory is a set of concepts, definitions, relationships, and assumptions or propositions derived from nursing models or from other disciplines and project a purposive, systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing, explaining, predicting, and /or prescribing. The Neuman’s system model has two major components i.e. stress and reaction to stress. The client in the Neuman’s system model is viewed as an open system in which repeated cycles of input, process, out put and feed back constitute a dynamic organizational pattern. The client may be an individual, a group, a family, a community or an aggregate. In the development towards growth and development open system continuously become more differentiated and elaborate or complex. As they become more complex, the internal conditions of regulation become more complex. Exchange with the environment are reciprocal, both the client and the environment may be affected either positively or negatively by the other. The system may adjust to the environment to itself. The ideal is to achieve optimal stability. As an open system the client, the client system has propensity to seek or maintain a balance among the various factors, both with in and out side the system, that seek to disrupt it. Neuman seeks these forces as stressors and views them as capable of having either positive or negative effects. Reaction to the stressors may be possible or actual with identifiable responses and symptom.

MAJOR CONCEPTS I. PERSON VARIABLESEach layer, or concentric circle, of the Neuman model is made up of the five person variables. Ideally, each of the person variables should be considered simultaneously and comprehensively. 1. Physiological - refers of the physicochemical structure and function of the body. 2. Psychological - refers to mental processes and emotions. 3.

Sociocultural - refers to relationships; and social/cultural expectations and activities.

4. Spiritual - refers to the influence of spiritual beliefs. 5.

Developmental - refers to those processes related to development over the lifespan. II. CENTRAL COREThe basic structure, or central core, is made up of the basic survival factors that are common to the species (Neuman, 1995, in George, 1996). These factors include: system variables, genetic features, and the strengths and weaknesses of the system parts. Examples of these may include: hair color, body temperature regulation ability, functioning of body systems homeostatically, cognitive ability, physical strength, and value systems. The person's system is an open system and therefore is dynamic and constantly changing and evolving. Stability, or homeostasis, occurs when the amount of energy that is available exceeds that being used by the system. A homeostatic body system is constantly in a dynamic process of input, output, feedback, and compensation, which leads to a state of balance. III. FLEXIBLE LINES OF DEFENSEThe flexible line of defense is the outer barrier or cushion to the normal line of defense, the line of resistance, and the core structure. If the flexible line of defense fails to provide adequate protection to the normal line of defense, the lines of resistance become activated. The flexible line of defense acts as a cushion and is described as accordion-like as it expands away from or contracts closer to the normal line of defense. The flexible line of defense is dynamic and can be changed/altered in a relatively short period of time. IV. NORMAL LINE OF DEFENSEThe normal line of defense represents system stability over time. It is considered to be the usual level of stability in the system. The normal line of defense can change over time in response to coping or responding to the environment. An example is skin, which is stable and fairly constant, but can thicken into a callus over time. V. LINES OF RESISTANCEThe lines of resistance protect the basic structure and become activated when environmental stressors invade the normal line of defense. Example: activation of the immune response after invasion of microorganisms. If the lines of resistance are effective, the system can reconstitute and if the lines of resistance are not effective, the resulting energy loss can result in death. VI. RECONSTITUTIONReconstitution is the increase in energy that occurs in relation to the degree of reaction to the stressor. Reconstitution begins at any point following initiation of treatment for invasion of stressors. Reconstitution may expand the normal line of defense beyond its previous level, stabilize the system at a lower level, or return it to the level that existed before the illness. VII. STRESSORS-The Neuman Systems Model looks at the impact of stressors on health and addresses stress and the reduction of stress (in the form of stressors). Stressors are capable of having either a positive or negative effect on the client system. A stressor is any environmental force which can potentially affect the stability of the system: they may be: •

Intrapersonal - occur within person, e.g. emotions and feelings

•

Interpersonal - occur between individuals, e.g. role expectations

•

Extra personal - occur outside the individual, e.g. job or finance pressures

The person has a certain degree of reaction to any given stressor at any given time. The nature of the reaction depends in part on the strength of the lines of resistance and defense. By means of primary, secondary and tertiary interventions, the person (or the nurse) attempts to restore or maintain the stability of the system. VII. PREVENTIONAs defined by Neuman's model, prevention is the primary nursing intervention. Prevention focuses on keeping stressors and the stress response from having a detrimental effect on the body. •

Primary -Primary prevention occurs before the system reacts to a stressor. On the one hand, it strengthens the person (primarily the flexible line of defense) to enable him to better deal with stressors, and on the other hand manipulates the environment to reduce or weaken stressors. Primary prevention includes health promotion and maintenance of wellness.

•

Secondary-Secondary prevention occurs after the system reacts to a stressor and is provided in terms of existing systems. Secondary prevention focuses on preventing damage to the central core by strengthening the internal lines of resistance and/or removing the stressor.

•

Tertiary -Tertiary prevention occurs after the system has been treated through secondary prevention strategies. Tertiary prevention offers support to the client and attempts to add energy to the system or reduce energy needed in order to facilitate reconstitution.

NURSING METAPARADIGM A. PERSONThe person is a layered multidimensional being. Each layer consists of five person variables or subsystems: •

Physical/Physiological

•

Psychological

•

Socio-cultural

•

Developmental

•

Spiritual

The layers, usually represented by concentric circle, consist of the central core, lines of resistance, lines of normal defense, and lines of flexible defense. The basic core structure is comprised of survival mechanisms including: organ function, temperature control, genetic structure, response patterns, ego, and what Neuman terms 'knowns and commonalities'. Lines of resistance and two lines of defense protect this core. The person may in fact be an individual, a family, a group, or a community in Neuman's model. The person, with a core of basic structures, is seen as being in constant, dynamic interaction with the environment. Around the basic core structures are lines of defense and resistance (shown diagrammatically as concentric circles, with the lines of resistance nearer to the core. The person is seen as being in a state of constant change and-as an open system-in reciprocal interaction with the environment (i.e. affecting, and being affected by it).

B. THE ENVIRONMENTThe environment is seen to be the totality of the internal and external forces which surround a person and with which they interact at any given time. These forces include the intrapersonal, interpersonal and extra personal stressors which can affect the person's normal line of defense and so can affect the stability of the system. •

The internal environment exists within the client system.

•

The external environment exists outside the client system.

•

Neuman also identified a created environment which is an environment that is created and developed unconsciously by the client and is symbolic of system wholeness.

C. HEALTHNeuman sees health as being equated with wellness. She defines health/wellness as "the condition in which all parts and subparts (variables) are in harmony with the whole of the client (Neuman, 1995)". As the person is in a constant interaction with the environment, the state of wellness (and by implication any other state) is in dynamic equilibrium, rather than in any kind of steady state. Neuman proposes a wellness-illness continuum, with the person's position on that continuum being influenced by their interaction with the variables and the stressors they encounter. The client system moves toward illness and death when more energy is needed than is available. The client system moves toward wellness when more energyis available than is needed. D. NURSINGNeuman sees nursing as a unique profession that is concerned with all of the variables which influence the response a person might have to a stressor. The person is seen as a whole, and it is the task of nursing to address the whole person. Neuman defines nursing as actions which assist individuals, families and groups to maintain a maximum level of wellness, and the primary aim is stability of the patient/client system, through nursing interventions to reduce stressors. Neuman states that, because the nurse's perception will influence the care given, then not only must the patient/client's perceptions be assessed, but so must those of the caregiver (nurse). The role of the nurse is seen in terms of degrees of reaction to stressors, and the use of primary, secondary and tertiary interventions. Neuman envisions a 3-stage nursing process: 1. Nursing Diagnosis - based of necessity in a thorough assessment, and with consideration given to five variables in three stressor areas. 2. Nursing Goals - these must be negotiated with the patient, and take account of patient's and nurse's perceptions of variance from wellness 3. Nursing Outcomes - considered in relation to five variables, and achieved through primary, secondary and tertiary interventions. NURSING PROCESS BASED ON SYSTEM MODEL Assessment: Neuman’s first step of nursing process parallels the assessment and nursing diagnosis of the six phase nursing process. Using system model in the assessment phase of nursing process the nurse focuses on obtaining a comprehensive client data base to determine the existing state of wellness and actual or potential reaction to environmental stressors.

Nursing diagnosis- the synthesis of data with theory also provides the basis for nursing diagnosis. The nursing diagnostic statement should reflect the entire client condition. Outcome identification and planning- it involves negotiation between the care giver and the client or recipient of care. The overall goal of the care giver is to guide the client to conserve energy and to use energy as a force to move beyond the present. Implementation – nursing action are based on the synthesis of a comprehensive data base about the client and the theory that are appropriate to the client’s and caregiver’s perception and possibilities for functional competence in the environment. According to this step the evaluation confirms that the anticipated or prescribed change has occurred. Immediate and long range goals are structured in relation to the short term goals. Evaluation – evaluation is the anticipated or prescribed change has occurred. If it is not met the goals are reformed. -------------------------------------------------------------------

ASSESSMENT PATIENT PROFILE

1. Name- Mr. AM 2. Age- 66 years 3. Sex-Male 4. Marital status-married 5. Referral source- Referred from ------- Medical College, ------STRESSORS AS PERCEIVED BY CLIENT

(Information collected from the patient and his wife) 1. Major stress area, or areas of health concern •

Patient was suffering from severe abdominal pain , nausea, vomiting, yellowish discolorations of eye, palm, and urine, reduced appetite and gross weight loss(8kg with in 4 months)

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Patient is been diagnosed to have Periampullary carcinoma one week back.

•

Patient underwent operative procedure i.e. WHIPPLE’S PROCEDUREPancreato duodenectomy on 27/3/08.

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Psychologically disturbed about his disease condition- anticipating it as a life threatening condition. Patient is in depressive mood and does not interacting.

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Patient is disturbed by the thoughts that he became a burden to his children with so many serious illnesses which made them to stay with him at hospital.

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Patient has pitting type of edema over the ankle region, and it is more during the evening and will not be relieved by elevation of the affected extremities.

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He had developed BPH few months back (2008 January) and underwent surgery TURP on January 17. Still he has mild difficulty in initiating the stream of urine.

•

Patient is a known case of Diabetes since last 28 years and for the last 4 years he is on Inj. H.Insulin (4U-0-0). It is adding up his distress regarding his health.

2. Life style patterns •

patient is a retired school teacher

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cares for wife and other family members

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living with his son and his family

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active in church

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participates in community group meeting i.e. local politics

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has a supportive spouse and family

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taking mixed diet

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no habits of smoking or drinking

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spends leisure time by reading news paper, watching TV, spending time with family members and relatives

3. Have you experienced a similar problem? •

The fatigue is similar to that of previous hospitalization (after the surgery of the BPH)

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Severity of pain was some what similar in the previous time of surgery i.e. TURP.

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Was psychologically disturbed during the previous surgery i.e. TURP.

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What helped then- family members psychological support helped him to over come the crisis situation

4. Anticipation of the future •

Concerns about the healthy and speedy recovery.

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Anticipation of changes in the lifestyle and food habits

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Anticipating about the demands of modified life style

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Anticipating the needs of future follow up

5. What doing to help himself? •

Talking to his friends and relatives

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Reading the religious materials i.e. reading the Bible

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Instillation of positive thoughts i.e. planning about the activities to be resume after discharge, spending time with grand children, going to the church, return back to the social interactions etc

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Avoiding the negative thoughts i.e. diverts the attentions from the pain or difficulties, try to eliminate the disturbing thoughts about the disease and surgery etc

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Trying to accept the reality etc..

6. What is expected of others? •

Family members visiting the patient and spending some time with him will help to a great extent to relieve his tension.

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Convey a warm and accepting behaviour towards him.

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Family members will help him to meet his own personal needs as much as possible.

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Involve the patient also in taking decisions about his own care, treatment, follow up etc

STRESSORS AS PERCEIVED BY THE CARE GIVER.

1. Major stress areas •

Persistent fatigue

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Massive weight loss i.e.( 8 kg of body weight with in 4 months)

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History of BPH and its surgery

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Persistence of urinary symptoms (difficulty in initiating the stream of urine) and edema of the lower extremities

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Persistent disease- chronic hypertensive since last 28 years

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Depressive ideations and negative thoughts

2. Present circumstances differing from the usual pattern of living •

Hospitalization

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acute pain ( before the surgery patient had pain because of the underlying pathology and after the surgery pain is present at the surgical site)

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nausea and vomiting which was present before the surgery and is still persisting after the surgery also

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anticipatory anxiety concerns the recovery and prognosis of the disease

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negative thoughts that he has become a burden to his children

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Anticipatory anxiety concerning the restrictions after the surgery and the life style modifications which are to be followed.

3. Clients past experience with the similar situations

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Patient verbalized that the severity of pain, nausea, fatigue etc was similar to that of patient’s previous surgery. Counter checked with the family members that what they observed.

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Psychologically disturbed previously also before the surgery. (collected from the patient and counter checked with the relatives)

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Client perceived that the present disease condition is much more severe than the previous condition. He thinks it is a serious form of cancer and the recovery is very poor. So patient is psychologically depressed.

4. Future anticipations •

Client is capable of handling the situation- will need support and encouragement to do so.

•

He has the plans to go back home and to resume the activities which he was doing prior to the hospitalization.

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He also planned in his mind about the future follow up ie continuation of chemotherapy

5. What client can do to help himself? •

Patient is using his own coping strategies to adjust to the situations.

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He is spending time to read religious books and also spends time in talking with others

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He is trying to clarify his own doubts in an attempt to eliminate doubts and to instill hope.

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He sets his major goal i.e. a healthy and speedy recovery.

6. Client's expectations of family, friends and caregivers •

he sees the health care providers as a source pf information.

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He tries to consider them as a significant members who can help to over come the stress

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He seeks both psychological and physical support from the care givers, friends and family members

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He sees the family members as helping hands and feels relaxed when they are with him.

Evaluation/ summary of impressionsThere is no apparent discrepancies identified between patients perception and the care givers perceptions. INTRAPERSONAL FACTORS 1. Physical examination and investigations Height- 162 cm Weight – 42 kg TPR- 37o C, 74 b/m, 14 breaths per min

BP- 130/78 mm of Hg

2.

•

Eye- vision is normal, on examination the appearance of eye is normal. Conjunctiva is pale in appearance. Pupils reacting to the light.

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Ear- appearance of ears normal. No wax deposition. Pinna is normal in appearance and hearing ability is also normal.

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Respiratory system- respiratory rate is normal, no abnormal sounds on auscultation. Respiratory rate is 16 breaths per min.

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Cardiovascular system- heart rate is 76 per min. on auscultation no abnormalities detected. Edema is present over the left ankle which is non pitting in nature.

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GIT- patient has the complaints of reduced appetite, nausea; vomiting etc. food intake is very less. Mouth- on examination is normal. Bowel sounds are reduced. Abdomen could not be palpated because of the presence of the surgical incision. Bowel habits are not regular after the hospitalization

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Extremities- range of motion of the extremities are normal. Edema is present over the left ankle which is non pitting in nature. Because of weakness and fatigue he is not able to walk with out support

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Integumentary system- extremities are mild yellowish in color. No cyanosis. Capillary refill is normal.

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Genitor urinary system- patient has difficulty in initiating the urine stream. No complaints of painful micturation or difficulty in passing urine.

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Self acre activities- perform some of his activities, for getting up from the bed he needs some other person’s support. To walk also he needs a support. He do his personal care activities with the support from the others

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Immunizations- it is been told that he has taken the immunizations at the specific periods itself and he also had taken hepatitis immunization around 8 years back

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Sleep –. He told that sleep is reduced because of the pain and other difficulties. Sleep is reduced after the hospitalization because of the noisy environment.

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Diet and nutrition- patient is taking mixed diet, but the food intake is less when compared to previous food intake because of the nausea and vomiting. Usually he takes food three times a day.

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Habits- patient does not have the habit of drinking or smoking.

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Other complaints- patient has the complaints of pain fatigue, loss of appetite, dizziness, difficulty in urination, etc...

Psycho- socio cultural •

Anxious about his condition

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Depressive mood

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Patient is a retired teacher and he is Christian by religion.

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Studied up to BA

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Married and has 4 children(2sons and 2 daughters)

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Congenial home environment and good relationship with wife and children

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Is active in the social activities at his native place and also actively involves in the religious activities too.

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Good and congenial relationship with the neighbours

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Has some good and close friend at his place and he actively interact with them. They also very supportive to him

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Good social support system is present from the family as well as from the neighborhood

3. Developmental factors •

Patient confidently says that he had been worked for 32 years as a teacher and he was a very good teacher for students and was a good coworker for the friends.

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He told that he could manage the official and house hold activities very well

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He was very active after the retirement and once he go back also he will resume the activities

4. Spiritual belief system •

Patient is Christian by religion

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He believes in got and used to go to church and also an active member in the religious activities.

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He has a personal Bible and he used to read it min of 2 times a day and also whenever he is worried or tensed he used to pray or read Bible.

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He has a good social support system present which helps him to keep his mind active.

INTERPERSONAL FACTORS •

has supportive family and friends

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good social interaction with others

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good social support system is present

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active in the agricultural works at home after the retirement

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active in the religious activities.

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Good interpersonal relationship with wife and the children

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Good social adjustment present

EXTRAPERSONAL FACTORS •

All the health care facilities are present at his place

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All communication facilities, travel and transport facilities etc are present at his own place.

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His house at a village which is not much far from the city and the facilities are available at the place.

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Financially they are stable and are able to meet the treatment expenses.

Summary •

Physiological- thin body built pallor of extremities, yellowish discoloration of the mucus membrane and sclera of eye. Nausea, vomiting, reduced appetite, reduced urinary out put. Diagnosed to have periampullary carcinoma.

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Psycho socio cultural factors- patient is anxious abut his condition. Depressive mood. Not interacting much with others. Good support system is present.

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Developmental –no developmental abnormalities. Appropriate to the age.

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Spiritual- patient’s belief system has a positive contribution to his recovery and adjustment.

CLINICAL FEATURES •

pain abdomen since 4 days

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Discoloration of urine

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Complaints of vomiting

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Fatigue

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Reduced appetite

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on and off fever

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Yellowish discoloration of eye, palms and nails

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Complaints of weight loss

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Edema over the left leg

INVESTIGATIONS Investigations

Values

Hemoglobin(1319g/dl)

6.9

HCT (40-50%)

21.9

WBC (4000-11000 cells/cumm)

12200

Neutrophil 75%)

(40-

77.2

Lymphocyte 45%)

(25-

10.5

Monocyte (2-10%)

4.5

Eosinophil 10%)

(0-

2.6

Basophil (0-2%)

.2

Platelet (150000400000 cells/cumm)

345000

ESR (0-10mm/hr)

86

RBS mg/dl)

148

(60-150

Pus C/S

_

USG

USG shows mild diffuse cell growth at the Ampulla of Vater which suggests peri ampullary carcinoma of Grade I with out metastasis and gross spread.

Urea (8-35mg/dl)

28

Creatinine (0.6-1.6 mg/dl)

1.8

Sodium (130-143 mEq/L)

136

Potassium (3.5-5 mEq/L)

4

PT (patient)(11.415.6 sec)

12.3

APTT- patient (2432.4 sec)

26.4

Blood group

A+

HIV

Negative

HCV

Negative

HBsAg

Negative

Urine Protein (negative)

Negative

Urine WBC (0-5 cells/hpf)

Nil

RBC (nil )

Nil

Epithelial cell(0-5)

4-5

Cast – granular cast (absent)

Nil

THERAPEUTIC MANAGEMENT Initial Treatment: Patient got admitted to ---Medical college for 3 days and the symptoms not relieved. So they asked for discharge and came to --this hospital

Post operative period (immediate post op)

There treated with • •

Inj Tramazac IV SOS IV fluids – DNS

Treatment at this hospital...

•

Inj Pethedine 1mg SOS

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Inj Phenargan SOS

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Inj Pantodac 40 mg IV OD

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Inj Clexane 0.3 ml S/C OD

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Inj Vorth P 40 mg IM Q12H

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Inj calcium Gluconate 10 ml over 10 min

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IV fluids – DNS

Pre operative period •

Tab Clovipas 75 mg 0-1-0

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Tab Monotrate 10-1

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Tab Metalor XL 10-0

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Inj H Insulin S/C 6-0-6U

• •

Late post op period after 3 days of surgery) •

Inj Tramazac 50 mg IV Q8H

Inj H Insulin S/C 6-0-6U

•

Inj Emset 4 mg Q8H

Tab Pantodac 40 mg 1-0-0

•

Cap

beneficiale

•

Tab Pantodac 40 mg 1-0-0

•

•

Cap beneficiale 01-0

Tab Clovipas 75 mg 0-1-0

•

•

Syp Aristozyme 1-1-1

Tab Monotrate 10-1

•

•

K bind I sachet TID

Tab Metalor XL 10-0

Surgical management Patient underwent Whipple’s procedure (pancreato duodenectomy)

0-1-0

Other instructions •

Incentive spirometry

•

Steam inhalation

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Early ambulation

•

Diabetic diet

NURSING PROCESS I. NURSING DIAGNOSIS Acute pain related to the presence of surgical wound on abdomen secondary to periampullary carcinoma Desired Outcome/goal : Patient will get relief from pain as evidenced by a reduction in the pain scale score and verbalization Nursing action Primary prevention •

Assess severity of pain by using a pain scale

•

Check the surgical site for any signs of infection or complicatio ns

•

•

Secondary prevention •

Teach the patient about the relaxation techniques and make him to do it

•

Encourage the patient to divert his mind from pain and to engage in pleasurable activities like taking with others

Support the areas with extra pillow to allow the normal alignment and to prevent strain

•

Do not allow the patient to do strainous activities. And explain to the patient why those activities are contraindicated.

Handle the area gently. Avoid unnecessar y handling as this will affect the

•

Involve the patient in making decisions about his own care and provide a positive psychological support

Tertiary prevention •

Educate the client about the importance of cleanliness and encourage him to maintain good personal hygiene.

•

Involve the family members in the care of patient

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Encourage relatives to be with the client in order provide a psychologic al well being to

healing process •

Clean the area around the incision and do surgical dressing at the site of incision to prevent any form of infections

•

Provide nonpharmacolo gical measures for pain relief such as diversional activity which diverts the patients mind.

•

Administer the pain medication s as per the prescriptio n by the pain clinics to relieve the severity of pain.

•

Keep the patients body clean in order to avoid infection.

•

Provide the primary preventive care when ever necessary.

patient . •

Educate the family members about the pain managemen t measures.

•

Provide the primary and secondary preventive measures to the client whenever necessary.

Evaluation – patient verbalized that the pain got reduced and the pain scale score also was zero. His facial expression also reveals that he got relief from pain. II. NURSING DIAGNOSIS

Activity intolerance related to fatigue secondary to pain at the surgery site, and dietary restrictions Outcome/ goals: Client will develop appropriate levels of activity free from excess fatigue, as evidenced by normal vital signs & verbalized understanding of the benefits of gradual increase in activity & exercise.

Nursing actions Primary prevention •

Adequately oxygenate the client

•

Instruct the client to avoid the activities which causes extreme fatigue

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Provide the necessary articles near the patients bed side.

•

Assist the patient in early ambulation

•

Monitor client’s response to the activities in order to reduce discomfort s.

•

Provide

Secondary prevention •

•

Instruct the client to avoid the activities which causes extreme fatigue. Advice the client to perform exercises to strengthen the extremities& promote activities

•

Tell the client to avoid the activities such as straining at stool etc

•

Teach the client about the importance of early ambulation and assist the patient in early

Tertiary prevention •

Encourage the client to do the mobility exercises

•

Tell the family members to provide nutritious diet in a frequent intervals

•

Teach the patient and the family about the importance of psychological well being in recovery.

•

Provide the primary and secondary level care if necessary.

nutritious diet to the client. •

Avoid psychologic al distress to the client. Tell the family members to be with him.

•

Schedule rest periods because it helps to alleviate fatigue

ambulation •

Teach the mobility exercises appropriate for the patient to improve the circulation

Evaluation – patient verbalized that his activity level improved. He is able to do some of his activities with assistance. Fatigue relieved and patient looks much more active and interactive.

NURSING DIAGNOSIS-III Impaired physical mobility related to presence of dressing, pain at the site of surgical incision Outcomes/goals: Patient will have improved physical mobility as evidenced by walking with minimum support and doing the activities in limit.

Nursing action Primary prevention •

•

•

•

Provide active and passive exercises to all the extremities to improve the muscle tone and strength. Make the patient to perform the breathing exercises which will strengthen the respiratory muscle. Massage the upper and lower extremities which help to improve the circulation. Provide articles near to the patient and encourage doing activities within limits which promote

Secondary prevention •

Provide positive reinforcement for even a small improvement to increase the frequency of the desired activity.

•

Teach the mobility exercises appropriate for the patient to improve the circulation and to prevent contractures

•

Mobilize the patient and encourage him to do so whenever possible

•

Motivate the client to involve in his own care activities

•

Provide primary preventive measures whenever necessary

Tertiary prevention •

Educate and reeducate the client and family about the patients care and recovery

•

Support the patient, and family towards the attainment of the goals

•

Coordinate the care activities with the family members and other disciplines like physiotherapy.

•

Teach the importance of psychological well being which influence indirectly the physical recovery

•

Provide primary preventive measures whenever necessary

a feeling of well being.

Evaluation – patient’s physical activity improved and he is able to move from bed with support. Patient started doing the active and passive exercises and he verbalized improvement. ----------------------------------------------------------Conclusion The Neuman’s system model when applied in nursing practice helped in identifying the interpersonal, intrapersonal and extra personal stressors of Mr. AM from various aspects. This was helpful to provide care in a comprehensive manner. The application of this theory revealed how well the primary, secondary and tertiary prevention interventions could be used for solving the problems in the client. References 1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed. Missouri: Elsevier Mosby Publications; 2002. 2. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002 3. George JB .Nursing Theories: The Base for Professional Nursing Practice,5th ed. New Jersey :Prentice Hall;2002.

APPLICATION OF ROY’S ADAPTATION MODEL IN NURSING PRACTICE Outline • • • • • • • • •

Introduction Assumptions of Roy's Adaptation Model Roy's Adaptation Model (RAM) –Terms Nursing Process First Level Assessment Second Level Assessment Nursing Care Plan Conclusion Reference

INTRODUCTION 

Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and Mrs. Fabien Roy



At age 14 she began working at a large general hospital, first as a pantry girl, then as a maid, and finally as a nurse's aid.



She entered the Sisters of Saint Joseph of Carondelet.



she earned a Bachelor of Arts with a major in nursing from Mount St. Mary's College, Los Angeles in 1963.



a master's degree program in pediatric nursing at the University of California ,Los Angeles in 1966.



She also earned a master’s & PhD in Sociology in 1973 & 1977 ,respectively



Sr. Callista had the significant opportunity of working with Dorothy E. Johnson



Johnson's work with focusing knowledge for the discipline of nursing convinced Sr. Callista of the importance of describing the nature of nursing as a service to society and prompted her to begin developing her model with the goal of nursing being to promote adaptation.

Sister Callista Roy (1984), Introduction to Nursing: An Adaptation Model (2nd ed) ASSUMPTIONS OF ROY’S ADAPTATION MODEL Scientific         

Systems of matter and energy progress to higher levels of complex selforganization Consciousness and meaning are constitutive of person and environment integration Awareness of self and environment is rooted in thinking and feeling Humans by their decisions are accountable for the integration of creative processes Thinking and feeling mediate human action System relationships include acceptance, protection, and fostering of interdependence Persons and the earth have common patterns and integral relationships Persons and environment transformations are crated in human consciousness Integration of human and environment meanings results in adaptation

Philosophical

    

Persons have mutual relationships with the world and God Human meaning is rooted in an omega point convergence of the universe God is intimately revealed in the diversity of creation and is the common destiny of creation Persons use human creative abilities of awareness, enlightenment, and faith Persons are accountable for the processes of deriving, sustaining, and transforming the universe

PERSONS AND RELATING PERSONS     

An adaptive system with coping processes Described as a whole comprised of parts Functions as a unity for some purpose Includes people as individuals or in groups (families, organizations, communities, nations, and society as a whole) An adaptive system with cognator and regulator subsystems acting to maintain adaptation in the four adaptive modes: physiologic-physical, selfconcept-group identity, role function, and interdependence

ENVIRONMENT 

 

All conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups with particular consideration of mutuality of person and earth resources Three kinds of stimuli: focal, contextual, and residual Significant stimuli in all human adaptation include stage of development, family, and culture

HEALTH AND ADAPTATION  



 

Health: a state and process of being and becoming integrated and whole that reflects person and environmental mutuality Adaptation: the process and outcome whereby thinking and feeling persons, as individuals and in groups, use conscious awareness and choice to create human and environmental integration Adaptive Responses: responses that promotes integrity in terms of the goals of the human system, that is, survival, growth, reproduction, mastery, and personal and environmental transformation Ineffective Responses: responses that do not contribute to integrity in terms of the goals of the human system Adaptation levels represent the condition of the life processes described on three different levels: integrated, compensatory, and compromised

NURSING • •

Nursing is the science and practice that expands adaptive abilities and enhances person and environment transformation Nursing goals are to promote adaptation for individuals and groups in the four adaptive modes, thus contributing to health, quality of life, and dying with dignity

•

This is done by assessing behavior and factors that influence adaptive abilities and by intervening to expand those abilities and to enhance environmental interactions

ROY ADAPTATION MODEL (RAM) –TERMS System-a set of parts connected to function as a whole for some purpose. Stimulus-something that provokes a response, point of interaction for the human system and the environment • • •

Focal Stimuli-internal or external stimulus immediately affecting the system Contextual Stimulus-all other stimulus present in the situation. Residual Stimulus-environmental factor, that effects on the situation that are unclear.

Regulator Subsystem-automatic response to stimulus (neural, chemical, and endocrine) Cognator Subsystem-responds through four cognitive responds through four cognitive-emotive channels (perceptual and information processing, learning, judgment, and emotion) Behavior -internal or external actions and reactions under specific circumstances Physiologic-Physical Mode • • • •

Behavior pertaining to the physical aspect of the human system Physical and chemical processes Nurse must be knowledgeable about normal processes 5 needs (Oxygenation, Nutrition, Elimination, Activity & Rest, and Protection)

Self Concept-Group Identity Mode The composite of beliefs and feelings held about oneself at a given time. Focus on the psychological and spiritual aspects of the human system. Need to know who one is, so that one can exist with a state of unity, meaning, and purposefulness of 2 modes (physical self, and personal self) Role function Mode Set of expectations about how a person occupying one position behaves toward a occupying another position. Basic need-social integrity, the need to know who one is in relation to others Interdependence Mode Behavior pertaining to interdependent relationships of individuals and groups. Focus on the close relationships of people and their purpose. Each relationship exists for some reason. Involves the willingness and ability to give to others and accept from

others. Balance results in feelings of being valued and supported by others. Basic need - feeling of security in relationships   

Adaptive Responses-promote the integrity of the human system. Ineffective Responses-neither promote not contribute to the integrity of the human system Copping Process-innate or acquired ways innate or of interacting with the changing of environment

NURSING PROCESS 1. A problem solving approach for gathering data, identifying the capacities and needs of the human adaptive system, selecting and implementing approaches for nursing care, and evaluation the outcome of care provided • •

• • • •

Assessment of Behavior: the first step of the nursing process which involves gathering data about the behavior of the person as an adaptive system in each of the adaptive modes Assessment of Stimuli: the second step of the nursing process which involves the identification of internal and external stimuli that are influencing the person’s adaptive behaviors. Stimuli are classified as: 1) Focal- those most immediately confronting the person; 2) Contextual-all other stimuli present that are affecting the situation and 3) Residual- those stimuli whose effect on the situation are unclear. Nursing Diagnosis: step three of the nursing process which involves the formulation of statements that interpret data about the adaptation status of the person, including the behavior and most relevant stimuli Goal Setting: the forth step of the nursing process which involves the establishment of clear statements of the behavioral outcomes for nursing care. Intervention: the fifth step of the nursing process which involves the determination of how best to assist the person in attaining the established goals Evaluation: the sixth and final step of the nursing process which involves judging the effectiveness of the nursing intervention in relation to the behavior after the nursing intervention in comparison with the goal established. DEMOGRAPHIC DATA • •

Name Age

•

Sex

•

IP number

•

Education

•

Occupation

•

Marital status

•

Religion

•

Mr. NR

•

53 years

•

Male

•

-----

•

Degree

•

Bank clerk

•

Married

•

Informants

•

Hindu

•

Date of

•

Patient and Wife

admission

•

21/01/08

FIRST LEVEL ASSESSMENT PHYSIOLOGIC-PHYSICAL MODE Oxygenation: Stable process of ventilation and stable process of gas exchange. RR= 18Bpm. Chest normal in shape. Chest expansion normal on either side. Apex beat felt on left 5th inter-costal space mid-clavicular line. Air entry equal bilaterally. No ronchi or crepitus. NVBS. S1& S2 heard. No abnormal heart sounds. Delayed capillary refill+. JVP0. Apex beat felt- normal rhythm, depth and rate. Dorsalis pedis pulsation of affected limp is not palpable. All other pulsations are normal in rate, depth, tension with regular rhythm. Cardiac dull ness heard over 3rd ICS near to sternum to left 5ht ICS mid clavicular line. S1& S2 heard. No abnormal heart sounds. BP- Normotensive. . Peripheral pulses felt-Normal rate and rhythm, no clubbing or cyanosis. Nutrition He is on diabetic diet (1500kcal). Non vegetarian. Recently his Weight reduced markedly (10 kg/ 6 month). He has stable digestive process. He has complaints of anorexia and not taking adequate food. No abdominal distension. Soft on palpation. No tenderness. No visible peristaltic movements. Bowel sounds heard. Percussion revealed dullness over hepatic area. Oral mucosa is normal. No difficulty to swallow food Elimination: No signs of infections, no pain during micturation or defecation. Normal bladder pattern. Using urinal for micturation. . Stool is hard and he complaints of constipation. Activity and rest: Taking adequate rest. Sleep pattern disturbed at night due unfamiliar surrounding. Not following any peculiar relaxation measure. Like movies and reading. No regular pattern of exercise. Walking from home to office during morning and evening. Now, activity reduced due to amputated wound. Mobility impaired. Walking with crutches. Pain from joints present. No paralysis. ROM is limited in the left leg due to wound. No contractures present. No swelling over the joints. Patient need assistance for doing the activities. Protection: Left lower fore foot is amputated. Black discoloration present over the area. No redness, discharge or other signs of infection. Nomothermic. Wound healing better

now. Walking with the use of left leg is not possible. Using crutches. Pain form knee and hip joint present while walking. Dorsalis pedis pulsation, not present over the left leg. Right leg is normal in length and size. Several papules present over the foot. All peripheral pulses are present with normal rate, rhythm and depth over right leg. Senses: No pain sensation from the wound site. Relatively, reduced touch and pain sensation in the lower periphery; because of neuropathy. Using spectacle for reading. Gustatory, olfaction, and auditory senses are normal. Fluids and electrolytes: Drinks approximately 2000ml of water. Stable intake out put ratio. Serum electrolyte values are with in normal limit. No signs of acidosis or alkalosis. Blood glucose elevated Neurological function: He is conscious and oriented. He is anxious about the disease condition. Like to go home as early as possible. Showing signs of stress. Touch and pain sensation decreased in lower extremity. Thinking and memory is intact. Endocrine function He is on insulin. No signs and symptoms of endocrine disorders, except elevated blood sugar value. No enlarged glands. SELF CONCEPT MODE Physical self: He is anxious about changes in body image, but accepting treatment and coping with the situation. He deprived of sexual activity after amputation. Belongs to a Nuclear family. 5 members. Stays along with wife and three children. Good relationship with the neighbours. Good interaction with the friends. Moderately active in local social activities Personal self: Self esteem disturbed because of financial burden and hospitalization. He believes in god and worshiping Hindu culture. ROLE PERFORMANCE MODE: He was the earning member in the family. His role shift is not compensated. His son doesn’t have any work. His role clarity is not achieved. INTERDEPENDENCE MODE:

He has good relationship with the neighbours. Good interaction with the friends relatives. But he believes, no one is capable of helping him at this moment. He says ”all are under financial constrains”. He was moderately active in local social activities SECOND LEVEL ASSESSMENT FOCAL STIMULUS: Non-healing wound after amputation of great and second toe of left leg- 4 week. A wound first found on the junction between first and second toe-4 month back. The wound was non-healing and gradually increased in size with pus collected over the area. He first showed in a local (---) hospital. From there, they referred to ---- medical college; where he was admitted for 1 month and 4 days. During hospital stay great and second toe amputated. But surgical wound turned to non- healing with pus and black colour. So the physician suggested for below knee amputation. That made them to come to ---Hospital, ---. He underwent a plastic surgery 3 week before. CONTEXTUAL STIMULI: Known case DM for past 10 years. Was on oral hypoglycemic agent for initial 2 years, but switched to insulin and using it for 8 years now. Not wearing foot wear in house and premises. RESIDUAL STIMULI: He had TB attack 10 year back, and took complete course of treatment. Previously, he admitted in ---Hospital for leg pain about 4 year back. . Mother’s brother had DM. Mother had history of PTB. He is a graduate in humanities, no special knowledge on health matters. CONCLUSION Mr.NR who was suffering with diabetes mellitus for past 10 years. Diabetic foot ulcer and recent amputation made his life more stressful. Nursing care of this patient based on Roy's adaptation model provided had a dramatic change in his condition. Wound started healing and he planned to discharge on 25th april. He studied how to use crutches and mobilized at least twice in a day. Patient’s anxiety reduced to a great extends by proper explanation and reassurance. He gained good knowledge on various aspect of diabetic foot ulcer for the future self care activities.

NURSING CARE PLAN ASSESS. OF BEHAVIO UR

Ineffeciti ve protectio n and sense in physicalphysiolog ical mode (No pain sensation from the wound site.)

ASSESSMEN NURSING T OF DIAGNOSIS STIMULI

Focal stimuli:

1. Impaired Non-healing skin wound after integrity amputation of related to fragility of great and second toe of the skin secondary left leg- 4 to vascular week insufficienc y

GOAL

INTERVENTIO EVALUATIO N N

Long-term objective:

§ Maintain the wound area 1. amputated clean as area will be contamination affects the completely healing healed by process. 20/5/08 § Follow 2.Skin will sterile remain technique while intact with no providing cares ongoing to prevent ulcerations. infection and Short-Term delay in Objective: healing. i. Size of wound decreases to 1x1 cm within 24/4/08. ii. No signs of infection over the wound within 1-wk

§ Perform wound dressing with betadine which promote healing and growth of new tissue.

Short term goal: Met: size of wound decreased to less than 1x1 cms. WBC values became normal on 24/4/08 Long term goal: Partially Met: skin partially intact with no ulcerations. Continue plan Reassess goal and interventions

§ Do not move the affected area Unmet: not frequently as it achieved affects the iii. Normal complete granulation WBC values healing of tissue within 1-wk amputated formation. area. iv. Presence § Monitor for Continue plan of healthy signs and Reassess goal

granular tissues in the wound site within 1-wk

symptoms of infection or delay in healing. § Administer the antibiotics and vitamin C supplementatio n which will promote the healing process.

and interventions

Impaired activity in physicalphysiolog ical mode

Focal stimuli:

2. Impaired physical During hospital stay mobility related to great and amputation second toe of the left amputated. But surgical forefoot wound turned and presence of to nonhealing with unhealed pus and black wound colour.

Long term Objective: Patient will attain maximum possible physical mobility with in 6 months. Short term objective: i. Correct use of crutches with in 22/4/08

§ Assess the level of restriction of movement § Provide active and passive exercises to all the extremities to improve the muscle tone and strength.

Short term goal: Met: used crutches correctly on 22/4/08. he is self motivated in doing minor excesses Partially Met: walking with minimum support.

§ Make the patient to perform the ROM exercises to lower ii. walking extremities Long term with which will goal: minimum strengthen the Unmet: not supportmuscle. attained 22/4/08 § Massage the maximum iii. He will upper and possible be self lower physical motivated in extremities mobilityactivitieswhich help to Continue plan 20/4/08. improve the Reassess goal circulation. and interventions § Provide articles near to the patient and encourage performing activities within limits which promote a feeling of well being. § Provide positive reinforcement for even a small improvement to increase the frequency of the desired activity. § Measures for pain relief

should be taken before the activities are initiated as pain can hinder with the activity.

Alteration in Physical self in Selfconcept mode (He is anxious about changes in body image) Change in Role performa nce mode. (He was the earning member in the family. His role shift is not compensat e)

Contextual stimuli:

3. Anxiety Known case related to hospital DM for past 10 years and admission on treatment and unknown with insulin Outcome of for 8 years. the disease and financial Residual stimuli: no constrains. special knowledge in health matters

Long term Objective:

§ Allow and encourage the The client will client and remain free family to ask from anxiety questions. Bring up common Short term concerns. objective: § Allow the i. demonstratin g appropriate range effective coping in the treatment ii. Being able to rest and iii. Asking fewer questions

Short term goal: Met: demonstrated appropriate range effective coping with treatment

client and family to verbalize anxiety.

He is able to rest quietly.

§ Stress that frequent assessment are routine and do not necessarily imply a deteriorating condition.

Long term goal:

§ Repeat information as necessary because of the reduced attention span of the client and family § Provide comfortable quiet environment for the client and family

Unmet: client not completely remained free from anxiety due to financial constrainsContinue plan Reassess goal and interventions

Contextual stimuli:

------

4. deficient knowledge Known case regarding the foot DM for past 10 years and care, on treatment wound care, with insulin diabetic for 8 years. diet, and need of follow up Residual care. stimuli: no special knowledge in health matters

Long term Objective:

§ Explain the treatment measures to Patient will the patient and acquire their benefits in adequate a simple knowledge regarding the understandable language. t foot care, wound care, § Explain diabetic diet, about the home and need of care. Include follow up the points like care and care of wounds, practice in nutrition, their day to activity etc. day life. § Clear the Short term objective:

doubts of the patient as the patient may i. Verbalization present with some matters and demonstratio of importance. n of foot § Repeat the care. information ii. Strictly whenever necessary to following diabetic diet reinforce learning. plan iii. Demonstratio n of wound care.

Short term goal: Met: Verbalization and demonstratio n of foot care. Strictly following diabetic diet plan Unmet: Demonstratio n of wound care. Long term goal: Unmet: not completely acquired and practiced the required knowledge. Continue plan Reassess goal and interventions

REFERENCE 1) Marriner TA, Raile AM. Nursing theorists and their work. 5th ed. St Louis: Mosby; 2005 2) George BJ, Nursing Theories- The Base for Nursing Practice.3rd ed. Chapter 8. Lobo ML. Behavioral System Model. St Louis: Mosby; 2005 3) Alligood MR “Nursing Theory Utilization and Application” 5th ed. St Louis: Mosby; 2005 4) Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th ed. Philadelphia: Elsevier Mosby; 2006. 5) Brunner LS, Suddharth DS. Text book of Medical Surgical Nursing. 6 th ed. London: Mosby; 2002 6) Boon NA, Colledge NR, Walker BR, Hunter JAA. Davidson’s principle and practices of medicine. 20th ed. London: Churchill Livingstone Elsevier; 2006.

APPLICATION OF INTERPERSONAL THEORY IN NURSING PRACTICE

Outline • • • • • • • •

Introduction The four phases of nurse-patient relationships are Overlapping phases in nurse- patient relationship Peplau’s theory and nursing process Peplau’s theory application nursing process Summary Evaluation of the theory of application References:

Introduction Peplau’s theory focuses on the interpersonal processes and therapeutic relationship that develops between the nurse and client. The interpersonal focus of Peplau’s theory requires that the nurse attend to the interpersonal processes that occur between the nurse and client. Interpersonal process is maturing force for personality. Interpersonal processes include the nurse- client relationship, communication, pattern integration and the roles of the nurse. Psychodynamic nursing is being able to understand one’s own behavior to help others identify felt difficulties and to apply principles of human relations to the problems that arise at all levels of experience. This theory stressed the importance of nurses’ ability to understand own behavior to help others identify perceived difficulties. The four phases of nurse-patient relationships are: 1. Orientation: During this phase, the individual has a felt need and seeks professional assistance. The nurse helps the individual to recognize and understand his/ her problem and determine the need for help. 2. Identification The patient identifies with those who can help him/ her. The nurse permits exploration of feelings to aid the patient in undergoing illness as an experience that reorients feelings and strengthens positive forces in the personality and provides needed satisfaction. 3. Exploitation During this phase, the patient attempts to derive full value from what he/ she are offered through the relationship. The nurse can project new goals to be achieved through personal effort and power shifts from the nurse to the patient as the patient delays gratification to achieve the newly formed goals. 4. Resolution

The patient gradually puts aside old goals and adopts new goals. This is a process in which the patient frees himself from identification with the nurse. Overlapping phases in nurse- patient relationship

Peplau’s theory and nursing process: Peplau defines Nursing Process as a deliberate intellectual activity that guides the professional practice of nursing in providing care in an orderly, systematic manner. Peplau explains 4 phases such as: •

Orientation: Nurse and patient come together as strangers; meeting initiated by patient who expresses a “felt need”; work together to recognize, clarify and define facts related to need. • • •

Identification: Patient participates in goal setting; has feeling of belonging and selectively responds to those who can meet his or her needs. Exploitation: Patient actively seeks and draws knowledge and expertise of those who can help. Resolution: Occurs after other phases are completed successfully. This leads to termination of the relationship.

In Nursing Process, the orientation phase parallels with assessment phase where both the patient and nurse are strangers; meeting initiated by patient who expresses a felt need. Conjointly, the nurse and patient work together, clarifies and gathers important information. Based on this assessment the nursing diagnoses are formulated, outcome and goal set. The interventions are planned, carried out and evaluation done based on mutually established expected behaviours. Peplau’s theory application nursing process:

The nursing process for Mrs. JL based on Peplau’s theory is as follows: Mrs. JL 27 years Diagnosis: Inter vertebral disc prolapse Assessment Nursing Planning Implementation (Orientatio diagnosis (Identification (Exploitation n phase) phase) phase) Mrs. JL is Impaired Goal setting Carried out plans on pelvic physical was done along mutually agreed traction and mobility with patient upon. she is related to restricted the to bed. presence of pelvic traction. The need for bed rest and restriction was discussed.

Patient will have improved physical mobility as evidenced by participating in self care within the limits.

Provide active and passive exercises to all the extremities to improve the muscle tone and strength.

Provided active and passive exercises to all the extremities

Made the patient to perform breathing exercises

Make the patient to perform the breathing exercises which Massaged the will strengthen upper and lower the respiratory extremities muscle. Provided article within the reach Massage the of the patient upper and lower extremities which help to improve the

Evaluation (Resolution phase) Mrs. JL was free to express problems regarding difficulty in mobilizing.

She expressed satisfaction when able to move without difficulty.

circulation.

Provided positive reinforcement to Provide articles the patient near to the patient and encourage doing activities within limits. Provide positive reinforcement for even a small improvement to increase the frequency of the desired activity.

Assessmen t (Orientatio n phase)

Nursing diagnosis

Planning (Identification phase)

Implementation (Exploitation phase)

Evaluation (Resolution phase)

Mrs. JL expresses pain in the low back region.

Regarding pain, discussion was made to assess the severity and the type and duration of pain. Also the measures to reduce pain were discussed.

Pain related to Goal setting was Carried out plans Mrs. JL was free to the done along with mutually agreed express problems of degenerative patient upon. pain. changes in the lumbar region. Mrs. JL will have reduction in pain as evidenced by her verbalisation of reduction in pain responses. Provide nonpharmacological measures for pain relief such as diversional activity which diverts the patients mind.

Provided non Expressed that she pharmacological got slight relief from measures like pain. diversion, massaging, and pelvic traction.

Give the client a neutral position

Provided supine position to the Always use back client support while turning the Supported the patient that reduces the strainback during position change on the back. Support the areas with extra pillow Used pillows to to allow the normal alignment support the back. and to prevent strain. Administered Tab. Administer Hifenac P and analgesics as prescribed by the Cap. Myoril 4mg as prescribed. physician.

Provide pelvic traction to the patient

Given pelvic traction and explained the need for traction

Assessment (Orientatio n phase) Mrs. JL expresses that she need assistance to get down from bed.

Regarding self care discussion was done and discussed regarding the measures to solve the problems.

Nursing diagnosis

Planning Implementation Evaluation (Identification (Exploitation (Resolution phase) phase) phase) Self care Goal setting Carried out plans Mrs. JL was free to deficit was done along mutually agreed express problems of related to with patient upon. self care. the presence of pelvic traction. Client will She used to call for achieve and maintain self care activities with assistance of caregiver or within her limits.

Kept the articles Keep all the within t he reach articles within of the client the reach of the patient.

Provide a bell to patient to in emergency

call the call any

Frequently visited the patient and enquired for any Frequently visitneeds the patient and enquire for any needs. Assisted the client in doing her self care activities Assist the patient in doing her self care Removed the activities. weight as and when needed. Remove weight of

the the

the needs and all her needs were met appropriately

She achieved and maintained self care activities within her limits

traction as needed by the patient.

Assessment (Orientatio n phase)

Nursing diagnosis

Planning (Identification phase)

Implementation (Exploitation phase)

Evaluation (Resolution phase)

Mrs. JL is enquiring about the disease condition, its outcome and need for surgery

Discussed with the client regarding the disease process and the findings in the client

Anxiety related to hospital admission as evidenced by verbalisation and client & family appearing withdrawn

Goal setting was Carried out plans Mrs. JL was free to done along with mutually agreed express problems of patient upon. self care.

Client will have reduced feeling of anxiety as evidenced by

She asked her doubts regarding the illness and the diagnostic procedures

asking fewer questions She verbalized that Taught the family her anxiety has reduced to some regarding the Teach the family disease process extent. and client in simple regarding the Kannada disease process. Explain in simple understandable language of the client.

Allowed the client and family members to ask questions

Allow and encourage the client and family to ask questions. She and her Allow the client husband and family to expressed their verbalize anxiety. anxiety Stress that frequent assessment are routine and do not necessarily imply a deteriorating condition. Allow the family members to visit the client frequently

Allowed the family members to frequently visit the client

Assessment (Orientatio n phase) Mrs. JL is enquiring about the disease condition, its outcome and need for surgery

Discussed with the client regarding the disease process and the need for follow up

Nursing diagnosis

Planning Implementation Evaluation (Identification (Exploitation (Resolution phase) phase) phase) Goal setting was Carried out plans Mrs. JL was free to done along with mutually agreed express problems of patient upon. self care.

Deficient knowledge related to the treatment measures to be Patient will continued acquire adequate even after knowledge the regarding the discharge. treatment and

She expressed acquisition of knowledge regarding the disease and the signs of aggravation of illness

home care.

Explained Explain the treatment treatment measures and the measures to the need for follow up patient and their benefits Explained regarding the Explain to the signs of client the signs aggravation of of aggravation of disease illness

Use simple and understandable terms

Clarify all the doubts of the patient of importance.

Repeat the information whenever necessary to reinforce

Used simple and understandable terms for explaining Clarified her doubts

Repeated the information

learning.

Summary: 1. Orientation phase • • •

Client is initially reluctant to talk due to pain. Client is expressing that while standing she is having much pain. Client expressed without movement and supine position gave her relief from pain.

2. Identification • • • •

The client participates and interdependent with the nurse Expresses the need for measure to get relief from pain Expresses need for improving the mobility Expresses need to know more about prognosis, discharge and home care and follow up.

3. Exploitation • • •

Client explains that she gets relief of pain when lying down supine. Cooperates and participates actively in performing exercises. Client mobilizes changes position and cooperates during position changes.

4. Resolution •

Client expressed that pain has reduced a lot and she is able to tolerate it now

• •

She has agreed upon to continue the exercises at home She also expressed that she would come for regular follow up after discharge.

Evaluation of the theory of interpersonal relations by Peplau With the help of the theory of interpersonal relations, the client's needs could be assessed. It helped her to achieve them within her limits. This theory application helped in providing comprehensive care to the client. References: 1. Chinn P L, and Kramer M K. Theory and nursing- a systemic approach. 3rd edition. Philadelphia: Mosby year book;1991 2. George J B. Nursing theories. 5th edition. New Jersey: Prentice hall; 2002 3. Alligood M R, Tomey A M. Nursing theory- utilization and application. 3rd edition. Missouri: Mosby Elsevier; 2006 4. Craven R F, Hirnle C J. Fundamentals of nursing – human health and function. 5th edition. Philadelphia: Lippincott Williams and Wilkins; 2007 5. McQuiston C M and Webb A A. Foundations of nursing theoryContributions of 12 key theorists. New Delhi: Sage Publications; 1995

APPLICATION OF THEORY IN NURSING PROCESS

Introduction Theories are a set of interrelated concepts that give a systematic view of a phenomenon (an observable fact or event) that is explanatory & predictive in nature. Theories are composed of concepts, definitions, models, propositions & are based on assumptions. They are derived through two principal methods; deductive reasoning and inductive reasoning. Objectives •

to assess the patient condition by the various methods explained by the nursing theory

•

to identify the needs of the patient

•

to demonstrate an effective communication and interaction with the patient.

•

to select a theory for the application according to the need of the patient

•

to apply the theory to solve the identified problems of the patient

•

to evaluate the extent to which the process was fruitful.

Definition: Nursing theory is an organized and systematic articulation of a set of statements related to questions in the discipline of nursing. A nursing theory is a set of concepts, definitions, relationships, and assumptions or propositions derived from nursing models or from other disciplines and project a purposive, systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing, explaining, predicting, and /or prescribing.. Importance of nursing theories: • • • • •

• • •

Nursing theory aims to describe, predict and explain the phenomenon of nursing It should provide the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future Theory is important because it helps us to decide what we know and what we need to know It helps to distinguish what should form the basis of practice by explicitly describing nursing The benefits of having a defined body of theory in nursing include better patient care, enhanced professional status for nurses, improved communication between nurses, and guidance for research and education The main exponent of nursing – caring – cannot be measured, it is vital to have the theory to analyze and explain what nurses do As medicine tries to make a move towards adopting a more multidisciplinary approach to health care, nursing continues to strive to establish a unique body of knowledge This can be seen as an attempt by the nursing profession to maintain its professional boundaries

Characteristics of theories: Theories are • • • • • • •

Interrelating concepts in such a way as to create a different way of looking at a particular phenomenon. Logical in nature. Generalizable. Bases for hypotheses that can be tested. Increasing the general body of knowledge within the discipline through the research implemented to validate them. Used by the practitioners to guide and improve their practice. Consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated.

Purposes of theory in practice: • • • • • •

Assist nurses to describe, explain, and predict everyday experiences. Serve to guide assessment, intervention, and evaluation of nursing care. Provide a rationale for collecting reliable and valid data about the health status of clients, which are essential for effective decision making and implementation. Help to establish criteria to measure the quality of nursing care Help build a common nursing terminology to use in communicating with other health professionals. Ideas are developed and words defined. Enhance autonomy (independence and self-governance) of nursing by defining its own independent functions.

If theory is expected to benefit practice, it must be developed co- operatively with people who practice nursing. People who do research and develop theories think differently about theory when they perceive the reality of practice. Theories do not provide the same type of procedural guidelines for practice as do situation- specific principles and procedures or rules. Procedural rules or principles help to standardise nursing practice and can also be useful in achieving minimum goals of quality of care. Theory is ought to improve the nursing practice. One of the most common ways theory has been organized in practice is in the nursing process of analyzing assessment data. • • • • •

Application Goal Attainment Theory Application Orem's Self-care Deficit Theory Theories used in Community Health Nursing Application of Suchman’s Stages of Illness Mode Application of Betty Neuman's Systems Model in Nursing Care

REFERENCES 1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed. Missouri: Elsevier Mosby Publications; 2002. 2. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002

3. George JB .Nursing Theories: The Base for Professional Nursing Practice .5th ed. New Jersey :Prentice Hall;2002.

TRANSCULTURAL NURSING Outline • • •

INTRODUCTION TRADITIONAL CONCEPTS OF HEALTH AND DISEASE CONCEPT OF CULTURE

• • • • • • • •

PURPOSES OF KNOWING THE PATIENTS CULTURE AND RELIGION FOR HEALTH CARE PERSONNEL USE OF SUBSTANCES ILLNESS CAUSE AND PREVENTION RELATED TO FOOD ECONOMIC BARRIERS SOCIOCULTURAL FACTORS AND THE NURSING PROCESS ROLE OF NURSE CONCLUSION REFERENCES

INTRODUCTION Transcultural nursing with established clinical approached to clients with varying cultures are relatively new. According to Madeleine Leininger (1987) founder of the filed of transcultural nursing in the mid 1960s. The education of nursing students in this field is only now beginning to yield significant results. Today nurses with a deeper appreciation of human life and values are developing cultural sensitivity for appropriate individualized clinical approaches. Religious and Cultural knowledge is an important ingredient in health care. If the client do not respond as nurse expects the nurse may interpret it as unconcern or resistance the nurse then can be anxious and frustrated in order to incorporate cultural knowledge in care cultural knowledge in care. It is important to understand some definition and cultural components that are important in health care. For a nurse to successfully provide care for a client of a different cultural or ethnic to background, effective intercultural communication must take place. Intercultural communication occurs when each person attempts to understand the other’s point of view from his or her own cultural frame of reference. Effective intercultural communication is facilitated by the nurse identification of areas of commonalities. After reaching a cultural. understanding, the nurse must consider cultural factor throughout the nursing process. Major Nursing organizations have emphasized in the last decade the importance of considering culture factors when delivering nursing care. According to the American Nurses’ s Association (1976)”Consideration of individual value systems and lifestyles should be included in the planning and health care for each client Nursing curriculum recognize the contribution nursing to the health care needs of a diverse and multi cultural society life-style may ret1ect cultural heritage. •

Culture-Broadly defines set of values, beliefs and traditions, that are held by a specific group of people and handed down from generation to generation. Culture is also beliefs, habits, likes, dislikes, customs and rituals learn from one’s family. (Specter 1991)

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Culture is the learned, shared and transmitted values, beliefs, norms and life way practices of a particular group that guide thinking, decisions, and actions in patterned ways.

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Religion:

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Is a set of belief in a divine or super human power (or powers) to be obeyed and worshipped as the creator and ruler of the universe? Ethical

values and religion system of beliefs and practices, difference within the culture and across culture are found •

Ethnic: refers to a group of people who share a common and distinctive culture and who are members of a specific group.

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Ethnicity :a consciousness of belonging to a group.

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Cultural Identify: the sense of being part of an ethnic group or culture

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Culture-universals: commonalities of values, norms of behavior, and life patterns that are similar among different cultures.

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Culture-specifies ; values, beliefs, and patterns of behavior that tend to be unique to a designate culture.

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Material culture; refers to objects (dress, art, religious arti1acts)

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Non-material culture; refers to beliefs customs, languages, social institutions. Subculture: -composed of people who have a distinct identity but are related to a larger cultural group.

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Bicultural : a person who crosses two cultures, lifestyles, and sets of values.

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Diversity: refers to the fact or state of being different. Diversity can occur between cultures and within a cultural group.

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Acculturation; individuals who have taken on, usually observable, features of another culture. People of a minority group tend to assume the attitudes, values, beliefs, find practices of the dominant society resulting in a blended cultural pattern.

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Cultural shock:-the state of being disoriented or unable to respond to a different cultural environment because of its sudden strangeness, unfamiliarity, and incompatibility to the stranger's perceptions and expectations at is differentiated from others by symbolic markers (cultures, biology, territory, religion).

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Ethnic groups; share a common social and cultural heritage that is passed on to successive generations.,

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Ethnic identity;- refers to a subjective perspective of the person's heritage and to a sense of belonging to a group that is distinguishable from other groups.

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Race: the classification of people according to shared biologic characteristics, genetic markers, or features. Not all people of the same race have the same culture.

TRADITIONAL CONCEPTS OF HEALTH AND DISEASE When viewed across a variety of multicultural groups, explanations for health and disease that characterized, many traditional beliefs about disease causation, treatment, and general health practices can be seen as highly complex, dynamic, and interactive. These explanations often involve family, community, and/or supernatural agents in cause and effect, placation, and treatment rituals to prevent, control, or cure illness. A failure to understand and appreciate these "differences" can have serious implications for the success of any Health Promotion and Disease Prevention (HPDP) effort.

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Be aware that the health concepts held by many cultural, groups may result in people choosing not to seek Western medical treatment procedures because they do not view the illness or disease as coming from within themselves

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Be aware that in many Eastern cultures and other cultures in the developing world, the locus of control for disease causality often is centered outside the individual, whereas in Western cultures, the locus of control tends to be more internally oriented (Dim-out, 1995).

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Remember that if the more traditional person does seek Western medical treatment, then that person might not be able to provide or describe his or her symptoms in precise terms that the Western medical practitioner can readily treat (Landline & Logoff, 1992).

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Recognize that individuals from other cultures might not follow through with health-promoting or treatment recommendations because they perceive the medical or other health- promoting encounter as a negative or perhaps even hostile experience.

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Acknowledge that many individual patients and health care practitioners have specific notions about health and disease causality and treatment called explanatory models. These models are generally a conglomeration of the respective cultural and social training, beliefs, and values; the personal beliefs, values, and behaviors-, and the understanding of biomedical concepts that each group holds (Klein man, 1980).

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Recognize that the more disparate the differences are between the biomedical model and the lay/popular explanatory models, the greater the potential for, on to encounter resistance to Western HPDP programs.

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Be aware of the need to be flexible in the design of programs, policies, and services to meet the needs and concerns of the culturally diverse population, groups that are likely to be encountered.

Traditional Concepts of Illness Causality •

Be aware that folk illnesses are generally learned syndromes that individuals from particular cultural groups claim to have and from which their culture defines the etiology, behaviors, diagnostic procedures, prevention methods, and traditional healing or curing practices.

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Remember that most cases of lay illness have multiple causalities and may require several different approaches to diagnosis, treatment, and cure including folk and Western medical interventions

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Recognize that folk illnesses, which are perceived to arise from a variety of causes, often require the services of a folk healer who may be a local corianders, shaman, native healer, spiritualist, root doctor, or other specialized healer.

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Recognize that the use of traditional or alternate models of health care delivery is widely varied and may come into conflict with Western models of health care practice.

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Understanding these differences may help us to be more sensitive to the special beliefs and practices of multicultural target groups when planning a program. Culture guides behavior into acceptable ways for the people in a specific group as such culture originates and develops within the social structure through inter personal interactions.

CONCEPT OF CULTURE •

Culture is learned by each generation through both formal and informal life experiences. Language is primary through means of transmitting culture

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The practices of particular culture often arise because of the group's social and physical environment

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Culture practice and beliefs are adapted over time but they mainly remain constant as long as they satisfy needs.

Cultural awareness It is an in-depth self-examination of one's own background, recognizing biases and prejudices and assumptions about other people

PURPOSES OF KNOWING THE PATIENTS CULTURE AND RELIGION FOR HEALTH CARE PERSONNEL Cultural background affect a person's health in all dimensions, so the nurse should consider the client's cultural background when planning care

Although basic human needs are the same for all people, the way a person seeks to meet those needs is influenced by culture. •

To heighten awareness of ways in which their own faith system. Provides resources for encounters with illness, suffering and death.

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To foster understanding, respect and appreciation for the individuality and diversity of patients beliefs, values, spirituality and culture regarding illness, its meaning, cause, treatment, and outcome.

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To strengthen in their commitment to relationship-centered medicine that emphasizes care of the suffering person rather than attention simply more to the pathophysiology of disease, and recognizes the physician as a dynamic component of that relationship.

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To facilitate in recognizing the role of the hospital chaplain and the patient's clergy as partners in the health care team in providing care for the patient.

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To encourage in developing and maintaining a program of physical, emotional and spiritual self-care introduce therapies from the East, such as ayurveda and pancha karma

Leininger (1991,2002a) has defined transcultural nursing as a comparative study of cultures to understand similarities (culture universal) and difference (culturespecific) across human groups Culturally congruent care; Care that fits the people's valued life patterns and set of meanings -which is generated from the people themselves, rather than based on predetermined criteria. Discovering client's culture care values, meanings, beliefs and practices as they relate to nursing and health care requires nurses to assumes the roles of learners of client’s culture and copartners with client's and families in defining the characteristics of meaningful and beneficial care.(Leininger,2002 Culturally competent care is the ability of the practitioner to bridge cultural gaps in caring, work with cultural differences and enable clients and families to achieve meaningful and supportive caring. Culturally competent care requires specific knowledge, skills, and attitudes in the delivery of culturally congruent care and awareness. Pacquiato (2003) identifies three distinct levels of cultural competence at the practitioner, organizational and social levels. Nursing Decisions Leininger (1991) identified three nursing decision and action modes to achieve culturally congruent care. All three modes of professional decisions and actions are aimed to assist, support, facilitate, or enable people of particular cultures The three modes for congruent care, decisions, and actions proposed in the theory are predicted to lead to health and well being, or to face illness and death. 1. Cultural preservation or maintenance: Retain and or preserve relevant care values so that clients can maintain their well-being, recover from illness, or face handicaps and/or death . 2.Cultural care accommodation or negotiation- Adapt or negotiate with the others for a beneficial or satisfying health outcome 3. Cultural care repatterning or restructuring : Records, change, or greatly modify client’s life ways for a new, different and beneficial health care pattern

PURPOSE AND GOAL OF THE THEORY The central purpose of the theory is to discover and explain diverse and universal culturally based care factors influencing the health, well-being, illness, or death of individuals or groups. The purpose and goal of the theory is to use research findings to provide culturally congruent, safe, and meaningful care to clients of diverse or similar cultures. Status of Traditional Practices Many traditional practices are used to prevent and a redemptive practice used to prevent illness and harm treat illness, including objects and substances and religious practices. (Morgenstern, 1966) USE OF PROTECTIVE OBJECTS Protective objects can be worn or carried or hung in the home. Amulets are objects with magical powers, for all walks of life and cultural and ethnic backgrounds is example, charms worn on a string or chain around the neck, wrist, or waist to protect the wearer from the evil eye or evil spirits. Amulets exist in societies all over the world and are associated with protection from trouble (Budge, 1978) USE OF SUBSTANCES Substances are ingested in certain ways or amounts regimen, an effort must be made to determine if they are worn or hung in the home. This practice uses diet and consists of many different observances. It is believed that the body is kept in balance or harmony by the type of food eaten so many food taboos and combinations exist in traditional belief systems. For example, it is believed that some food substances can be ingested to prevent illness. People from many ethnic backgrounds eat raw garlic or onion In an effort to prevent illness or wear them on' the body or hang them in the home. Jews also believe that milk and meat must never be mixed or eaten at the same meal (Steinberg, 1947) mind, and spirit, or the restoration of holistic health RELIGIOUS PRACTICES Another traditional approach to illness prevention female centers around religion and includes practices such as from a divine source the burning of candles, rituals of redemption, and In many instances a heritage consistent person may prayer. Religion strongly affects the way people attempt to prevent illness, and it plays a strong role in rituals associated with health protection. Religion dictates social, moral, and dietary practices designed to keep a traditional healer (Kaptchuk and Croucherl987) Traditional Remedies The admitted use of folk or traditional medicine increasing, and the practice is seen among people from all walks of life and cultural ethnic back ground Use of folk medicine is not a new practice among heritage consistent people, so many of the remedies have been used and passed on for generations. The pharmaceutical, must be made to determine properties of vegetation-plants, roots, tested stems, flowers, seeds, and herbs-have been studied tested, cataloged, and used for countless centuries. Many of these plants are used by specific communities. Others cross ethnic and community lines and are used in certain Geographic areas in the person's country of origin. When patients -do not adhere to a pharmacological regimen an effort must be made to determine the remedy if they are taking traditional remedies. Frequently,

the active ingredients of traditional remedies are unknown. If a client is believed to be, taking them an effort must be made to determine the remedy as well as its active in gradients Often, these ingredients can be antagonistic or synergistic to prescribed medications. Over dose may occur. Healer's In the traditional context, healing is the restoration of the person to a state of harmony between the body, Within a given community, specific people are known to have the power to heal. The healer may be male or and is thought to have received the gift of healing In many instances a heritage consistent person may consult a traditional healer before, instead of, or in conjunction with a modern health care provider. Many differences exist between the Western physician and the Eastern A broad range of health and illness beliefs exist many of these beliefs have roots in the culture, ethnic, religious, or social back ground .of a person family, or community. 'When people anticipate fear or experience an illness or crisis, they may use a modern or traditional approach toward prevention and healing. These approach may originate in culture, ethnicity or religion. These beliefs and practices may be internal or personal and person may be able to define or describe them. However, they may be due to external social forces not within the person's control Examples of external social forces include communication barriers, such as language differences, or economic barriers causing limited access or lack of access to modem, health care facilities. IMMIGRATION Every immigrant group has its own cultural attitudes ranging beliefs and practices regarding these areas Health and illness can be interpreted in terms of personal experience and expectations. There are countless ways to explain health and illness, and people base their responses on cultural, religious, and ethnic back ground. The responses are culture specific, based on a client's experience and perception. Gender Roles In many cultures, the male is dominant figure. In cultures where this is time, males make decisions for other family members well as for themselves. For example, no matter which family member is involved cultures where the male dominate. The female usually is passive. In African -American families, however as well as in many Caucasian families, the female often is dominant Knowledge of the dominant member of the family is important consideration in planning Nursing care folk illnesses, which are perceived to arise from a variety of causes, often require the services of a folk healer who may be a local curandero, shaman, native healer, spiritualist, root doctor, or other specialized healer. Recognize that the use of traditional or alternate models of health care deliveries widely varied and may come into conflict with Western models of health care practice. Understanding these differences may help you to be more sensitive to the special beliefs and practices of multicultural target groups when planning a program.

ILLNESS CAUSE AND PREVENTION RELATED TO FOOD Several factors cause illness. A hot-cold imbalance, for example, is primarily caused by improper diet. Food substances are classified as hot or cold with and without regard to their actual temperature. This classification can vary from

person to person, but essentially, certain foods are known to be hot, and others are known to be cold. Examples of cold food are, honey, avocados, bananas, and lima beans. Examples of hot foods-are chocolate, coffee, com meal, garlic, kidney beans, onions, and peas. Illness can occur if these foods are eaten in improper combinations or amounts. . Traditional beliefs about mental health In the traditional belief system, mental illnesses are caused by a lack of harmony of emotions or, sometimes, by evil spirits. Mental wellness occurs when psychological and physiologic functions are integrated. Some elderly Asian Americans share the Buddhist belief that problems in this life are most likely related to transgressions committed in a past life. In addition our previous life and our future life are as much a part of the life cycle. ECONOMIC BARRIERS Several economic barriers, such as unemployment, underemployment, homelessness, lack of health insurance poverty prevent people from entering the health care system. Poverty is by far the most critical factor. Poverty a relative term and changes from time and place. In the United States, poverty is pervasive and found extensively among people in certain norms geographical areas, such as rural populations, the elderly migrant workers, and illegal aliens. Poor health, crippling diseases, drug and alcohol abuse, poor education; and inferior are contributing social causes of poverty. Several programs, both governmental and private, aid people with short- and long-tem problems. It is important for the nurse to be aware clients needs and financial resources available in the local community. Time orientation It is varies for different cultures groups. A client may be late for an appointment not because of reluctance or lack of respect for the nurse but because he is less concerned about planning ahead to be on time than with the activity in which he is currently engaged. PERSONAL SPACE AND TERRITORIALITY; Personal space involves a person's set of behaviors and attitudes toward the space around himself. Staff members and other clients frequently encroach on a client's territory in the hospital, which includes his room, bed, closet, and belongings. The nurse should try, to respect the client's territory as much as possible, especially when performing nursing procedures. The nurse should also welcome visiting members of the family and extended family. This can remind the client of home, lessening the effects of isolation and shock from hospitalization. SOCIOCULTURAL FACTORS AND THE NURSING PROCESS Religious belief that effect the care Nursing; Belief about birth &death. Belief about diet and food practices. Belief regarding medical care Comments (cremation is preferred) ROLE OF NURSE 1. The nurse should begin the assessment by attempting to determine the client's cultural heritage and language skills. The client should be asked if any of his health beliefs relate to the cause of the illness or to the problem.

The nurse should then determine what, if any, home remedies the person is taking to treat the symptoms 2. Nurses should evaluate their attitudes toward ethnic nursing care. Some nurses may believe they should treat all clients the same and simply act naturally, but this attitude fails to acknowledge that cultural differences do exist and that there is no one "natural" human behavior The nurse cannot act the same with all clients and still hope to deliver effective, individualized ,holistic care. 3. Sometimes, inexperienced nurses are so self-conscious about cultural differences and so afraid of making a mistake that they impede the nursing process by not asking questions about areas of difference or by asking so many questions that they seem to try into the client' personal life. 4. The process of self-evaluation can help the nurse become more comfortable when providing care to clients from diverse backgrounds 5. Culture is the sum total of mores traditions & beliefs about how people function encompasses others products of human works & thoughts. Specific to member of an intergenerational group, community or population. 6. Nurses have a responsibility to understand the influence of culture, race ðnicity on the development of social emotional relationship child rearing practices &attitude toward health. 7. A child's self concepts evolves from ideas about his or her social roles 8. Primary groups are characterized by intimate contact mutual support and pressure for conformity. 9. Important sub culture influences on children include ethnicity social class, occupation school peers and mass culture 10. Socioeconomic influences play major role in ability to seek opportunity for health promotion for wellness 11. Religious practices greatly influences health promotion belief in families. 12. Many ethnic and cultural groups in country retain the cultural heritage of their original culture. 13. How culture influences behaviors, attitudes, and values depends on many factors and thus is not the same for different members of a cultural group. 14. Ethnocentrism can impede the delivery of care to ethnic minority clients and, when pervasive, can become cultural racism. 15. Stereotyping ethnic group members can lead to mistaken assumptions about a client. 16. The nurse should have an understanding of the general characteristics of the major ethnic groups, but should always individualize care rather than generalize about all clients in these groups. 17. Before assessing the cultural background of a client, nurses should assess how they are influenced by their own culture. 18. The nursing diagnosis for clients should include potential problems in their interaction with the health care system and problems involving the effects of culture.

19. The planning and implementation of nursing interventions should be adapted as much as possible to the client's cultural background. 20. Evaluation should include the nurse's self-evaluation of attitudes and emotions toward providing nursing care to clients from diverse sociocultural backgrounds. 21. When nurses provide care to clients from a background other than their own, they must be aware of and sensitive to the clients' sociocultural background, assess and listen carefully to health and illness beliefs and practices, and respect and not challenge cultural, ethnic, or religious values and health care beliefs. The nursing process enables the nurse to provide individualized care 22. The nurse should begin the assessment by attempting to determine the client's cultural heritage and language skills. The client should be asked if any of his health beliefs relate to the cause of the illness or to the problem. The nurse should then determine what, if any, home remedies the person is taking to treat the symptoms 23. Assessment enables the nurse to cluster relevant data and develop actual or potential nursing diagnoses related to the cultural or ethnic need of the client. In addition the nursing diagnosis should state the probable cause .The identification of the cause of the problem further individualizes the nursing care plan and encourages selection of appropriate interventionscultural variables as they relate to the client. The extended family should be involved in the care the Client's strongest support group. Cultural beliefs and practices can be in-corporate into therapy. 24. The client’s the nursing process; educational level and language skills should be considered when planning teaching activities. 25. Explanations of and practices into nursing therapies; aspects of care usually not questioned by acculturated clients may be required for nonEnglish speaking or non- acculturated clients to avoid confusion, misunderstanding, or cultural conflict. 26. The nurse may have to alter her usual ways of interacting with clients to avoid offend ignore alienating a client with different attitudes toward social interaction and etiquette. A client who is modest and self-conscious about the body may need psychological preparation before some procedures and tests. 27. The nurse can find out what care the client considers appropriate by involving him and his family in planning care and asking about their expectations. This should be done in every case, even if the nursing care cannot be modified. Because both the nurse and the client are likely to take many aspects of their cultures for granted, questions should be clear and explanations should be explicit. 28. Discussing cultural questions related to care with the client and family during the planning stage helps the nurse understand how cultural variables are related to the client's health beliefs and practices, so that interventions can be individualized for the client. 29. The nurse evaluates the results of nursing care for ethnic clients as for all clients, determining the extent to which the goals of care have been met. Evaluation continues throughout the nursing process and should include feedback from the client and family. With an ethnic minority client, however, self-evaluation

by the nurse is crucial as he or she increases skills for interaction. The nurse should consider questions such as the following: . •

Am I open to understanding ways in which the client's values differ from mine?

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Have I given sufficient attention to communicating with the client with limited language skills?

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Have I have successful client's family in nursing process?

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Am I incorporating the client's traditional beliefs and practices into nursing therapies?

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Is my therapeutic relationship with the client grounded on respect for the client regardless of cultural differences?

CONCLUSION Nurses need to be aware of and sensitive to the cultural needs of clients. The body of knowledge relevant to this sensitive area is growing, and it is imperative that nurses from all cultural backgrounds be aware of nursing implications in this area. The practice of nursing today demands that the nurse identify and meet the cultural needs of diverse groups, understand the social and cultural reality of the client, family, and community, develop expertise to implement culturally acceptable strategies to provide nursing care, and identify and use resources acceptable to the client (Boyle, 1987). REFERENCES 1. Boyle, JS: The practice of trans cultural nursing, Transcultural Nursing Morgenstern, J: Rites of birth, marriage, death, and kindred occasions 2. George Julia B. Nursing theories: The base of professional nursing practice 3rd edition. Norwalk, CN: Appleton and Lange; 1990. 3. Kozier B, Erb G, Barman A, Synder AJ. Fundamentals of nursing; concepts, process and practice, Edn 7th, 2001. 4. Leninger M, McFarland M. Transcultural Nursing: Concepts, Theory, Research, and Practice; Edn 3rd, McGraw-Hill Professional; New York, 2002. 5. Potter A, Perry G .Basic Nursing-Theory and Practice, Edn 3rd Mosby Company.

HELPING AND HUMAN RELATIONSHIPS THEORY

By ROBERT R. CARKHUFF Introduction When adults have reached full maturity, they can communicate fully, they have satisfied their needs for fullness in all aspects of life and become full persons. They are now prepared to help others to achieve their own levels of wholeness. They will not only communicate fully with others struggling to grow and develop, they will also teach the others the skills they need to grow and develop themselves. They will become the models and the agents for the growth of others. They will give their lives meaning through their productivity in living, learning and working arenas. They will create new life through their helping skills. The cycle of life continues. Helping Helping is a process leading to new behavior for the person being helped . An effective helper is initially nourishing or responsive. This nourishment prepares the person being helped for the more directionful or initiative behavior of the helper. Children as they become capable of both nourishing and directionful behavior, they assume the mantle of adulthood and later perhaps parenthood. They can act constructively in the lives of their own and others thus we call them fully adults or they are now helpers for they are capable of helping others as well as themselves. Persons who are fully alive help other persons to become fully alive. Responsive and initiative behaviours are the basic dimensions of helping and development. Potentially all relationships are helping relationships. It depends upon the helping skills one has, the effects of skills depend upon how we sequence them. Thus helping in real sense is a developmental process like child rearing. Effective parenting involves both responsive and initiative skills. Helpers who are fully responsive and fully initiative teach their helpees to be fully responsive and fully initiative. Human Relationships Human Relationships may be facilitative or retarding effects. Like a marriage, the consequences of all human relationships may be for better or for worse. Consequences may be constructive or destructive, may produce persons and non persons; health care provider-patient; employee-employer etc. The effects may be positive or negative or any of the degrees in between these extremes. The effects are seen in physical, emotional and intellectual functioning. With facilitative agents the recipients may be physically energetic, emotionally expansive and intellectually acute; with retarding agents the recipients may be physically listless, emotionally shallow and intellectually dull. Power and human relationships The effects of human relationships depend upon the power relationship. If the person is ceded the power in the relationship is functioning at a high level, then all parties involved can benefit from the relationship. Eg. Parents. Unfortunately power relations are developed for reasons other than functionality like tradition, politics etc. It makes good sense that if people have not discovered themselves they can only handicap others in finding their own way of life. The effects of the power relationships depend upon the skills.

Skills Most fundamentally, it is the powerful person’s level of functioning in basic human relations skills that determines the effects of relationships. There are two sets of skills which are the basic ingredients of all human relationships in the areas of endeavor. Responding and initiating skills These skills are cycled in an individual’s personal development before his or her interpersonal development. A person must respond to understand himself before initiating an action program or product. There is no effective action that is not based upon a depth of understanding. Responsiveness Responsiveness is the basic ingredient of human relations, which involves empathy. Responsiveness is the most profound variable in the human condition. To know more than that person does of her own experience, to be able to describe and predict and influence that experience constructively, is the test of responsive skills. Responsive skills thus involve experiencing another’s condition and communicating to her own experience. It involves the other person in a process leading to her own self-exploration and self-understanding. Initiative Initiative is the basic ingredient of human functionality. It involves operationalizing the goal or breaking it down into it’s components. It involves developing the steps and systems to achieve the goal, it is more than a mechanical process. It begins with a vision of the possible, building upon our own experience to see a goal, further it stimulates the other person to take action to achieve the goal. •

When people share their problems, what skills do you have to truly show that you are responding to their experience?

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How do you physically show this? Emotionally? Intellectually?

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What do you do and say that will assure the people that you are sensitively attuned to their experience? How do you show you heard them? What feedback do you give?

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When you are wrestling with their problems, how do you share your experience to help them to develop achievable goals that solve their problems?

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Now that you have responded to their experience, how do you help them to initiate steps to get to their goals.

New Behaviour Before we can acquire the skills of helping, we must understand the goals of helping. New behavior is the overall goal of helping. One must explore where she is, explore herself in relation to herself and in relation to her world. We must know the problems before we can change the behavior. In exploring herself, the person seeking help is attempting to understand where she is in relation to where she wants to be. Self understanding is not real until the individual has acted upon it. In acting the person acts upon how to get from where she is to where she wants to be. The more accurately a person understands herself, the more constructively she can act for herself and others. Evolution of dimensions

Before we understand the dimensions, we must understand four things. i. Helping Sources: There are two approaches to helping -insight and action. The insight approach was supported by many traditional therapeutic schools, emphasized the client’s insight as the basis for the development of an effective set of assumptions about his or her world. The action approach has been promulgated by the learning theory and behaviour modification schools as well as the trait and factor school, which matches people to jobs and vice versa, who emphasized the client’s development and implementation of rational action plans for managing his or her world. In order to effectively help human beings to change behaviour the insight and action approaches must be integrated into one effective helping process. ii. Helping Process: In order to demonstrate gain in behaviour, the helpees must act differently from the way they did before. Thus they must have insights or understand accurately the gaols and ways to achieve them; in order to understand their goals, the helpees must explore their world experientially. Finally they must act to get from where they are to where they want to be. With the feedback they can recycle the learning process Exploration -----------Understanding------------Action-----------Feedback Feedback-------further exploration----self understanding--------real understanding Real Understanding-----------modification of action (effective action). iii. Helper Skills: The historic dimension of empathy was complemented by unconditional positive regard and genuineness, which were then operationalized into accurate empathy, respect and genuineness. These were in turn complemented by other dimensions including specificity or concreteness, self disclosure, confrontation and immediacy; then factored into responsive and initiative dimensions. The responsive dimensions (empathy, respect, specificity of expression) responded to the helpee’s experience and thus facilitated the helpee’s movement towards understanding. The initiative dimensions (genuineness, self disclosure, confrontation, immediacy and concreteness) were generated from the helper’s experience and stimulated the helpee’s movement toward action. The initiative dimensions were later extended to incorporate the problem solving skills and program development skills needed to fully help the helpee's to achieve appropriate outcomes. iv. Helpee Outcomes: emphasized the emotional changes or gains of he helpee's. Since the helping methods were insight oriented, the process emphasized helpee exploration and outcome assessments measured the changes in the helpee’s level of emotional insights, which were restrictive because they were assessing only one dimension of the helpee’s functioning. These were later extended to incorporate the interpersonal functioning of the helpee's. The dimension of physical functioning was added, to measure fitness and energy; intellectual dimension to measure the intellectual achievement and capabilities. Levels and styles of functioning Carkhuff and Berenson(1967) described five levels of dimensions. The dimensions are empathy, respect or regard, genuineness, concreteness, warmth. Levels: First: no empathy is taking place( no evidence of the helper characteristic)

Second: Empathizing very little and at a level that detracts from helpee functioning(10% of time) Third: minimum level of feeling response necessary to be efective(50% of time) Fourth and fifth: Higher levels of helper empathy(4th – 75%; 5th – consistently present) The responsibility continuum:

Helping skills

The responsive and initiative factors of helping dominate the helping process facilitating E+ U+A That culminate in the physical, emotional and intellectual helpee outcomes. As a result of attempts to teach they are further refined into concrete helping skills (A+R+P+I). The attending skills are transitional between responding and initiating. Attending : “Being attentive to to the helpee” is made up of attending physically, observing and listening to the helpee. The function of attending is to give them the feelings of security that make their involvement in the helping process. By attending physically the helper communicates interest in the helpee’s welfare, by observing and listening, helper learns from and about the helpee. By communicating interest in the helpee, helper establishes the conditions for the helpee’s involvement in the helping process. Responding: Responding to the helpee’ s expression of her experience, involves responding to content, feeling and feeling and content together. The function of he responding to the helpee’s experience is to facilitate self exploration. T thus she signals her readiness for the next goal of helping- understanding, which signals the helper to begin personalizing. They serve to stimulate the helpee’s exploration of where he or she is in his or her experiences of the world and that the helper is fully in tune with the helpee’s experience. Personalizing: “To enable the helpee to understand where she is in relation to where she wants or needs to be”, involves building a base of interchangeable responses before personalizing the meaning, the problem, the feelings and the goal. The purpose is to facilitate helpee self understanding in the areas of concern to her, thus she signals readiness for using initiating. They are used to provide a transition from responding to initiating and from exploring to acting. Personalizing skills culminate in the helpee’s personal experience of the problem as the inability to handle difficult situations.

Initiating: ”Finding direction in life or acting in following the direction, bringing direction to culmination – giving life meaning in productivity and creativity”. It involves operationalizing goals and initiating steps, schedules and reinforcements to achieve these goals. These goals resolve helpee’s problems. Fosters the development and implementation of the mechanical steps required to achieve the personally meaningful goals that the helpee has developed. Initiating skills conclude the first cycle of helping process in which helper facilitate helpee’s acting to get to where he or she wants to be in the world. If you have attended to to the helpee’s needs and responded to her experience, you have facilitated her exploration of where she is. If you have personalized your understanding of the helpee, you have facilitated her understanding of where she is in relation to where wants to be. If you have initiated to help the helpee achieve her goals have facilitated her acting to get from where she is to where she wants to be. Thus you have helped her solve her problems and achieve her goals. You have seen her grow and develop. But growth is not static, is life long learning. Life long Learning is recycling exploring, understanding and acting. A growing person is constantly involved in the learning person. Growing is more than learning and helping. It is helping others to learn, which means to explore, understand and act plus recycle. E.g. All people can do with each other in their daily contacts, first and foremost by attending and making an effective response to the other. Having begun by attending and responding, over an extended period of time each person can learn to personalize and initiate with the people with whom they are involved At the highest level people communicate with immediacy, which means understanding and interpreting in the moment what is going on between you and the helpee (highest levels of responsive and initiative behaviour). It means being simultaneously aware of both the helpee’s and one’s own experience. A less than whole person is never actually talking about what she seems to be talking about, may talk in comparison or relation to other people. A whole person is always talking about what she seems to be talking about, communicates fully. As helpers our tasks is to become whole people. Thus helping is a process of teaching people who do not communicate fully to communicate fully with themselves and others. Whatever the effective helper or the whole person is doing, she is always checking back with the helpee accuracy of the responses. She makes this by making responses that are interchangeable with the feeling and content expressed by the helpee, no matter how advanced is the stage of the helping relationship. The helper is fully alive, concerned and capable of communicating thierliving energy, concern and capability to those who are most in need. In fully alive communication each person may be helper to the other. But one must initiate the helping process by communicating her openness to understanding the other. In doing so she establishes the model for the other to imitate, Mutual problems are resolved. There is no edge in helping. The helpee informs us that she is ready to function as a helper by her behaviour. One clear demonstration of the helpee’s readiness to terminate the helping process, to go out on her own is her ability to respond to the experience of the helper. THE CLEAR DEMONSTRATION OF THE ABILITY TO FUNCTION AS A HELPER WILL BE ONE’S ABILITY TO RESPOND AND INITIATE EFFECTIVELY. The Assumption

The only assumption made in developing the helping skill programs involves one’s motivation. Other assumption is that one wants to grow, want to be like the facilitative helpers and teachers one has experienced, one wants to become involved in a life long learning process.- CARKHUFF Brammer and Macdonald•

The basic interpersonal communication processes implied by the specialized helping relationships are similar

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People know their needs

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Basically it is a process of enabling the person to grow in the directions that person chooses, to solve problems and to face crises.

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Voluntary quality of the helping process is a crucial point since many persons wanting to help others have their own helping agenda and seek to meet their own unrecognised needs.

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The act of helping people with the presumed goal of doing something for them or changing them in some way has an arrogant quality too.

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The aim of all help is self help and self sufficiency.

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Each individual behaves in a competent and trustworthy manner if given the freedom and encouragement to do so.

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Helper must assume some responsibility for creating conditions of trust whereby helpeescan respond in a trusting manner and help themselves.

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Helper must be alert to the impact on the helpee of other people and of the physical environment.

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Helping takes place over the lifespan. Each developmental period and the transitions between usually require some form of outside help to make life more effective and satisfying. .

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The nature of the informal agreement implies a growth contract, that helpees will try to change under their own initiative, with minimal helper assistance.

Basic Helping scale I + E + U + A = New learning (behaviour) 5.0 Initiating steps 4.5 Initiating goal operationalization 4.0 Personalizing problem, feelings and goal 3.5 Personalizing meaning 3.0 Responding to feeling and content 2.5 Responding to feeling 2.0 Responding to content 1.5 Attending 1.0 Non attending Non attending covers all behaviours, both verbal and non verbal that are unrelated or irrelevant to the helpee’s situation or expressions.

Attending: includes the verbal and non verbal behaviours that are directly related to involving the helpee, but do not respond to what the helpee has shared about where she is. Responding to content: involves summarising what the helpee has shared concerning her situation. Responding to feeling: involves accurately identifying a feeling word that is interchangeable with the helpee’s experience of the situation. Responding to feeling and content: involves the clear communication of helper understanding of both the content and feelings expressed by the helpee. Personalizing meaning: involves responding to identify the personal significance or implications of the expressed situation for the helpee. Personalizing problem, feelings and goal: involves responding to identify the personal deficits (assets) of the helpee that are contributing to the problem or situation, the feelings that the helpee is experiencing about her deficits (assets) and the goal that the helpee wants to achieve. Initiating goal operationalization: covers responses that express a clear understanding of the helpee’s personalized problem, feelings and goal in behavioural terms. Initiating steps: involves responses that identify specific steps toward accomplishing the operationalised goal. Ingredients to secret of success a. Skills of helping: Apply the skills then only you recognise the need for more skills. The most of basic of all skills is learning how to learn. N ext is the basic skill of teaching. b. Discipline: Employ skills with discipline. The accuracy of the discriminations and communications is the effective ingredient. c. Work: Our real learning in life comes from working very hard, applying skills with disciplines in a variety of human experiences. While working hard they must protect themselves by receiving the maximum return for the minimum investment. e.g. Once you understand the response deficits of the helpees they will tend to employ teaching in groups as the preferred mode of treatment. Evaluation of theory i. 1960’s: (Eysenk, 1960, 1965; Levitt 1963; Lewis 1965) stated that psychotherapy and counseling did not make a difference. They discovered that both adults and children who were in control groups that were not assigned to professional practitioners, gained as much on the average as people assigned to professional counselors and therapists. About two thirds of the patients improved and remained out of the hospital a year after treatment whether they were treated or not. This research was updated in longitudinal studies in more than 50 treatment setting by Anthony(1979) who studied lasting effects of counseling, rehabilitation and psychotherapeutic techniques. Within 3-5 years after treatment 65-75% of the patients were once again patients. The gainful employment of patients was below 20%. Conclusion was that psychotherapy has lasting positive effects in 17-22% of the cases. ii. Naturalistic studies: (Rogers et al 1967, Traux and Carkhuff 1967) The clients and patients of professional helpers demonstrated a greater range of effects than those in professionally untreated groups. But study revealed a very distressing conclusion that counseling and psychotherapy have a two edged effect- they may

be harmful or helpful. The effects could be determined by the levels of functioning of the helpers on certain interpersonal dimensions such as empathy/empathetic understanding. One who offered high level of core interpersonal dimensions facilitated the process movement. iii. Predictive studies: involved manipulating the levels of helpers functioning on interpersonal dimensions such as empathy and its effects both within the helping process and upon the helping outcomes. (Carkhuff and Alexik 1967, Holder et al 1967; Piaget et al 1968; Traux and Carkhuff 1967). Helpees of helpers functioning at high levels of these interpersonal dimensions moved towards higher levels of functioning (explored their problems in meaningful ways) iv. Generalization Studies: To study the effects of teacher’s levels of interpersonal functioning upon learner’s development. The students of teachers offering high levels of these interpersonal dimensions demonstrated significant constructive gains in areas of emotional, interpersonal and intellectual functioning (Aspy and Roebuck, 1977) These effects have been generalised in all areas of helping and human relationships where the more knowing person influences the less knowing person, parent child relations (Carkhuff 1971, 1976); Student teacher relations (Carkhuff 1969); counselor –client relation and therapist patient relations v. Extension studies: Michelson and Stevic(1971) found that career information seeking behaviour was dependent upon the helper’s levels of interpersonal functioning in interaction with their reinforcement program Helping dimensions were validated in predictive studies of both helping process and outcome. The acceptance of the fundamental ingredients of helping has been widely demonstrated in the professional literature. The applications: i. With credentialed counselors and therapists: Trained counselors were able to demonstrate success rates between 74-91%. Aspy and Roebuck(1977) demonstrated positive effects of helping skills upon student physical, emotional and intellectual functioning. ii. Functional Professionals: Staff personnel, such as nurses, hospital attendants, policeman, prison guards, dormitory counselors, community volunteers were trained and their effects in treatment studied. Lay helpers were able to elicit significant changes in work behaviours, discharge rates, recidivism rates and a variety of other areas including self reports, significant other reports and expert reports. iii. Indigenous personnel: They can work effectively with the populations from which they are drawn. For example, new career teachers, drawn from the ranks of unemployed have systematically helped others to learn the skills they needed in order to get and hold meaningful jobs. iv. Helpee population: in the kinds of skills which they need to service themselves. Thus parents of emotionally disturbed children were systematically trained in the skills which they needed to function effectively with themselves and their children. Patients were trained to offer each other rewarding human relationships. The results were significantly more positive than all other forms of treatment. The concept of training as treatment led to the development of programs to train entire communities to create a therapeutic milieu. v. Science and art of helping: On implication of the research into helping is to select persons as helpers who already possess the artful qualities and then quickly and systematically give them basic helping skills and behaviour concepts.

vi. Self Help Groups: Hurvitz (1970) studied many groups as participant observer and concluded saying much of their effectiveness was due to peer relationships, inspirational methods, explicit goals, fellow ship and a variety of helping procedures. They use many sources of help that are outside conventional helping methods. Helping Relationship (Brammer) The third component of the helping relationship is described as the working alliance, which is the agreement of helper and helpee on the goals and tasks and the experience of an emotional bond in this mutual act. The working alliance is considered equal in importance to helper attitudes (Gelso & Carter, 1994). Helping relationship is dynamic at verbal and nonverbal levels, the relationship is the principal process vehicle for both helper and helpee to express and fulfill their needs as well as to mesh helpee problems with helper expertise. All authorities on the helping process agree that the quality of the helping relationship is important to effective helping(Sexton and Whiston 1994.)All agree that good working relationship established early, yield a helping relationship. Its dimensions are (Brammer, Abrego and Shostrom 1993) uniqueness-commonality and intellectual – emotional content. However helping relationship is different from friendship, is not a reciprocal relationship. The focus is on the helpee’s emotional and intellectual issues, the helper must resist the urge to move the focus to his or her experience.

Helping affiliations Helping affiliations can be classified into formal and structured (professional, paraprofessionals and volunteer helper) to informal and unstructured (friendships, family, community& general human). Stages in helping process There are eight stages contained in the two basic phases of the helping process. Phase 1: Building relationships: •

Entry: preparing the helpee and opening relationship

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Clarification: state the problem or concern and reasons for seeking help

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Structure: formulating the contract and the structure

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Relationship: building the helping relationship

Phase 2: Facilitating Positive Action •

Exploration: exploring problems, formulating goals, planning strategies, gathering facts, expressing deeper feelings, learning new skills.

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Consolidation: exploring alternatives, working through feelings, practicing new skills

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Planning: developing a plan of action using strategies to resolve conflicts, reducing painful feelings, and consolidating and generalizing new skills or behaviours to continue self-directed activities.

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Termination: evaluating outcomes and terminating the relationship.

Helping skills for understanding: of self and others i. Listening skills •

Attending – noting verbal and nonverbal behaviours

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Paraphrasing – responding to basic messages

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Clarifying – self disclosing and focusing discussion

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Perception checking – determining accuracy of learning

ii. Leading Skills •

Indirect leading – getting started

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Direct leading – encouraging and elaborating discussion

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Focusing – controlling confusion, diffusion and vagueness

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Questioning – conducting open and closed inquiries

iii. Reflecting skills •

Reflecting feeling – responding to feelings

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Reflecting experience – responding to toal experience

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Reflecting content – repeating ideas in fresh words or for emphasis

iv. Confronting skills: •

Recognising feelings in oneself – being aware of helper experience

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Describing and sharing feelings – modeling feeling expression

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Feeding back opinions – reacting honestly to helpee expressions

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Self-confrontation

v. Interpreting skills •

INTERPRETIVE QUESTIONS – FACILITATING AWARENESS

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FANTASY AND METAPHOR- SYMBOLIZING IDEAS AND FEELINGS

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Informing skills •

Advising – giving suggestions and opinions based on experience

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Informing- giving valid information based on expertise

vii. Summarising Skills •

Pulling themes together.

Ethical issues in helping relationships: Informed consent Worker self care- recognise own weak spots and work on prevention Dual relationships- recognise them and manage them Ask following questions. Is there a a power difference between us?

What other role obligations do I have in this situation? How will my knowledge about you change our relationship? Physical contact with helpees: Sexual relationships of any kind are unethical Touching clients for support, out of compassion or to express care is controversial. Conclusion Our task in life is to improve the quantity and quality of human experience, our own as well as others which is growth. Life is process, is growth and growth is learning skills. When we use the helping skills effectively, we can be healthy and we can help each other to actualize our human potential. The only meaning to life is to grow for growing is life. References 1. Carkhuff R. The art of helping. 4th ed. Amherst: Human Resource Development press; 1983 2. Brammer L M, Macdonald G. Helping relationship process and skills. 6th ed. Boston: Allyn and Bacon; 1996. 3. Shea C A, Pelletier L R, Poster E C, Stuart G W, Verhey M P. Advanced practice nursing in psychiatric and mental health care. St. Louis: Mosby; 1999 4. Topalis M, Aguilera D C. Psychiatric nursing. 7th ed. St Louis: C V Mosby; 1978. 5. Morrison M. Foundations of mental health nursing. St. Louis: Mosby; 1997. 6. Taylor C, Lillis C, Le Mone P, Lynn P. Fundamentals of nursing. 6th ed. Philadelphis: Lippincott Williams & Wilkins; 2005. 7. Dexter G, Walsh M. Psychiatric skills a pateint centred approach. 2nd ed. London: Chapman & Hall; 1995. 8. Stuart G W, Laraia M T. Principles and practice of psychiatric nursing. St Louis: Mosby Harcourt Pvt. Limited; 2001. 9. Boon NA, Colledge NR, Walker BR, Hunter JAA. Davidson’s principle and practices of medicine. 20th ed. London: Churchill Livingstone Elsevier; 2006.