Nightingale's environmental theory
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Florence Nightingale, also known as the Lady with the Lamp, providing care to wounded and ill soldiers during the Crimean War Florence Nightingale (1820±1910), considered the founder of educated and scientific nursing and widely known as "The Lady with the Lamp"[1], wrote the first nursing notes that became the basis of nursing practice and research. The notes, entitled Notes on Nursing: What it is, What is not (1860), listed some of her theories that have served as foundations of nursing practice in various settings, including the succeeding conceptual frameworks and theories in the field of nursing.[2] Nightingale is considered the first nursing theorist. One of her theories was the Environmental Theory, which incorporated the restoration of the usual health status of the nurse's clients into the delivery of health care²it is still practiced today.
Contents
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1 Environmental effects 2 Environmental factors affecting health 3 Provision of care by environment 4 See also 5 References
[edit] Environmental effects
She stated in her nursing notes that nursing "is an act of utilizing the environment of the patient to assist him in his recovery" (Nightingale 1860/1969),[3], that it involves the nurse's initiative to configure environmental settings appropriate for the gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic and physiologic processes, and his development.[4]
[edit] Environmental factors affecting health
Adequate ventilation has also been regarded as a factor contributing to changes of the patient's process of illness recovery Defined in her environmental theory are the following factors present in the patient's environment:
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Pure or fresh air Pure water Sufficient food supplies Efficient drainage Cleanliness Light (especially direct sunlight)[5]
Any deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status.[6]
[edit] Provision of care by environment
The factors posed great significance during Nightingale's time, when health institutions had poor sanitation, and health workers had little education and training and were frequently incompetent and unreliable in attending to the needs of the patients. Also emphasized in her environmental theory is the provision of a quiet or noise-free and warm environment, attending to patient's dietary needs by assessment, documentation of time of food intake, and evaluating its effects on the patient.[7] Nightingale's theory was shown to be applicable during the Crimean War when she, along with other nurses she had trained, took care of injured soldiers by attending to their immediate needs, when communicable diseases and rapid spread of infections were rampant in this early period in the development of disease-capable medicines. The practice of environment configuration according to patient's health or disease condition is still applied today, in such cases as patients infected with Clostridium tetani (suffering from tetanus), who need minimal noise to calm them and a quiet environment to prevent seizure-causing stimulus. Theory of Interpersonal Relations
Hildegard. E. Peplau This page was last updated on November 6, 2010 ======================================================== Introduction Born in Reading, Pennsylvania [1909] Graduated from a diploma program in Pottstown, Pennsylvania in 1931.
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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 Understanding of ones own behavior To help others identify felt difficulties To apply principles of human relations to the problems that arise at all levels of experience
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In her book she discussed the phases of interpersonal process,
roles in nursing situations and methods for studying nursing as an interpersonal process.
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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. Nursing is an interpersonal process because it involves interaction between two or more individuals with a common goal. The attainment of goal is achieved through the use of a series of steps following a series of pattern. The nurse and patient work together so both become mature and knowledgeable in the process.
Definitions
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Person :A developing organism that tries to reduce anxiety caused by needs Environment : Existing forces outside the organism and in the context of culture 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.
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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.
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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
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Counselors : helps to understand and integrate the meaning of current life circumstances ,provides guidance and encouragement to make changes
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Surrogate: helps to clarify domains of dependence interdependence and independence and acts on clients behalf as an advocate.
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Leader : helps client assume maximum responsibility for meeting treatment goals in a mutually satisfying way
Additional Roles include: 1. Technical expert 2. Consultant 3. Health teacher 4. Tutor 5. Socializing agent 6. Safety agent 7. Manager of environment 8. Mediator 9. Administrator 10. Recorder observer 11. Researcher Theory of interpersonal relations Middle range descriptive classification theory Influenced by Harry Stack Sullivan's theory of inter personal relations (1953)
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Also influenced by Percival Symonds , Abraham Maslow's and Neal Elger Miller
Identified four sequential phases in the interpersonal relationship: 1. 2. 3. 4. Orientation Identification Exploitation 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
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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
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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
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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
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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
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Both use observation communication and recording as basic tools utilized by nursing
Assessment
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Orientation
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Data collection and analysis [continuous] May not be a felt need
Non continuous data collection Felt need Define needs
Nursing diagnosis Planning
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Identification
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Mutually set goals
Interdependent goal setting
Implementation
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Exploitation
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Plans initiated towards achievement of mutually set goals May be accomplished by patient , nurse or family
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Patient actively seeking and drawing help Patient initiated
Evaluation
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Resolution
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Based on mutually expected behaviors May led to termination and initiation of new plans
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Occurs after other phases are completed successfully Leads to termination a
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.
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The nurse patient interaction can apply to the concepts of human being, health, environment and nursing. Theories must be logical in nature. This theory 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
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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.
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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.
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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
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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 Hays .D. (1961).Phases and steps of experimental teaching to patients of a concept of anxiety: Findings revealed that when taught
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by the experimental method, the patients were able to apply the concept of anxiety after the group was terminated.
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Burd .S.F. Develop and test a nursing intervention framework for working with anxious patients: Students developed competency in beginning interpersonal relationship
Overview of Nurse Theorist
Nightingale's Environmental Theory
Florence Nightingale, often considered the first nurse theorist, defined nursing over 100 years ago as "the act of utilizing the environment of the patient to assist him in his recovery". She linked health with five environmental factors:
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pure or fresh air pure water efficient drainage cleanliness light, especially direct sunlight
Nightingale's environmental factors attain significance when one considers that sanitation conditions in hospitals of the mid-1800s were extremely poor and that women working in the hospitals were often unreliable, uneducated, and incompetent to care for the ill. In addition to those factors, Nightingale also stressed the importance of keeping the client warm, maintaining a noise-free environment, and attending to the client's diet in terms of assessing intake, timeliness of the food, and its effect on the person. Nightingale set the stage for further work in the development of nursing theories. Her general concepts about ventilation, cleanliness, quiet, warmth, and diet remain integral parts of nursing and health care today. Return to Top
Myra Levine's Conservation Theory
"Ethical behaviour is not the display of one's moral rectitude in times of crisis, it is the dayto-day expression of one's commitment to other persons and the ways in which human beings relate to one another in their daily interactions." - Levine, Myra (1972)
Myra Estrin Levine
INTRODUCTION and BIOGRAPHY The nursing profession is continuously evolving and dynamic. Ever since Florence Nightingale started writing her notes on nursing, more theories and models about the nursing profession flourished during the last decade; one of these is Myra Levine·s Conservational Theory which was completed on 1973. Myra Estrin Levine (1920-1996) was born in Chicago, Illinois. She was the oldest of three children. She had one sister and one brother. Levine developed an interest in nursing because her father (who had gastrointestinal problems) was frequently ill and required nursing care on many occasions. Levine graduated from the Cook County School of Nursing in 1944 and obtained her BS in nursing from the University of Chicago in 1949. Following graduation, Levine worked as a private duty nurse, as a civilian nurse for the US Army, as a surgical nursing supervisor, and in nursing administration. After earning an MS in nursing at Wayne State University in 1962, she taught nursing at many different institutions (George, 2002) such as the University of Illinois at Chicago and Tel Aviv University in Israel. She authored 77 published articles which included ´An Introduction to Clinical Nursingµ with multiple publication years on 1969, 1973 & 1989. She also received an honorary doctorate from Loyola University in 1992. She died on 1996. Levine told others that she did not set out to develop a ´nursing theoryµ but had wanted to find a way to teach the major concepts in medical-surgical nursing and attempt to teach associate degree students a new approach for daily nursing activities. Levine also wished to move away from nursing education practices that were strongly procedurally oriented and refocus on active problem solving and individualized patient care (George, 2002).
COMPOSITION OF CONSERVATION MODEL Levine·s Conservation Model is focused in promoting adaptation and maintaining wholeness
using the principles of conservation. The model guides the nurse to focus on the influences and responses at the organismic level. The nurse accomplishes the goals of the model through the conservation of energy, structure, and personal and social integrity (Levine, 1967). Although conservation is fundamental to the outcomes expected when the model is used, Levine also discussed two other important concepts critical to the use of her model ² adaptation and wholeness. Adaptation is the process of change, and conservation is the outcome of adaptation. Adaptation is the process whereby the patient maintains integrity within the realities of the environment (Levine, 1966, 1989a). Adaptation is achieved through the ´frugal, economic, contained, and controlled use of environmental resources by the individual in his or her best interestµ (Levine, 1991, p. 5). Wholeness is based on Erikson·s (1964, p. 63) description of wholeness as an open system: ´Wholeness emphasizes a sound, organic, progressive mutuality between diversified functions and parts within an entirety, the boundaries of which are open and fluid.µ Levine (1973, p. 11) stated that ´the unceasing interaction of the individual organism with its environment does represent an ¶open and fluid· system, and a condition of health, wholeness, exists when the interaction or constant adaptations to the environment, permit ease³the assurance of integrity«in all the dimensions of life.µ This continuous dynamic, open interaction between the internal and external environment provides the basis for holistic thought, the view of the individual as whole. Conservation, on the other hand, is the product of adaptation. Conservation is from the Latin word conservatio, meaning ´to keep togetherµ (Levine, 1973). ´Conservation describes the way complex systems are able to continue to function even when severely challenged.µ (Levine, 1990, p. 192). Through conservation, individuals are able to confront obstacles, adapt accordingly, and maintain their uniqueness. ´The goal of conservation is health and the strength to confront disabilityµ as ´... the rules of conservation and integrity holdµ in all situation in which nursing is requiresµ (Levine, 1973, pp. 193- 195). The primary focus of conservation is keeping together of the wholeness of the individual. Although nursing interventions may deal with one particualr conservation principle, nurses must also recognize the influence of other conservation principles (Levine, 1990).
MAJOR CONCEPTS Over the years, nurses (like Myra Levine) have developed various theories that provide different explanations of the nursing discipline. Like her Conservation Model, all theories share four central or major concepts: person, environment, nursing and health. In addition to this, Levine·s Model also discussed that person and environment merge or become congruent over time, as it will be discussed below. I. The person is a holistic being who constantly strives to preserve wholeness and integrity
and one ´who is sentient, thinking, future-oriented, and past-aware.µ The wholeness (integrity) of the individual demands that the ´individual life has meaning only in the context of social lifeµ (Levine, 1973, p. 17). The person is also described as a unique individual in unity and integrity, feeling, believing, thinking and whole system of system. II. The environment completes the wholeness of the individual. The individual has both an internal and external environment. The internal environment combines the physiological and pathophysiological aspects of the individual and is constantly challenged by the external environment. The internal environment also is the integration of bodily functions that resembles homeorrhesis rather than homeostasis and is subject to challenges of the external environment, which always are a form of energy. Homeostasis is a state of energy sparing that also provides the necessary baselines for a multitude of synchronized physiological and psychological factors, while homeorrhesis is a stabilized flow rather than a static state. The internal environment emphasizes the fluidity of change within a space-time continuum. It 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. The external environment is divided into the perceptual, operational, and conceptual environments. The perceptual environment is that portion of the external environment which individuals respond to with their sense organs and includes light, sound, touch, temperature, chemical change that is smelled or tasted, and position sense and balance. The operational environment is that portion of the external environment which interacts with living tissue even though the individual does not possess sensory organs that can record the presence of these factors and includes all forms of radiation, microorganisms, and pollutants. In other words, these elements may physically affect individuals but are not perceived by the latter. The conceptual environment is that portion of the external environment that consists of language, ideas, symbols, and concepts and inventions and encompasses the exchange of language, the ability to think and experience emotion, value systems, religious beliefs, ethnic and cultural traditions, and individual psychological patterns that come from life experiences.
III. Health and disease are patterns of adaptive change. Health is implied to mean unity and integrity and ´is a wholeness and successful adaptationµ. The goal of nursing is to promote health. Levine (1991, p. 4) clarified what she meant by health as: ´« the avenue of return to the daily activities compromised by ill health. It is not only the insult or the injury that is repaired but the person himself or herself« It is not merely the healing of an afflicted part. It is rather a return to self hood, where the encroachment of the disability can be set aside entirely, and the individual is free to pursue once more his or her own interests without constraint.µ On the other hand, disease is ´unregulated and undisciplined change and must be stopped or death will ensueµ. IV. Nursing involves engaging in ´human interactionsµ (Levine, 1973, p.1). ´The nurse enters into a partnership of human experience where sharing moments in time³some trivial, some dramatic³leaves its mark forever on each patientµ (Levine, 1977, p. 845). The goal of nursing is to promote adaptation and maintain wholeness (health). The goal of nursing is to promote wholeness, realizing that every individual requires a unique and separate cluster of activities. The individual·s integrity is his/her abiding concern and it is the nurse·s responsibility to assist the patient to defend and to seek its realization. The goal of nursing is accomplished through the use of the conservation principles: energy, structure, personal, and social integrity. V. As it was mentioned above, Levine·s Conservation Model discussed that the way in which the person and the environment become congruent over time. It is the fit of the person with his or her predicament of time and space. The specific adaptive responses make conservation possible occur on many levels; molecular, physiologic, emotional, psychologic, and social. These responses are based on three factors (Levine, 1989): historicity, specificity and redundancy.
1. Historicity refers to the notion that adaptive responses are partially based on personal and genetic past history. Each individual is made up of a combination of personal and genetic history, and adaptive responses are the result of both. 2. Specificity refers the fact that each system that makes up a human being has unique stimulus-response pathways. Responses are stimulated by specific stressors and are task oriented. Responses that are stimulated in multiple pathways tend to be synchronized and occur in a cascade of complimentary (or detrimental in some cases) reactions. 3. Redundancy describes the notion that if one system or pathway, is unable to ensure adaptation, then another pathway may be able to take over and complete the job. This may be helpful when the response is corrective (e.g., the use of allergy shots over a lengthy period of time to diminish the effects of severe allergies by gradually desensitizing the immune system). However, redundancy may be detrimental, such as when previously failed responses are reestablished (e.g., when autoimmune conditions cause a person·s own immune system to attack previously healthy tissue in the body). A change in behavior of an individual during an attempt to adapt to the environment is called an organismic response. It helps individual to protect and maintain their integrity. There are four types, namely (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; and (4) Perceptual: Involves gathering information from the environment and converting it in to a meaning experience.
KEY CONCEPTS (Conservational principle) The core, or central concept, of Levine·s theory is conservation (Levine, 1989). When a
person is in a state of conservation, it means that individual adaptive responses conform change productively, and with the least expenditure of effort, while preserving optimal function and identity. Conservation is achieved through successful activation of adaptive pathways and behaviors that are appropriate for the wide range of responses required by functioning human beings. Myra Levine described the Four Conservation Principles. These principles focus on conserving an individual's wholeness. She advocated that nursing is a human interaction and proposed four conservation principles of nursing which are concerned with the unity and integrity of individuals. Her framework includes: energy, structural integrity, personal integrity, and social integrity.
I. Conservation of energy: Refers to balancing energy input and output to avoid excessive fatigue. It includes adequate rest, nutrition and exercise. Examples: Availability of adequate rest; Maintenance of adequate nutrition
II. Conservation of structural integrity: Refers to maintaining or restoring the structure of body preventing physical breakdown and promoting healing. Examples: Assist patient in ROM exercise; Maintenance of patient·s personal hygiene
III. 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
IV. Conservation of social integrityAn: 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: Help the individual to preserve his or her place in a family, community, and society.
ASSUMPTIONS Myra Levine·s Model also discusses other assertions and assumptions:
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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
LIMITATIONS Despite the comprehensiveness and wide application of Levine's theory, the model is not without limitation. For example, Levine's conservation model focuses on illness as opposed to health; thus, nursing interventions are limited to addressing only the presenting condition of an individual. Hence, nursing interventions under Levine's theory have a present and shortterm focus and do not support health promotion and illness prevention principles, even though these are essential components of current nursing practice. Thus, the major limitation is the focus on individual in an illness state and on the dependency of patient. Furthermore, the 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. There are a number of limitations when it comes to the four principles. On conservation of energy, Levine·s goal is to avoid fatigue or excessive use of energy. This is manageable in the bedside care of ill clients. In cases where energy needs to be utilized rather than conserved like in manic patients, ADHD in children or those with limited movements such as paralyzed clients, Levine·s theory does not apply. On conservation of structural integrity, the focus is to preserve the anatomical structure of the body as well as to prevent damage to the anatomical structure. This, again, has limitations. In cases where the anatomical structure is not so perfect but without identified disfigurement or problems as in plastic surgeries, procedures like breast enhancements and liposuctions; the person's structural integrity is compromised but it is the patient's choice seeking physical beauty and psychological satisfaction that is taken into consideration. Otherwise such, procedures should not be promoted. On conservation of personal integrity, the nurse is expected to provide knowledge and the patient need to be respected, provided with privacy, encouraged and psychologically s supported. The limitations here will center on clients who are psychologically impaired and
incapacitated and cannot comprehend and absorb knowledge, i.e. comatose patients, suicidal individuals or clients. Lastly, conservation of social integrity·s aim is to preserve and recognition of human interaction, particularly with the clients, significant others who comprise his support system. The limitation specific for this, is when the client has no significant others like family members. Abandoned children, psychiatric patients who are unable to interact, unresponsive clients like unconscious individuals, the focus here is no longer the patient himself but the people involved in his/her health care.
APPLICATIONS Nursing research
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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 (n.d.) 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
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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 (n.d.) 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 (n.d.) 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 (n.d.) for families of patient in critical care setting
Nursing practice
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Conservational model has been used for nursing practice in different settings Bayley (n.d.) 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 (n.d.) used conservation model for guiding the nursing care of homeless at a clinic, shelters or streets
Nursing Process Assessment
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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
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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
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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
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Testing the hypothesis Interventions are designed based on the conservation principles Mutually acceptable Goal is to maintain wholeness and promoting adaptation
Evaluation
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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
*** To summarize, Levine expressed the view that within the nurse-patient relationship a patient·s state of health is dependent on the nurse-supported process of adaptation. This guides nurses to focus on the influences and responses of a client to promote wholeness through the Conservation Principles. The goal of this model is to accomplish this through the conservation of energy, structural, personal and social integrity. The goal of nursing is to recognize, assist, promote, and support adaptive processes that benefit the patient.
Johnson's Behaviour System Model
This page was last updated on November 3, 2010 =========================================== Introduction Dorothy E. Johnson was born August 21, 1919, in Savannah, Georgia.
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B. S. N. from Vanderbilt University in Nashville, Tennessee, in 1942; and her M.P.H. from Harvard University in Boston in 1948.
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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.
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Dorothy Johnson has had an influence on nursing through her publications since the 1950s. Johnson 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 ³the efficient and effective behavioral functioning in the patient to prevent illness".
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She also stated that nursing was ³concerned with man as an integrated whole and this is the specific knowledge of order we require´.
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In 1980 Johnson published her conceptualization of ³behavioral 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 ³an 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
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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 Tthere are 4 assumptions of system: 1. First assumption states that there is ³organization, interaction, interdependency and integration of the parts and elements of behaviors that go to make up The system ´ 2. A system ³tends 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 ³system balance reflects adjustments and adaptations that are successful in some way and to some degree.´ The integration of these assumptions provides the behavioral system with the pattern of action to form ³an 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 ³from the form the behavior takes and the consequences it achieves can be inferred what ³drive´ has been stimulated or what ³goal´ is being sought´
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Each individual has a ³predisposition to act with reference to the goal, in certain ways rather than the other ways´. This predisposition is called as ³set´.
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Each subsystem has a repertoire of choices or ³scope of action´ The fourth assumption is that it produce ³observable outcome´ that is the individual¶s behavior.
Each subsystem has three functional requirements System must be ³protected" from noxious influences with which system cannot cope´.
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Each subsystem must be ³nurtured´ through the input of appropriate supplies from the environment. Each subsystem must be ³stimulated´ 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.
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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.
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These behaviors are ³orderly, purposeful and predictable and sufficiently stable and recurrent to be amenable to description and explanation´
Johnson¶s Behavioral Subsystem Attachment or affiliative subsystem: ³social inclusion intimacy and the formation and attachment of a strong social bond.´
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Dependency subsystem: ³approval, attention or recognition and physical assistance´ Ingestive subsystem: ³the emphasis is on the meaning and structures of the social events surrounding the occasion when the food is eaten´
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Eliminative subsystem: ³human cultures have defined different socially acceptable behaviors for excretion of waste ,but the existence of such a pattern remains different from culture to Culture.´
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Sexual subsystem:" both biological and social factor affect the behavior in the sexual subsystem´ 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´
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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
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Elimination Ingestion Achievement
The four major concepts Johnson views ³human 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. ³Society´ relates to the environment on which the individual exists. According to Johnson an individual¶s behavior is influenced by the events in the environment
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³Health´ is a purposeful adaptive response, physically mentally, emotionally, and socially to internal and external stimuli in order to maintain stability and comfort.
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³Nursing´ 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: Affiliation Dependency Sexuality Aggression Elimination Ingestion Achievement Restorative
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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: Insufficiency Discrepancy Incompatibility Dominance
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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. Assessment
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Affiliative subsystem between mother and John. Dependency subsystem between mother and John Affiliative subsystem between Mrs.Kim and her mother. Insufficiency ingesion subsystem.
Diagnosis
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Insufficient development of the affiliative subsystem.
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Insufficient development of the dependency subsystem
Planning and implementation Increasing mother¶s awareness of the baby¶s clues. Assisting her to talk with the baby. Teach her to bring a bond between her and the baby by touch, pat and cuddles etc. Evaluation Johnny's weight gain or weight loss will be carefully assessed.
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The ±infant interaction could be reassessed, using the nursing child assessment feeding scale. The interaction of Mrs. Kim with her mother.
Johnson¶s and Characteristics of a theory Interrelate concepts to create a different way of viewing a phenomenon.
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Theories must be logical in nature. Theories must be simple yet generalizable Theories can be bases of hypothesis that can be tested. Theories contribute to and assist in increasing the body of knowledge within the discipline through the research implemented to validate them
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Theories can be utilized by practitioners to guide and improve their practice. Theories must be consistent with other validated theories, laws and principles but will leave unanswered questions that need to be investigated.
Limitation
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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.
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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.
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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.
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Any imbalance in each system results in disequilibrium .it is nursing role to assist the client to return to the state of equilibrium. Introduction to Nursing Theories This page was last updated on November 13, 2010 ================================================= INTRODUCTION
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Each discipline has a unique focus for knowledge development that directs its inquiry and distinguishes it from other fields of study.(Smith & Liehr, 2008).
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Nursing knowledge is the inclusive total of the philosophies, theories, research, and practice wisdom of the discipline.As a professional discipline this knowledge is important for guiding practice.(Smith & Liehr, 2008).
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Theory-guided, evidence-based practice is the hallmark of any professional discipline.
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Nursing is a professional discipline (Donaldson & Crowley, 1978). Nursing theory is the term given to the body of knowledge that is used to support nursing practice Almost 90% of all Nursing theories are generated in the last 20 years. Nursing models are conceptual models, constructed of theories and concepts
COMPONENTS OF A THEORY
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..
Based on the knowledge structure levels the theoretical works in nursing can be studied under the following headings:
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Metaparadigm (Person, Environment, Health & Nursing) ± (Most abstract) Nursing philosophies. Conceptual models and Grand theories. Nursing theories and Middle range theories (Least abstract)
NURSING PHILOSOPHIES Theory Florence Nightingale¶s Legacy of caring Key emphasis Focuses on nursing and the patient environment relationship. Helping process meets needs through the art of individualizing care. Nurses should identify patients µneed-for ± help¶ by:
Ernestine Wiedenbach: The helping art of clinical nursing
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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. Patient¶s problems determine nursing care
Faye G.Abedellah¶s Typology of twenty one Nursing problems Lydia E. Hall :Care, Cure, Nursing care is person directed towards Core model self love. Jean Watson¶s Philosophy Caring is moral ideal: mind -body ± soul and Science of caring 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 Caring is central to the essence of of caring 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 Self±care maintains wholeness. care deficit theory in nursing 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 Holism is maintained by conserving conservation model integrity Proposed that the nurses use the principles of conservation of:
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Client Energy Personal integrity Structural integrity Social integrity A conceptual model with three nursing theories ± Conservation Redundancy Therapeutic intention
Martha E.Roger¶s: Person environment are energy fields that Science of unitary human evolve negentropically beings 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 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
Dorothy E.Johnson¶s Behavioural system model
sexual. Disturbances in these causes nursing problems. 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 Reconstitution is a status of adaptation to stressors A conceptual model with two theories ³Optimal 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. 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 Individuality in living. and A.J.Tierney A model for nursing based A conceptual model of nursing from which on a model of living theory of goal attainment is derived. Living is an amalgam of activities of living (ALs).
Sister Callista: Royµs Adaptation model
Betty Neuman¶s : Health care systems model
Imogene King¶s Goal attainment theory
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. Interpersonal process is maturing force for personality. Stressed the importance of nurses¶ ability to understand own behaviour to help others identify perceived difficulties.
Hildegard E. Peplau: Psychodynamic Nursing Theory
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The four phases of nurse-patient relationships are: 1. Orientation 2. Identification 3. Exploitations 4. Resolution
The six nursing roles are:
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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 Therapeutic human relationships. To Human Relationship Model 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. Growth and development of children and mother±infant relationships
Kathryn E. Barnard¶s Parent Child Interaction Model
Individual characteristics of each member influence the parent±infant system and adaptive behaviour modifies those characteristics to meet the needs of the system. Ramona T.Mercer¶s Parenting and maternal role attainment in :Maternal Role Attainment diverse populations A complex theory to explain the factors impacting the development of maternal role over time. 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. Caring is universal and varies transculturally. 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 Indivisible beings and environment co:Theory of human create health. becoming 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 Promoting optimum health supersedes
Katharine Kolcaba¶s Theory of comfort
Madeleine Leininger¶s Transcultural nursing, culture-care theory
Nola J.Pender¶s :The
Health promotion; model
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
Virginia Henderson's Need Theory
This page was last updated on November 6, 2010
======================================== ³Nursing theories mirror different realities, throughout their development; they reflected the interests of nurses of that time.´ Introduction
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³The Nightingale of Modern Nursing´ ³Modern-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
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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
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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 Catholic University of America, Pace University, University of Rochester,, University of Western Ontario, Yale University In 1985, Miss Henderson was honored at the Annual Meeting of the Nursing and Allied Health Section of the Medical Library Association.
Contribution
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In 1937 Henderson and others created a basic nursing curriculum for the National League for Nursing in the US in which education was ³patient 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) 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 ). Publications
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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:
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What do nurses do? What are their functions? What roles do nurses play? Answers to these questions focused on a number of theorists 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.
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School of thought in Nursing Theories-1950-1970 Need theorists Abdellah Henderson Orem interaction Theorists King Orlando Peterson and Outcome theorists Johnson Levine
Zderad Paplau Travelbee Wiedenbach
Rogers Roy
Analysis of nursing theories according to 1st School Focus Human being A developmental being. Patient Orientation Need Deficit Illness, disease Dependent on medical practice. Role of nurse Beginnings of independent functions Fulfill needs requisites Decision making Primarily health care professional Problems A set of needs or problems.
Henderson¶s Theory Background
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Henderson¶s concept of nursing was derived form her practice and education therefore, her work is inductive.. She called her definition of nursing her ³concept´ (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).
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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 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). The development of Henderson¶s definition of nursing Two events are the basis for Henderson¶s development of a definition of nursing.
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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. He believed the principles and practice or nursing must be built upon and derived from the definition of the profession.
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
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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 assumptions of the theory aret:
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"Nurses care for patients until patient can care for themselves once again. Patients desire to return to health, but this assumption is not explicitly
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stated. Nurses are willing to serve and that ³nurses 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 1. Individual :
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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.
2.Environment:
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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
3. Health:
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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.
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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?
4. Nursing
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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 ³complete´ ³whole", 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 o Categorized Nursing : nursing care o Non nursing: ordering supplies, cleanliness and serving food. In the Nature of Nursing ³ 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.´ ³Nurse should have knowledge to practice individualized and human care and should be a scientific problem solver.´ In the Nature of Nursing Nurse role is,´ to get inside the patient¶s skin and supplement his strength will or knowledge according to his needs.´ 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
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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 ³really the application of the logical approach to the solution of a problem. The steps are those of the scientific method.´ ³Nursing 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
Nursing Assessment Nursing Diagnosis Nursing plan Nursing implementation Nursing implementation Nursing process
Henderson¶s 14 components and definition of nursing
Henderson¶s 14 components Analysis: Compare data to knowledge base of health and disease. Identify individual¶s ability to meet own needs with or without assistance, taking into consideration strength, will or knowledge. Document how the nurse can assist the individual, sick or well. 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. Implementation based on the physiological principles, age, cultural background, emotional balance, and physical and intellectual capacities. Carry out treatment prescribed by the physician.
Nursing evaluation
Henderson¶s 14 components and definition of nursing 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 Breathe normally
Eat and drink adequately Eliminate by all avenues of elimination Move Physiological and maintain desirable posture needs 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 other Communicate with others worship according to one's faith Work at something providing a sense of accomplishment Esteem needs Play or participate in various forms of recreation Learn, discover, or satisfy curiosity
Characteristic of Henderson¶s theory y
Belongingness and love needs
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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 interaction-communication 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.
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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
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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
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Henderson believed nursing as primarily complementing the patient by supplying what he needs in knowledge, will or strength to perform
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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 ³Thorndike¶s fundamental needs of man´ (Henderson, 1991, p.16) had an influence on her beliefs.
Value in extending nursing science
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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
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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
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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
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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. ³Peaceful death´ is curious and significant nursing role.
PURPOSES OF NURSING THEORIES In Practice:
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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
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in communicating with other health professionals. Ideas are developed and words are defined. Enhance autonomy (independence and selfgovernance) of nursing through defining its own independent functions.
In Education:
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Provide a general focus for curriculum design Guide curricular decision making.
In Research:
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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
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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?
Hildegard Peplau
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Hildegard Peplau, Ed.D (September 1, 1909, Reading, Pennsylvania ± 17 March 1999) was a nursing theorist whose seminal work Interpersonal Relations in Nursing was published in 1952. Dr. Peplau emphasized the nurse-client relationship as the foundation of nursing practice. At the time, her research and emphasis on the give-and-take of nurse-client relationships was seen by many as revolutionary. Peplau went on to form an interpersonal model emphasizing the need for a partnership between nurse and client as opposed to the client passively receiving treatment (and the nurse passively acting out doctor's orders). The essence of Peplau's theories is the creation of a shared experience. Nurses, she thought, could facilitate this through observation, description, formulation, interpretation, validation, and intervention. For example, as the nurse listens to her client she or he develops a general impression of the client's situation. The nurse then validates his or her inferences by checking with the client for accuracy. The result may be experiential learning, improved coping strategies, and personal growth for both parties. Peplau died in 1999, aged 89.
Contents
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1 Life 2 Peplau's model o 2.1 Peplau's Seven Nursing Roles o 2.2 Peplau's Developmental Stages of the Nurse-Client Relationship 3 References
[edit] Life
Hildegard Peplau was born September 1, 1909, in Reading, PA, the second daughter of immigrants Gustav and Ottylie Peplau, and one of six children. As a child, she witnessed the devastating flu epidemic of 1918, a personal experience that greatly influenced her understanding of the impact of illness and death on families. Peplau began her career in nursing in 1931 as a graduate of the Pottstown, PA, School of Nursing. She then worked as a staff nurse in Pennsylvania and New York City. A summer position as nurse for the New York University summer camp led to a recommendation for Peplau to become the school nurse at Bennington College in Vermont. There she earned a bachelor¶s degree in interpersonal psychology in 1943. At Bennington and through field experiences at Chestnut Lodge, a private psychiatric facility, she studied psychological issues with Erich Fromm, Frieda FrommReichmann, and Harry Stack Sullivan. Peplau¶s life-long work was largely focused on extending Sullivan¶s interpersonal theory for use in nursing practice. From 1943 to 1945 she served in the Army Nurse Corps and was assigned to the 312th Field Station Hospital in England, where the American School of Military Psychiatry was located. Here she met and worked with all the leading figures in British and American psychiatry. After the war, Peplau was at the table with many of these same men as they worked to reshape the mental health system in the United States through the passage of the National Mental Health Act of 1946 and so on. Peplau held master¶s and doctoral degrees from Teachers College, Columbia University. She was also certified in psychoanalysis at the William Alanson White Institute of New York City. In the early 1950s, Peplau developed and taught the first classes for graduate psychiatric nursing students at Teachers College. Dr. Peplau was a member of the faculty of the College of Nursing at Rutgers University from 1954 to 1974. At Rutgers, Peplau created the first graduate level program for the preparation of clinical specialists in psychiatric nursing. She was a prolific writer and was equally well known for her presentations, speeches, and clinical training workshops. Peplau vigorously advocated that nurses should become further educated so they could provide truly therapeutic care to patients rather than the custodial care that was prevalent in the mental hospitals of that era. During the 1950s and 1960s, she conducted summer workshops for nurses throughout the United States, mostly in state psychiatric hospitals. In these seminars, she taught interpersonal concepts and interviewing techniques, as well as individual, family, and group therapy. Peplau was an advisor to the World Health Organization and was a visiting professor at universities in Africa, Latin America, Belgium, and throughout the United States. A strong advocate for graduate education and research in nursing, she served as a consultant to the U.S. Surgeon General, the U.S. Air Force, and the National Institutes of Mental Health. She participated in many government policy-making groups. After her retirement from Rutgers, she served as a visiting professor at the University of Leuven in Belgium in 1975 and 1976. There she helped establish the first graduate nursing program in Europe.[citation needed]
[edit] Peplau's model
Peplau's model has proved of great use to later nurse theorists and clinicians in developing more sophisticated and therapeutic nursing interventions
[edit] Peplau's Seven Nursing Roles
Peplau's Seven Nursing Roles illustrate the dynamic character roles typical to clinical nursing.
1. Stranger role: Receives the client the same way one meets a stranger in other life situations; provides an accepting climate that builds trust. 2. Resource role: Answers questions, interprets clinical treatment data, gives information. 3. Teaching role: Gives instructions and provides training; involves analysis and synthesis of the learner's experience. 4. Counseling role: Helps client understand and integrate the meaning of current life circumstances; provides guidance and encouragement to make changes. 5. Surrogate role: Helps client clarify domains of dependence, interdependence, and independence and acts on clients behalf as advocate. 6. Active leadership: Helps client assume maximum responsibility for meeting treatment goals in a mutually satisfying way. 7. Technical expert role: Provides physical care by displaying clinical skills; Operates equipment [edit] Peplau's Developmental Stages of the Nurse-Client Relationship
1. Orientation Phase 2. Working Phase -Identification Phase -Exploitation Phase 3. Termination / Resolution Phase Virginia Henderson's Need Theory
This page was last updated on November 6, 2010
======================================== ³Nursing theories mirror different realities, throughout their development; they reflected the interests of nurses of that time.´ Introduction ³The Nightingale of Modern Nursing´ ³Modern-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
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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
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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.
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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
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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 Catholic University of America, Pace University, University of Rochester,, University of Western Ontario, Yale University
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In 1985, Miss Henderson was honored at the Annual Meeting of the Nursing and Allied Health Section of the Medical Library Association.
Contribution
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In 1937 Henderson and others created a basic nursing curriculum for the National League for Nursing in the US in which education was ³patient centered and organized around nursing problems rather than medical diagnoses´ (Henderson,1991)
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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)
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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.
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In 1978 the fundamental concept of nursing was revisited by Virginia Henderson from Yale University School of Nursing ( USA ).
Publications 1956 (with B. Harmer)-Textbook for the principles and practices of Nursing.
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1966-The Nature of Nursing. A definition and its implication for practice,
Research and Education
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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 theorists describing functions and roles of nurses.
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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 King Orlando
Outcome theorists
Johnson Levine Rogers Roy
Abdellah Henderson Orem
Peterson and Zderad Paplau Travelbee Wiedenbach
Analysis of nursing theories according to 1st School
Focus Human being
Problems A set of needs or problems. A developmental being.
Patient Orientation
Need Deficit Illness, disease Dependent on medical practice.
Role of nurse
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..
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She called her definition of nursing her ³concept´ (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)
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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).
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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.
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Her 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). 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. He believed the principles and practice or nursing must be built upon and derived from the definition of the profession. 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
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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 assumptions of the theory aret: "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.
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Nurses are willing to serve and that ³nurses 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 1. Individual : Have basic needs that are component of health. Requiring assistance to achieve health and independence or a peaceful death.
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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.
2.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.
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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.
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Basic nursing care involves providing conditions under which the patient can perform the 14 activities unaided
3. Health: Definition based on individual¶s ability to function independently as outlined in the 14 components.
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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?
4. Nursing Temporarily assisting an individual who lacks the necessary strength, will and knowledge to satisfy 1 or more of 14 basic needs.
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Assists and supports the individual in life activities and the attainment of independence. Nurse serves to make patient ³complete´ ³whole", 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."
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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.
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Use nursing research
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Categorized Nursing : nursing care Non nursing: ordering supplies, cleanliness and serving food.
In the Nature of Nursing ³ 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.´
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³Nurse should have knowledge to practice individualized and human care and should be a scientific problem solver.´ In the Nature of Nursing Nurse role is,´ to get inside the patient¶s skin and supplement his strength will or knowledge according to his needs.´ 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
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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.
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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 ³really the application of the logical approach to the solution of a problem. The steps are those of the scientific method.´ ³Nursing 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 Nursing Assessment Nursing Diagnosis Nursing plan
Henderson¶s 14 components and definition of nursing Henderson¶s 14 components
Analysis: Compare data to knowledge base of health and disease. Identify individual¶s ability to meet own needs with or without assistance, taking into consideration strength, will or knowledge.
Nursing implementation Nursing implementation
Document how the nurse can assist the individual, sick or well. 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 process
Implementation based on the physiological principles, age, cultural background, emotional balance, and physical and intellectual capacities.
Carry out treatment prescribed by the physician. Nursing evaluation Use the acceptable definition of ;nursing and appropriate laws related to the practice of nursing. Henderson¶s 14 components and definition 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 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 Avoid environmental dangers and avoid injuring other Communicate with others worship according to one's faith
Work at something providing a sense of accomplishment
Physiological needs
Safety Needs
Belongingness and love needs
Esteem needs
Play or participate in various forms of recreation
Learn, discover, or satisfy curiosity
Characteristic of Henderson¶s theory y y
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
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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.
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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?
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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.
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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.
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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.
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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.
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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..."
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Henderson stated that ³Thorndike¶s fundamental needs of man´ (Henderson, 1991, p.16) had an influence on her beliefs.
Value in extending nursing science
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From an historical standpoint, her concept of nursing enhanced nursing science this has been particularly important in the area of nursing education.
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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
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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.
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Others concepts that Henderson (1966) proposed have been used in nursing education from the 1930s until the present O'Malley, 1996)
Testability
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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.
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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
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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. ³Peaceful 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.
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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.
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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.
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Practice
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
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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
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Background Achievements Publications Analysis of Nursing theories Development of Henderson¶s definition of nursing 14 components Major four concepts Nursing process with Henderson¶s theory Comparison with Maslow's Hierarchy need Assumptions Usefulness Testability Characteristics Limitation
Conclusion
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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.
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Her definition of nursing and the 14 components of basic nursing care are uncomplicated and self-explanatory. Faye Glenn Abdellah's Theory Twenty-One Nursing Problems This page was last updated on November 5, 2010 =============================================== INTRODUCTION Faye Glenn Abdellah, pioneer nursing researcher, helped transform nursing theory, nursing care and nursing education
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Birth:1919 Dr Abdellah worked as Deputy Surgeon General Former Chief Nurse Officer for the US Public Health Service , Department of Health and human services, Washington, D.C. a leader in nursing research and has over one hundred publications
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related to nursing care, education for advanced practice in nursing and nursing research.
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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.
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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:
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Recognizing the nursing problems of the patient Deciding the appropriate course of action to take in terms of relevant nursing principles
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Providing continuous care of the individuals total needs Providing continuous care to relieve pain and discomfort and provide immediate security for the individual
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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
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Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations
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Helping the individual to adjust to his limitations and emotional problems 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 peop (In 1973, the item 3, - ³providing continuous care of the individual¶s total health needs´ was eliminated.) 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.
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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 The language of Abdellah¶s framework is readable and clear. She uses the term µshe¶ for nurses, µhe¶ for doctors and patients, and refers to the object of nursing as µpatient¶ rather than client or consumer.
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She referred to Nursing diagnosis during a time when nurses were taught that diagnosis was not a nurses¶ prerogative. Assumptions were related to change and anticipated changes that affect nursing; The need to appreciate the interconnectedness of social enterprises and social problems;
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the impact of problems such as poverty, racism, pollution, education, and so forth on health care delivery; changing nursing education continuing education for professional nurses development of nursing leaders from under reserved groups
Abdellah and colleagues developed a list of 21 nursing problems.They also identified 10 steps to identify the client¶s problems. 11 nursing skills to be used in developing a treatment typology 10 steps to identify the client¶s problems Learn to know the patient Sort out relevant and significant data Make generalizations about available data in relation to similar nursing problems presented by other patients
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Identify the therapeutic plan Test generalizations with the patient and make additional generalizations Validate the patient¶s conclusions about his nursing problems Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his behavior Explore the patient¶s and family¶s reaction to the therapeutic plan and involve them in the plan Identify how the nurses feels about the patient¶s nursing problems Discuss and develop a comprehensive nursing care plan 11 nursing skills Observation of health status Skills of communication
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Application of knowledge Teaching of patients and families Planning and organization of work Use of resource materials Use of personnel resources Problem-solving Direction of work of others Therapeutic use of the self Nursing procedure 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
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To maintain good body mechanics and prevent and correct deformitiy 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 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
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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
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To identify and accept the interrelatedness of emotions and organic illness To facilitate the maintenance of effective verbal and non verbal communication To promote the development of productive interpersonal relationships To facilitate progress toward achievement of personal spiritual goals 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
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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 THEORY AND NURSING Abdellah¶s writings are not specific as to a theoretical statement. But, a theoretical statement can be derived by using her three major concepts of health, nursing problems, and problem solving. NURSING
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Abdellah¶s theory states that nursing is the use of the problem solving approach with key nursing problems related to health needs of people. 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
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functions can assist them to meet. The problem can be either an overt or covert nursing problem.
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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.
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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 PROBLEM SOLVING The problem solving process involves
1. 2. 3. 4. 5.
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.ss 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.
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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.
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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.
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Although Abdellah does not give a definition of health, she speaks to ³total health needs´ and ³a healthy state of mind and body´ in her description of nursing as a comprehensive service. SOCIETY AND ENVIRONMENT Society is included in ³planning 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.
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The environment is the home or community from which patient comes. ABDELLAH¶S WORK AND CHARACTERISTICS OF A THEORY Characteristic 1 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
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Nursing is the use of problem solving approach with key nursing problems related to health needs of people. Characteristic 2 Problem solving is an activity that is inherently logical in nature. Characteristic 3 Framework focus on nursing practice and individuals. Characteristic 4 The role of client within the framework. Characteristic 5 The results of testing such hypothesis would contribute to the general body of nursing knowledge Characteristic 6
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Abdellah¶s problem solving approach can easily be used by practitioners to guide various activities within their practice that deals with clients who have specific needs and specific nursing problems. Characteristic 7 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.
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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.
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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. Once the problem has been diagnosed, the nursing goals have been established. 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.
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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.
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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 µshortness of breath, tachycardia and profuse diaphoresis
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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 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
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PPC is tailoring of hospital services to meet patients needs PPC is caring for the right patient in the right bed with the right services at the right time PPC is systematic classification of patients based on their medical needs ELEMENTS OF PPC INTENSIVE CARE 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
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Intermediate care Patients assigned to this unit are both the moderately ill
and those for whom the treatment can only be palliative
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Self care Ambulatory patients who are convalescencing or require diagnosis or therapy may be cared for in this unit Long term care unit 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
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Home care 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
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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.
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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
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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.
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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
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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.
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Abdellah¶s publications on nursing education began with her dissertation; her interest in education for nurses continues into the present. 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.
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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 orientation Little emphasis on what the client is to achieve 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.
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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.
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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. Orlando's Nursing Process Theory This page was last updated on November 13, 2010 =============================================== INTRODUCTION Ida Jean Orlando, was born in 1926. Ida J. Orlando was one of the first nursing theorists to write about the nursing process based on her own research. ( Faust C, 2002) .
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Nursing diploma from New York Medical College
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BS in public health nursing from St. John's University, NY, MA in mental health nursing from Columbia University, New York. Associate Professor at Yale School of Nursing and Director of the Graduate Program in Mental Health Psychiatric Nursing. Aat Yale she was project investigator of a National Institute of Mental Health grant entitled: Integration of Mental Health Concepts in a Basic Nursing Curriculum.
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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.
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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.
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Orlando's theory was developed in the late 1950s from observations she recorded between a nurse and patient. INTRODUCTION TO THEORY The role of the nurse is to find out and meet the patient's immediate need for help.
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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.
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This process helps nurse find out the nature of the distress and what help the patient needs. MAJOR DIMENSIONS OF THE THEORY Distressis the experience of a patient whose need has not been met. Nursing role is to discover and meet the patient¶s immediate need for help.
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Patient¶s behavior may not represent the true need. The nurse validates his/her understanding of the need with the patient.
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Nursing actions directly or indirectly provide for the patient¶s immediate need. An outcome is a change in the behavior of the patient indicating either a relief from distress or an unmet need.
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Observable verbally and nonverbally.
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
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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
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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
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The perceptions stimulate automatic thought Each thought stimulates an automatic feeling
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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
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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
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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
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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
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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
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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
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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
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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
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Nurses are concerned with needs that patients cannot meet on their own DOMAIN CONCEPTS
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Nursing ± is responsive to individuals who suffer or anticipate a sense of helplessness
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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
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Goal of nursing ± increased sense of well being, increase in ability, adequacy in better care of self and improvement in patients behavior
4.
Health ± sense of adequacy or well being . Fulfilled needs. Sense of comfort
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Environment ± not defined directly but implicitly in the immediate context for a patient
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Human being ± developmental beings with needs, individuals have their own subjective perceptions and feelings that may not be observable directly
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Nursing client ± patients who are under medical care and who cannot deal with their needs or who cannot carry out medical treatment alone
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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
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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
10. Nurse ± patient relations ± central in theory and not differentiated from nursing therapeutics or nursing process 11. 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. 12. Indirect function ± calling for help of others , whatever help the patient may require for his need to be met 13. 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 14. 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
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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
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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
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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
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Use of field approach
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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
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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
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Theory is more congruent in guiding nurse ± patient interactions for assessing needs and in providing nursing therapeutics deemed necessary to patient care
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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
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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
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Theory is culturally bound
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Misinterpretation of continuous validation as lack of knowledge and expertise The uniqueness of individuals assumed by the theory could counteract automatic responses of nurses Use in Clinical Practice Nursing care plan Case studies 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 Orlando's Deliberative Nursing Process Theory focuses on the interaction between the nurse and patient, perception validation, and the use of the nursing process to produce positive outcomes or patient improvement. Orlando's key focus was to define the function of nursing. (Faust C., 2002)
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Orlando's theory remains one the of the most effective practice theories available. The use of her theory keeps the nurse's focus on the patient.
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The strength of the theory is that it is clear, concise, and easy to use. 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. The Helping Art of Clinical Nursing Ernestine Wiedenbach Last updated on November 13, 2010 =============================================== INTRODUCTION Ernestine Wiedenbach was born in August 18, 1900, in Hamburg, Germany.
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Wiedenbach's conceptual model of nursing is called ' The Helping Art of Clinical Nursing". Education:
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Career:
B.A. from Wellesley College in 1922 R.N. from Johns Hopkins School of Nursing in 1925 M.A. from Teachers College, Columbia University in 1934 Certificate in nurse-midwifery from the Maternity Center Association School for Nurse-Midwives in New York in 1946..
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Wiedenbach joined the Yale faculty in 1952 as an instructor in maternity nursing.
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Assistant professor of obstetric nursing in 1954 and an associate professor in 1956.
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She wrote Family-Centered Maternity Nursing in 1958. She was influenced by Ida Orlando in her works on the framework.
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She died on March 8, 1998. CONCEPTS AND DEFINITIONS Wiedenbach defined key terms commonly used in nursing practice. The patient "Any individual who is recieving help of some kind, be it care, instruction or advice from a member of the health profession or from a worker in the field of health."
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The patient is any person who has entered the healthcare system and is receiving help of some kind, such as care, teaching, or advice.
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The patient need not be ill since someone receiving health-related education would qualify as a patient. A need-for-help A need-for-help is defined as "any measure desired by the patient that has the potential to restore or extend the ability to cope with various life situations that affect health and wellness.
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It is crucial to nursing profession that a need-for-help be based on the individual perception of his own situation. Nurse The nurse is functioning human being. The nurse no only acts, but thinks and feels as well. Knowledge Knowledge encompasses all that has been percieved and grasped by the human mind.
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Knowledge may be :
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factual speculative or practical Judgment
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Clinical Judgment represents the nurse¶s likeliness to make sound decisions. Sound decisions are based on differentiating fact from assumption and relating them to cause and effect. Sound Judgment is the result of disciplined functioning of mind and emotions, and improves with expanded knowledge and increased clarity of professional purpose. Nursing Skills Nursing Skills are carried out to achieve a specific patient-centered purpose rather than completion of the skill itself being the end goal.
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Skills are made up of a variety of actions, and characterized by harmony of movement, precision, and effective use of self. Person
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Each Person (whether nurse or patient), is endowed with a unique potential to develop self-sustaining resources. People generally tend towards independence and fulfillment of responsibilities. Self-awareness and self-acceptance are essential to personal integrity and self-worth. Whatever an individual does at any given moment represents the best available judgment for that person at the time. KEY ELEMENTS Wiedenbach proposes 4 main elements to clinical nursing.
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a philosophy a purpose a practice and the art. The Philosophy
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The nurses' philosophy is their attitude and belief about life and how that effected reality for them. Wiedenbach believed that there were 3 essential components associated with a nursing philosophy:
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Reverence for life Respect for the dignity, worth, autonomy and individuality of each human being and
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resolution to act on personally and professionally held beliefs. The Purpose
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Nurses purpose is that which the nurse wants to accomplish through what she does. It is all of the activities directed towards the overall good of the patient. The Practice Practice are those observable nursing actions that are affected by beliefs and feelings about meeting the patient¶s need for help. The Art The Art of nursing includes
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understanding patients needs and concerns
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developing goals and actions intended to enhance patients ability and
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directing the activities related to the medical plan to improve the patients condition.
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The nurses also focuses on prevention of complications related to reoccurrence or development of new concerns. PRESCRIPTIVE THEORY Wiedenbach's prescriptive theory is based on three factors: The central purpose which the practitioner recognizes as essential to the particular discipline.
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The prescription for the fullfillment of central purpose. The realities in the immediate situation that influence the central purpose. Diagram
CONCLUSION Nursing is the practice of identification of a patient¶s need for help through
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observation of presenting behaviors and symptoms exploration of the meaning of those symptoms with the patient determining the cause(s) of discomfort, and determining the patient¶s ability to resolve the discomfort or if the patient has a need for help from the nurse or other healthcare professionals.
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Nursing primarily consists of identifying a patient¶s need for help.
Care, Cure and Core The Three C¶s of Lydia Hall This page was last updated on November 6, 2010 ===================================================== LYDIA HALL AND HER THEORY Lydia Hall was born in New York City on September 21, 1906. She promoted involvement of the community in health-care issues. She derived from her knowledge of psychiatry and nursing experiences in the Loeb Center the framework she used in formulating her theory of nursing.
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The theory contains of three independent but interconnected circles: 1. 2. 3. the core, the care and the cure
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The core is the person or patient to whom nursing care is directed and needed. The core has goals set by himself and not by any other person. The core behaved according to his feelings, and value system.
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The cure is the attention given to patients by the medical professionals. The theory contains of three independent but interconnected circles²the core, the care and the cure. .According to the theory, the core is the person or patient to whom nursing care is directed and needed. The core has goals set by himself and not by any other person, and that these goals need to be achieved.
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The core, in addition, behaved according to his feelings, and value system. The cure, on the other hand is the attention given to patients by the medical professionals. The model explains that the cure circle is shared by the nurse with other health professionals. These are the interventions or actions geared on treating or ³curing´ the patient from whatever illness or disease he may be suffering from.
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The care circle explains the role of nurses, and focused on performing that noble task of nurturing the patients, meaning the component of this model is the ³motherly´ care provided by nurses, which may include imited to provision of comfort measures, provision of patient teaching activities and helping the patient meet their needs where help is needed.
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It is easy to understand from the model that in all of the circles of the model, the nurse is always presents the bigger role she takes belongs to
the care circle where she acts a professional in helping the patient meet his needs and attain a sense of balance. Dorothea Orem's Self-Care Theory Dorothea Orem (1914-2007) This page was last updated on November 13, 2010 ========================================== INTRODUCTION
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One of foremost nursing theorists. Born 1914 in Baltimore. Earned her diploma at Providence Hospital ± Washington, DC 1939 ± BSN Ed., Catholic University of American 1945 ± MSN Ed., Catholic University of American Involved in nursing practice, nursing service, and nursing education 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 Published first formal articulation of her ideas in Nursing: Concepts of Practice in 1971.second in 1980,and finally in 1995 DEVELOPMENT OF THEORY
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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.
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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.
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Orem¶s Nursing: Concept of Practice was first published in 1971 and subsequently in 1980, 1985, 1991, 1995, and 2001. MAJOR ASSUMPTIONS
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People should be self-reliant and responsible for their own care and others in their family needing care People are distinct individuals Nursing is a form of action ± interaction between two or more persons Successfully meeting universal and development self-care requisites is an important component of primary care prevention and ill health A person¶s knowledge of potential health problems is necessary for promoting self-care behaviors
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Self care and dependent care are behaviors learned within a socio-cultural context DEFINITIONS OF DOMAIN CONCEPTS Nursing ± is art, a helping service, and a technology
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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
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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 «
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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 Environnent
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environnent components are environnemental factors, environnemental éléments, conditions, and développemental environnent Human being ± has the capacity to reflect, symbolize and use symbols
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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
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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.
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A human being is the focus of nursing only when a self ±care requisites
exceeds self care capabilities Nursing problem
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deficits in universal, developmental, and health derived or health related conditions Nursing process
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a system to determine (1)why a person is under care (2)a plan for care ,(3)the implementation of care Nursing therapeutics
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deliberate, systematic and purposeful action OREM¶S GENERAL THEORY OF NURSING Orem¶s general theory of nursing in three related parts:-
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Theory of self care Theory of self care deficit Theory of nursing syste A. Theory of Self Care This theory Includes :--
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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
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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"
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Self care requisites-action directed towards provision of self care. 3 categories of self care requisites are:-1. Universal
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Developmental Health deviation 2. Universal self care requisites
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Associated with life processes and the maintenance of the integrity of
human structure and functioning
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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 3. Developmental self care requisites
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Associated with developmental processes/ derived from a condition«. Or associated with an event
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E.g. adjusting to a new job adjusting to body changes
Health deviation self care
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Required in conditions of illness, injury, or disease .these include:--
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Seeking and securing appropriate medical assistance Being aware of and attending to the effects and results of pathologic conditions
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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
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Learning to live with effects of pathologic conditions B. Theory of self care deficit
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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:--
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Acting for and doing for others Guiding others Supporting another Providing an environment promoting personal development in relation to meet future demands
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Teaching another C. Theory of Nursing Systems
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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:-
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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
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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 endeavour ,with or without use of materials or instruments Categories of technologies 1. Social or interpersonal
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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 2. Regulatory technologies
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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
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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.
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The steps within the approach are considered to be the technical component of the nursing process.
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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
Orem¶s Nursing. Process
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Assessment
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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:-
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Nursing diagnosis Step 2 Plans with scientific rationale y
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
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Nurse designs a system that is wholly or partly compensatory or supportiveeducative. 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
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Implementation evaluation
Step 3
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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
Health Medical Self care deviation problem & deficits plan 29 yr. 32pack /yr Teenage Seeks Female Water-no pregnancy-2 medical Early restrictions OC-10 yrs attention adulthood Food ±nil Husband for overt transition Wt89lb emotionally away s/s Wt loss-19% Aware of nauseated disease No evidence 8th grade Urinary No BSE ability to Surgery on Difference Teenage retention Infrequent manage reproductive between pregnancy Intermittent physical effects organs knowledge No work self examination base & Married catheterization No HRT lifestyle Child-2 Pain Poor health Lives at Tearful EDU deprivation Will receive mother¶s Husband Oppressive living RT ,perform home. abusive conditions intermittent Environment Dissatisfied catheterization unclean with home Limited RT resources
Universal self Developmental care self care
Therapeutic self care demand Air Maintain effective respiration Water No problem Food maintain sufficient intake
Adequacy of self care agency Inadequate
Adequate Inadequate
Nursing Methods of helping diagnosis Potential for Guiding & directing impaired respiratory status P F fluid imbalance Actual nutritional Teaching deficit r/t ausea Providing physical support Personal development P/F injury Guiding & directing Guiding & directing
Hazards Prevent spouse abuse Promotion of normalcy
Inadequate
Inadequate
Maintain Inadequate developmental environment Support ed normalcy in Inadequate environment Prevent /manage dev threat Maintenance of Inadequate health status Management of Inadequate disease process Adherence to med Inadequate regimen
A/d in environment Shared housing Actual delay in Guiding & directing normaldev. R/T Providing psy support early parenthood Level of education Providing physical, psy support Dev deficit r/t loss of reproductive organs P/F contd. Guiding & directing, alterations in health teaching status Guiding & directing, P/F UTI teaching P/F ¯ adherence in teaching self catheterization & OPD RT Actual deficit in
Awareness of Inadequate potential problems
Adjust to loss of Inadequate reproductive ability & dev Guiding & directing healthy view of Actual self deficit in illness planning for future Adjust life style to Inadequate needs cope with change OREM¶S WORK AND THE CHARACTERISTICS OF A THEORY
awareness of teaching advisability of HRT & RT effects Actual threat to self Providing psy support image
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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
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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
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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
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The theory has been used as a conceptual framework in assoc. degree programs also in many nursing schools Strengths
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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
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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
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Appears that the theory is illness oriented rather with no indication of its use in wellness settings Summary
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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 RESEARCH ON OREM'S THEORY
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Self-care requirements for activity and rest: an Orem nursing focus Nursing diagnoses in patients after heart catheterization--contribution of Orem
3. 4. 5.
Self-care--the contribution of nursing sciences to health care Self-care: a foundational science Orem's self-care deficit nursing theory: its philosophic foundation and the state of the science
6. 7. 8. 9.
Dorothea E. Orem: thoughts on her theory Orem's theory in practice. Hospice nursing care Solving the Orem mystery: an educational strategy Orem's family evaluation Betty Neuman's System Model This page was last updated on November 9, 2010 =============================================== INTRODUCTION
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Betty Neuman¶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
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Betty Neuman 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
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She was a pioneer in the community mental health movement in the late 1960s. Betty Neuman 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.
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The model was published in 1972 as ³A 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
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Neuman¶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
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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.
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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.
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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
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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.
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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.
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Primary prevention relates to G.K. that is applied in client assessment and intervention, in identification and reduction of possible or actual risk factors.
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Secondary prevention relates to symptomatology following a reaction to stressor, appropriate ranking of intervention priorities and treatment to reduce their noxious effects.
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Tertiary prevention relates to adjustive processes taking place as reconstitution begins and maintenance factors move the back in circular manner toward primary prevention.
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The client as a system is in dynamic, constant energy exchange with the environment. CONCEPTS
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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 (Neuman,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.
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LOR: - The series of concentric circles that surrounds the basic structure.
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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
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Input- output: - The matter, energy, and information exchanged between client and environment that is entering or leaving the system at any point in time.
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Negentropy: - A process of energy conservation that increase organization and complexity, moving the system toward stability or a higher degree of wellness.
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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.
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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.
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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.
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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.
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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.
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Illness is a state of insufficiency with disrupting needs unsatisfied (Neuman, 2002).
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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
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According to 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 PREVENTION
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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
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On the other hand manipulates the environment to reduce or weaken stressors. Primary prevention includes health promotion and maintenance of wellness. SECONDARY PREVENTION
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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
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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
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The focus of the Neuman 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.
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Each layer consists of five person variable or subsystems:
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Physiological- Refer of the physicochemical structure and function of the body.
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Psychological- Refers to mental processes and emotions. Socio-cultural- Refers to relationships; and social/cultural expectations and activities.
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Spiritual- Refers to the influence of spiritual beliefs. Developmental- Refers to those processes related to development over the lifespan. ENVIRONMENT
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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.
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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.
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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. HEALTH
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Neuman sees health as being equated with wellness. She defines health/wellness as ³the condition in which all parts and subparts (variables) are in harmony with the whole of the client (Neuman, 1995)´.
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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
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Neuman 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.
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The person is seen as a whole, and it is the task of nursing to address the whole person. Neuman defines nursing as ³action 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.¶¶
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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).
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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
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It depends on acquisition of appropriate database; the diagnosis identifies, assesses, classifies, and evaluates the dynamic interaction of the five variables.
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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
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These must be negotiated with the patient, and take account of patient¶s and nurse¶s perceptions of variance from wellness. NURSING OUTCOMES
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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. Neuman¶S SYSTEM MODEL FORMAT
Neuman¶s nursing process format designates the following categories of data about the client system as the major areas of assessment. ASSESSMENT
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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
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The data collected are then interpreted to condition and formulate the Nursing diagnosis. Health seeking behaviors. Activity intolerance. Ineffective coping. Ineffective thermoregulation. GOAL
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In Neuman¶s systems model the goal is to keep the client system stable. PLANNING
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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
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Primary prevention : actions taken to retain stability Secondary prevention : actions taken to attain stability Tertiary prevention : actions taken to maintain stability EVALUATION
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The nursing process is evaluated to determine whether equilibrium is restored and a steady state maintained. ACCEPTANCE BY THE NURSING COMMUNITY
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Neuman¶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
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The Neuman systems model has been applied and adapted to various specialties include family therapy, public health, rehabilitation, and hospital nursing.
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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
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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.
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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.
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The patient is being relabeled as a consumer with individual needs and wants. EDUCATION
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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.
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In the associate degree program at Indiana University. One of the objectives for nursing graduate is to demonstrate ability to use the Neuman health care system in nursing practice. This helps prepare the students for developing a frame of reference centered on holistic care.
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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.
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Acceptance by the nursing community for education therefore is evident. RESEARCH
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A study was published by Riehl and Roy to test the usefulness of the Neuman model in nursing practice. There were two major objectives of the study.
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To test the model/assessment¶ tool for its usefulness as a unifying method of collecting and analyzing data for identifying client problems.
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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.
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Results indicated that the model can help categorize data for assessing and planning care and for guiding decision making. Neuman¶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. Neuman¶S AND THE CHARACTERISTICS OF A THEORY
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Theories connects the interrelated concepts in such a way as to create a different way of looking at a particular phenomenon. The Neuman model represents a focus on nursing interest in the total person approach to the interaction of environment and health.
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The interrelationships between the concepts of person, health, nursing and society/environment are repeatedly mentioned throughout the Neuman model and are considered to be basically adequate according to the criteria. Theories must be logical in nature
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Neuman¶s model in general presents itself as logically consistent.
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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.
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Theories should be relatively simple yet generalizable.
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Neuman¶s model is fairly simple and straightforward in approach. The terms used are easily identifiable and for the most part have definitions that are broadly accepted.
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The multiple use of the model in varied nursing situations (practice, curriculum, and administration) is testimony in itself to its broad applicability.
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The potential use of this model by other health care disciplines also attests to its generalizability for use ion practice.
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One drawback in relation to simplicity is the diagrammed model since it presents over 35 variables and tends to be awesome to the viewer.
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Theories can be the bases for hypotheses that can be tested.
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Neuman¶s model, due to its high level and breadth of abstraction, lends itself to theory development.
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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.
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Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them.
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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.
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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.
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Theories can be utilized by the practitioner to guide and improve their practice.
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One of the most significant attributes of the Neuman model is the assessment/intervention instrument together with comprehensive guidelines for its use with the nursing process.
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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.
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Theories must be consistent with other validated theories, laws and principles but will leave open unanswered questions that need to be investigated.
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In general, there is no direct conflict with other theories. There is, however, a lack of specificity in systems concepts such as ³boundaries´ which are indirectly addressed throughout the
model. Research Articles
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³Using the Neuman Systems Model for Best Practices¶¶--Sharon A. DeWan, Pearl N. Ume-Nwagbo, Nursing Science Quarterly, Vol. 19, No. 1, 31-35 (2006).
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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. Theory-based exemplars serve as teaching tools for students and practicing nurses.
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These case studies illustrate how nurses' actions, directed by Neuman's wholistic principles, integrate evidence-based practice and generate high quality care
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Melton L, Secrest J, Chien A, Andersen B.
³A community needs
assessment for a SANE program using Neuman's model´ J Am Acad Nurse Pract. 2001 Apr;13(4):178-86.
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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.
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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.
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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 Roy's Adaptation Model This page was last updated on November 13, 2010
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.
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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.
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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 µAdaptation 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
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Family Education Religious Background Mentors Clinical Experience THEORY DESCRIPTION
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The central questions of Roy¶s theory are:
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Who is the focus of nursing care? What is the target of nursing care? 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)
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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
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There is a dynamic objective for existence with ultimate goal of achieving dignity and integrity. Implicit assumptions
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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
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Adaptation -- goal of nursing Person -- adaptive system Environment -- stimuli Health -- outcome of adaptation Nursing -- promoting adaptation and health Concepts-Adaptation
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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
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Bio-psycho-social being in constant interaction with a changing
environment
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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
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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
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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
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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
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Cognator subsystem ² A major coping process involving 4 cognitiveemotive channels: perceptual and information processing, learning, judgment and emotion.
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Regulator subsystem ² a basic type of adaptive process that responds automatically through neural, chemical, and endocrine coping channels Relationships
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Derived Four Adaptive Modes 500 Samples of Patient Behavior What was the patient doing?
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What did the patient look like when needing nursing care? Four Adaptive Modes
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Physiologic Needs Self Concept Role Function Interdependence Four Adaptive Mode Categories
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Tested in practice for 10 years Criteria of significance, usefulness, and completeness were met Sample Proposition and Hypothesis for Practice
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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
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91 Propositions Described relationships between and among regulator and cognator and four adaptive modes 12 Generic propositions Questions Raised by 21st Century Changes
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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
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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.
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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
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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
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Includes relating persons, partners, families, organizations, communities, nations, and society as a whole Adaptive Modes A. Persons
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Physiologic Self Concept Role Function Interdependence B. Groups
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Physical Group Identity Role Function Interdependence Role Function Mode
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Underlying Need of Social integrity The need to know who one is in relation to others so that one can act
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The need for role clarity of all participants in group Adaptation Level
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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
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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
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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
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Adaptation level resulting from inadequate integrated and compensatory life processes Adaptation problem Compromised Adaptation Examples Hypoxia Unresolved Loss Stigma Abusive Relationships THE NURSING PROCESS
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RAM offers guidelines to nurse in developing the nursing process. The elements : First level assessment Second level assessment Diagnosis
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Goal setting Intervention evaluation Usefulness of Adaptation Model
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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
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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
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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
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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
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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
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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.
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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), 1259-1268.
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Chiou, C. (2000). A meta-analysis of the interrelationships between the modes in Roy's adaptation model. Nursing Science Quarterly. 13(3), 252258
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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
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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.
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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.
SISTER CALLISTA ROY: ADAPTATION THEORY
When push comes to a shove, we will seldom disappoint ourselves. We all harbour greater stores of strength than we think. Adversity brings the opportunity to test our mettle and discover for ourselves the stuff of which we are made.
Do not underestimate the power of a person to cope. He may be dependent now but deep within him lies the energy to adapt. I remember a particular a particular patient when I was still an ICU nurse. He was a pastor afflicted with a serious liver problem. Specialists come and go at his ICU bed but they cannot seem to diagnose the problem. Time is running out and the pastor is slipping fast. He s bleeding and God knows how many units of blood have been transfused to him. He went into coma. Doctors were giving up, and so were we. We ve primed the family but they just won t give up yet. The wife is always there at his side during visiting hours, always cheerful and full of hope. So is the daughter who even lets her dad listen to praise songs as if he is not comatose. Many days passed and to our amazement, the pastor woke up from coma. It s been uphill from there. Everything just fell into the right place. He was transferred to a regular room and eventually discharged with a clean bill of health. Amazing? What could it be? A miracle? Or could it be the medications working, or the transfusion? Or the family s fervent prayers? We couldn t tell but one thing is certain: human beings are made to persist. And that is what Sister Callista Roy believed, too.
Sister Callista Roy is a member of the Sisters of Saint Joseph of Carondelet. She received a bachelor of science in nursing from Mount Saint Mary·s College in Los Angeles California, a master of science in nursing from UCLA, and a master·s degree and doctorate in sociology from UCLA (Philips, 2002). Roy first proposed the RAM while studying for her master·s degree at UCLA, where Dorothy Johnson challenged students to develop conceptual models of nursing (Philips, 2002; Roy & Andrew, 1999). She received many honors and awards for her scholarly and professional work and is currently the Graduate Faculty Nurse Theorist at Boston College, School of Nursing (Roy, 2000).
PHILOSOPHICAL UNDERPINNINGS OF THE THEORY Johnson s nursing model was the impetus for the development of Roy s Adaptation Model. Roy also incorporated concepts from Helson s adaptation theory, von Bertalanffy s system model, Rapoport s system definition, the stress and adaptation theories of Dohrenrend and Selye, and the coping model of Lazarus (Philips, 2002).
MAJOR ASSUMPTIONS, CONCEPTS AND RELATIONSHIPS ASSUMPTIONS In the Adaptation Model, assumptions are specified as scientific assumptions or philosophical assumptions. Scientific Assumptions
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 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 created in human consciousness Integration of human and environment meanings results in adaptation (Roy&Andrew, 1999, p.35).
Philosophical Assumptions
Persons have mutual relationships with the world and God Human meaning is rooted in the 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 (Roy & Andrew, 1999, p. 35).
Reading through Roy s adaptation theory, I now understand man s immense capacity to adapt. I believe in a higher power, I believe in miracles, but I believe, too, that the greater miracle is the perfect interplay of all the factors that push a person to adapt at various modes.
The Four Modes of Adaptation 1. Physiologic-Physical Mode Physical and chemical processes involved in the function and activities of living organisms; the underlying need is physiologic integrity as seen in the degree of wholeness achieved through adaptation to change in needs. 2. Self-concept- Group Identity Mode
Focuses on psychological and spiritual integrity and sense of unity, meaning, and purposefulness in the universe. 3. Role Function Mode Roles that individuals occupy in society, fulfilling the need for social integrity. It is knowing who one is in relation to others. 4. Interdependence Mode The close relationships of people and their purpose, structure and development individually and in groups and the adaptation potential of these groups.
So how did the pastor recover? At the physiologic level, it was good that he was brought to the ICU immediately since the basic physiologic needs are met at once. He was intubated (for oxygenation), an NGT was put in place (for nutrition), a foley catheter was inserted (for elimination), and enema was also done to facilitate elimination of wastes. Visitors were restricted early on to provide optimum rest and to minimize cross contamination. Isolation measures were also instituted. Routine ICU care, so to speak. Every time the patient is assigned to me, I try to talk to him as if he listens and can answer. His churchmates were also there every time they are allowed to see him telling him that they are waiting for him at their church. The wife and the daughter never gave up on him. They are always there to tell him how much they love and need him. The adaptation process was a long one, but he did adapt and went on to recover. The ICU environment is not a very ideal place for adaptation, but given the situation and condition of the patient at that time, it was the best place to support the body s power to adapt.
ROY S THEORY AS APPLIED TO:
NURSING PRACTICE
Using Roy s six step nursing process, the nurse assesses first the behaviors and second the stimuli affecting those behaviors. In a third step the nurse makes a statement or nursing diagnosis of the person s adaptive state and fourth, sets goals to promote adaptation. Fifth, nursing interventions are aimed at managing the stimuli to promote adaptation. The last step in the nursing process is evaluation. By manipulating the stimuli and not the patient, the nurse enhances the interaction of the person with their environment, thereby promoting health. Hamner in 1989 discussed the Roy model and how it could be applied to nursing care in a cardiac unit (CCU). Hamner describes the model as enhancing care in the CCU and being consistent with the nursing process. Hamner found that the model assessed all patients behavior, so that none was excluded. The author discovered that the Roy model provides a structure in which manipulation of stimuli are not overlooked. The model puts emphasis on identifying and reinforcing positive behavior which speeds recovery.
EDUCATION
The adaptation model is also useful in educational setting. Roy states that the model defines for students the distinct purpose of nursing which is to promote man s adaptation in each of the adaptive
modes in situations of health and illness. In the early 1980 s the School of Nursing at the University of Ottawa experienced a major curriculum change. This change included incorporating a nursing model by which to base their new curriculum. The change included incorporating a nursing model by which to base their new curriculum. The Roy adaptation model was one of the models to be included in the first year of the baccalaureate program. The professors had to meet four challenges during this change:
1. 2. 3.
Adapting Developing
the
course teaching of
to
be
congruent suitable for
with for
the student student
Roy
model, learning. learning
tools content
Sequencing
4. Obtaining competent role models.
RESEARCH If research is to affect practitioners behavior, it must be directed at testing and retesting conceptual models for nursing practice. Roy has stated that theory development and the testing of developed theories are nursing s highest priorities. The model must be able to regenerate testable hypotheses for it to be researchable.
Fawcett and Tulman used the model for the design of studies measuring functional status after childbirth. They also used the model for retrospective and longitudinal studies of variables associated with functional status during the postpartum period. The model was also used for ongoing studies of functional status during pregnancy and after the diagnosis of breast cancer. The model facilitated the selection of study variables and clarified thinking about the classification of study variables. The model was a useful guide for the design and conduct of studies of functional status.
Human Becoming Theory
Rosemarie Rizzo Parse This page was last updated on November 13, 2010 ======================================== INTRODUCTION The Parse theory of human becoming guides nurses In their practice to focus on quality of life as it is described and lived (Karen & Melnechenko, 1995).
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The human becoming theory of nursing presents an alternative to both the conventional bio-medical approach and the bio-psychosocial-spiritual (but still normative) approach of most other theories of nursing.(ICPS)
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The human becoming theory posits quality of life from each person's own perspective as the goal of nursing practice.(ICPS) Rosemarie Rizzo Parse first published the theory in 1981 as the "Man-living-health" theory (ICPS) The name was officially changed to "the human becoming theory" in 1992 to remove the term "man," after the change in the dictionary definition of the word from its former meaning of "humankind."
ABOUT THE THEORIST
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Educated at Duquesne University, Pittsburgh MSN and Ph.D. from University of Pittsburgh Published her theory of nursing, Man-Living-Health in 1981 Name changed to Theory of Human Becoming in 1992 Editor and Founder, Nursing Science Quarterly Has published eight books and hundreds of articles about Human Becoming Theory Professor and Niehoff Chair at Loyola University, Chicago
THEORY DEVELOPMENT
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The human becoming theory was developed as a human science nursing theory in the tradition of Dilthey, Heidegger, Sartre, MerleauPonty, and Gadamer and Science of Unitary Human Beings by Martha Rogers .
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The assumptions underpinning the theory were synthesized from works by the European philosophers, Heidegger, Sartre, and Merleau-Ponty, along with works by the pioneer American nurse theorist, Martha Rogers.
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The theory is structured around three abiding themes: meaning, rhythmicity, and transcendence.
ASSUMPTIONS
About man The human is coexisting while coconstituting rhythmical patterns with the universe.
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The human is open, freely choosing meaning in situation, bearing responsibility for decisions. The human is unitary, continuously coconstituting patterns of relating. The human is transcending multidimensionally with the possibles
About Becoming Becoming is unitary human-living-health. Becoming is a rhythmically coconstituting human-universe process. Becoming is the human¶s patterns of relating value priorities. Becoming is an intersubjective process of transcending with the possibles.
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Becoming is unitary human¶s emerging
Three Major Assumptions of Human Becoming
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Meaning
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Human Becoming is freely choosing personal meaning in situations in the intersubjective process of living value priorities.
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Man¶s reality is given meaning through lived experiences Man and environment cocreate
Rhythmicity
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Human Becoming is cocreating rhythmical patterns of relating in mutual process with the universe.
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Man and environment cocreate ( imaging, valuing, languaging) in rhythmical patterns
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Transcendence
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Human Becoming is cotranscending multidimensionally with emerging possibles.
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Refers to reaching out and beyond the limits that a person sets
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One constantly transforms
SUMMARY OF THE THEORY
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Human Becoming Theory includes Totality Paradigm
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Man is a combination of biological, psychological, sociological and spiritual factors
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Simultaneity Paradigm
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Man is a unitary being in continuous, mutual interaction with environment
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Originally Man-Living-Health Theory
NURSING PARADIGMS AND PARSE'S THEORY
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Person Open being who is more than and different from the sum of the parts
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Environment
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Health
Everything in the person and his experiences Inseparable, complimentary to and evolving with
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Nursing
Open process of being and becoming. Involves synthesis of values
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A human science and art that uses an abstract body of knowledge to serve people
SYMBOL OF HUMAN BECOMING THEORY
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Black and white = opposite paradox significant to ontology of human becoming and green is hope Center joined =co created mutual human universe process at the ontological level & nurse-person process Green and black swirls intertwining = human-universe co creation as an ongoing process of becoming
STRENGTH AND WEAKNESSES Strengths
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Differentiates nursing from other disciplines Practice - Provides guidelines of care and useful administration Useful in Education Provides research methodologies Provides framework to guide inquiry of other theories (grief, hope, laughter, etc.)
Weaknesses Research considered to be in a ³closed circle´ Rarely quantifiable results - Difficult to compare to other research studies, no control group, standardized questions, etc.
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Does not utilized the nursing process/diagnoses Negates the idea that each person engages in a unique lived experience Not accessible to the novice nurse Not applicable to acute, emergent care
APPLICATION OF THE THEORY
Nursing Practice A transformative approach to all levels of nursing
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Differs from the traditional nursing process, particularly in that it does not seek to ³fix´ problems Ability to see patients perspective allows nurse to ³be with´ patient and guide them toward desired health outcomes Nurse-person relationship cocreates changing health patterns
Research
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Enhances understanding of human lived experience, health, quality of life and quality of nursing practice Expands the theory of human becoming Builds new nursing knowledge about universal lived experiences which may ultimately contribute to health and quality of life
CRITIQUE
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Congruence with personal values
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Nurse must subscribe to this world view to truly use it
Congruence with other professional values
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Complements and competes with other health care professionals¶ values
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Exoteric foundations Esoteric utility
Congruence with social values
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Fulfills society¶s expectations of nursing role
Social Significance
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Makes a substantial difference in the lives of clients and nurses
RESEARCH ON PARSE'S THEORY 1. Nursing practice in human becoming: the "Parse nurse" in French Switzerland 2. 3. 4. The lived experience of suffering: a parse research method study On joy-sorrow: a paradoxical pattern of human becoming Human becoming criticism--a critique of Florczak's study on the lived experience of sacrificing something important 5. 6. A Human Becoming perspective on quality of life Feeling respected: a Parse method study
Nursing theory
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Nursing theory is the term given to the body of knowledge that is used to define or explain various aspects of the profession of nursing.
Contents
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1 Types of nursing theories [1] o 1.1 Grand nursing theories o 1.2 Mid-range nursing theories o 1.3 Nursing practice theories 2 Major nursing theorists and theories 3 See also 4 References 5 External links
[edit] Types of nursing theories [1]
[edit] Grand nursing theories
Grand nursing theories have the broadest scope and present general concepts and propositions. Theories at this level may both reflect and provide insights useful for practice but are not designed for empirical testing. This limits the use of grand nursing theories for directing, explaining, and predicting nursing in particular situations. Theories at this level are intended to be pertinent to all instances of nursing.
[edit] Mid-range nursing theories
Middle-range nursing theories are narrower in scope than grand nursing theories and offer an effective bridge between grand nursing theories and nursing practice. They present concepts and propositions at a lower level of abstraction and hold great promise for increasing theory-based research and nursing practice strategies.
[edit] Nursing practice theories
Nursing practice theories have the most limited scope and level of abstraction and are developed for use within a specific range of nursing situations. Nursing practice theories provide frameworks for nursing interventions, and predict outcomes and the impact of nursing practice.
[edit] Major nursing theorists and theories
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Helen Erickson Virginia Henderson - Henderson's need theory Imogene King Madeleine Leininger Betty Neuman - Neuman systems model Margaret A. Newman - Health as expanding consciousness theory Dorothea Orem - Self-care deficit nursing theory Ida Jean Orlando (Pelletier) Ramona T Mercer - Maternal role attainment theory Anne Casey - Casey's model of nursing Hildegard Peplau - Theory of interpersonal relations Rosemarie Rizzo-Parse - Human becoming theory Isabel Hampton Robb Nancy Roper, Winifred W. Logan, and Alison J. Tierney - Roper-Logan-Tierney model of nursing Martha E. Rogers - Science of unitary human beings Callista Roy - Adaptation model of nursing Katharine Kolcaba Phil Barker - Tidal Model Moyra Allen - McGill model of nursing Erickson, Tomlin & Swain - Modeling and Role-Modeling Katie Eriksson Dr. Jean Watson Paterson & Zderad Boykin & Schoenhofer
Purposely omitted from this list is that most famous of all nurses, Florence Nightingale. Nightingale never actually formulated a theory of nursing science but was posthumously accredited with same by others who categorized her personal journaling and communications into a theoretical framework. Also not included are the many nurses who improved on these theorists' ideas without developing their own theoretical vision