Introduction to the Theory of Culture Care, Diversity, and Universality

Nurses are in constant inte raction with different clients from all walks of life. Regardless of their age, status or condition, we are bound to provide them with the utmost care they deserve. It is a pledge that we made, and one that we have lived by. However, sustaining the care we provide in ensuring that they maintain their well-being is an issue.

Health education and maintenance plays a major role in healthcare and one that is highly participated by nurses. Taking into account our client’s differences in their beliefs, values and practices is tantamount to the success of health promotion. It is with this premise that a sensitivity and knowledge on cultural differences takes the stage.

Madeleine Leininger was the first to identify the impact of culture in relation to nursing. She spent years understanding and developing their connection and how one can influence the other. In this regard, she studied anthropology and utilized it in nursing. The combination of the two brought about her Theory of Cultural Diversity and Universality.

In here, she defined Transcultural Nursing as a subjective area of study and practice focused on comparative cultural care (caring) values, beliefs and practices of individuals or groups of similar or different cultures with the goal of providing culture-specific and universal nursing care practices in promoting health or well-being or to help people face unfavourable human conditions, illness or death in culturally meaningful ways (Barnum, 1998). Moreover, it goes beyond an awareness state to that of culture care nursing knowledge to practice culturally congruent and responsible care (Tomey, 1998).

Cultural Diversity and Universality is therefore the highlight of Leininger’s theory. Cultural Diversity is defined as variations in each culture. In acknowledging these differences, the nurse is able to avoid stereotyping and assume that all clients will respond to nursing care in the same manner. Culture Universality on the other hand, pertains to the similarities. Both these concepts lead to the goal of the theory and that is, “to discover similarities and differences about care and its impact on the health and well-being of groups” (Leininger, 1995)

Internalizing the concepts on culture diversity and universality gives rise to culture-specific and culturally congruent care. The former refers to the identification the client’s care practices brought about by their culture and utilizing them to plan and apply nursing care. This in turn would bring about nursing care that “fit the specific care needs and life ways” of the client (Leininger, 1995). The latter, speaks about “cognitively based assistive, supportive, facilitative, or enabling acts or decisions in order for the nurse to provide meaningful, beneficial, satisfying care that leads to health and well-being” (Leininger, 1995). This, according to Leininger, is the central idea and goal of the Theory of Cultural Care.

The Sunrise-Enabler Model

Effective care is the ultimate task of nurses. We are the members of the health team who have direct patient/client interaction and therefore it is through our knowledge & understanding of the values, customs, beliefs & practices our patients’ culture that we can provide effective care. A better way of understanding the factors that influence a person’s perception of well-being is the sunrise enabler of Madeleine Leininger. Leininger’s model of cultural care can be viewed as a rising sun. When using this model, the nurse can begin anywhere depending on the focus of nursing assessment. The model reflects influences of one’s worldview on cultural and structure dimensions. The cultural and social structure dimensions include technological, religious, philosophic, kinship, social, value and lifeway, political, legal, economic, and educational factors. Each of these identified systems affects health. These cultural and social structure dimensions in turn influences environment and language, wherein emphasis should be placed since this is where the patient/client find themselves such as home conditions, access to particular types of food and family access to transport. Environment and language influence the involved health systems – the folk, professional and nursing systems. The folk health system includes the traditional beliefs and practices on health care while the professional health systems are those practices we learned cognitively through formal professional schools of learning. The combination of the folk health system and the professional health system meets the biological, psychosocial, and cultural health needs of the patient/client.

These factors influence the patterns and expressions of caring in relation to the health of individuals, families, groups, and communities. To be able to make sound nursing care decisions and actions, these factors should be assessed properly and always be taken into consideration.

To achieve culture congruent care, nursing actions are to be planned in one of three modes: culture care preservation/maintenance, culture care accommodation/negotiation, or culture care repatterning/restructuring.

A research project on health and social practices regarding dengue in 2008 on three countries in Southeast Asia could be used as an example on how Leininger’s sunrise enabler can be applied on the community level. Some of the cultural and social factors that were assessed are as follows:

Cultural and Social Structure Dimensions

Technological lack of awareness of first aid remedies and safety procedures on dengue prevention at home

Religious community people view dengue as a bad omen

Kinship and Social women are always the caregivers, thus more women are prone to psychological burden of caring for the sick member of the family

Cultural Values health is of lesser priority; more priority is given to basic needs such as food

Political and legal lack of policy programs by the local government regarding dengue prevention practices

Economic more males acquire dengue since most of them are night shift and farms/plantation workers

Educational low level of education is noted. Most are secondary level graduates, knowledge and comprehension on proper health practices on dengue prevention is low

Proper assessment of the cultural and social structure dimensions will lead to good planning and intervention, leading to a sustainable health care delivery to individual, families, or communities.

Orem’s Nursing Paradigm

By Allan Andan

Man

Orem viewed man as an integrated whole composed of an internal physical, psychologic, and social nature with varying degrees of self-care ability. He/she has the potential for learning and development as he/she is gifted with rational ability and capacity to reflect on his/her experience and use symbols (ideas and words). Under normal conditions, man is self-reliant, responsible and capable continuous self-care, not only of himself/herself, but also oh his/her dependents.

Orem viewed a patient as an individual with health related limitations that make him/her incapable of continuous self care or dependent care. His/ her self-care requisites or demands are beyond his/her self-care abilities which can be attributed to his/her lack of knowledge, skills, motivation or orientation.

Health

Orem defined health as a state of wholeness or integrity of a human being: a state where one is structurally and functionally whole or sound. She further added that a healthy being is one who has the necessary self-care ability to meet his/her changing self-care demands. She supported the concepts of health promotion and health maintenance and claimed that it is not just the individual’s responsibility, but also the society as a whole, including its members.

Environment

Orem viewed the environment as not just the elements external to man. She viewed man and environment as an integrated system. It includes conditions that can positively or negatively affect a person’s ability to provide self-care. She enumerated certain conditions which are conducive for one’s development and includes the following: opportunities to be helped; being with other persons or group where care is offered; opportunities for solitude and companionship; provision of help for personal and group concerns without limiting individual decisions and personal pursuits; shared respect and trust; recognition and fostering of developmental potential.

Nursing

According to Orem, nursing consists of actions deliberately selected and performed by nurses to help individuals or groups under their care to maintain or change conditions in themselves or their environment. She further viewed nursing as an art, community service and a technology. As an art, it has a theoretical base which serves as the basis in providing self-care towards improvement of one’s functioning and development. As a community service, it is geared towards deliberative actions of assisting another in maintaining or reestablishing balance between self-care abilities and demands also leading to improvement in one’s functioning and development. As a technology, it has specialized methods or practice of delivering self-care.

Theory of Self-care

By Rosinee Rosales

Self – care is the performance or practice of activities that individuals initiate and perform on their own behalf to maintain life, health and well-being. When self-care is effectively performed, it helps to maintain structural integrity and human functioning, and it contributes to human development (Orem, 1991).

Self – care agency is the human’s ability or power to engage in self-care. The individual’s ability to engage in self-care is affected by basic conditioning factors.

Basic conditioning factors are age, gender, developmental state, health state, sociocultural orientation, health care system factors, family system factors, patterns of living, environmental

factors, and resource adequacy and availability. (Nursing theories, Julia George)

“Normally, adults voluntarily care for themselves. Infants, children, the aged, the ill, and the disabled require complete care or assistance with self-care activities.” (Orem, 1991)

Two agents:Self – care agent is a person who provides self-careDependent self-care agent is a person other than the individual who provides the care (e.g. parent)

Therapeutic self – care demand is the totality of self-care actions to be performed for some duration in order to meet known self-care requisites by using valid methods and related sets of operation and actions. (Orem, 1991)

Self – care requisites are the actions or measures used to provide self-care, also called self – care needs. It consist three categories which are:Universal self – care requisites are associated with life processes and the maintenance and integrity of human structure and functioning. They are common to all human beings during all stages of life cycle and should be viewed as interrelated factors, each affecting the others. A common term for these requisites is the activities of daily living. (Nursing theories, Julia George)

Orem identifies self – care requisites as follows: (Orem, 1991)1. The maintenance of a sufficient intake of air2. The maintenance of a sufficient intake of water3. The maintenance of a sufficient intake of food4. The provision of care associated with elimination processes and excrements5. The maintenance of a balance between activity and rest6. The maintenance of a balance between solitude and social interaction7. The prevention of hazards to human life, human functioning, and human well-being8. The promotion of human functioning and development within social groups in accord with human potential, known human limitations, and the human desire to be normal.Normalcy is used in the sense of that which is essentially human and that which accord with the genetic constitutional characteristics and talents of individuals

Developmental self – care requisites are either specialized expressions of universal self-care requisites that have been particularized for developmental processes or they are new requisites derived from a new condition or associated with an event (Orem, 1991). In other words, these are needs resulting from maturation or develop due to a condition or an event. Two categories of developmental self-care requisites: Conditions that support life processes and promote specific developmental stages (Intrauterine life, neonatal life, infancy, childhood, adolescence, adulthood) Conditions affecting human development: (a) concerns the provision of care to prevent deleterious effects of adverse conditions (e.g. provision of adequate rest and sleep during pregnancy) (b) concerns the provision of care to prevent or overcome existing or potential deleterious effects of particular conditions or life events (e.g. adjusting in new job or change in social status)

Health deviation self – care is required in conditions of illness, injury, or disease, or may result from medical measure required to diagnose and correct the condition (e.g. learning to walk using crutches following fractured leg)

Health deviation self – care requisites are as follows: (Orem, 1991)1. Seeking and securing appropriate medical assistance2. Being aware of and attending to the effects and results of pathologic conditions and states3. Effectively carrying out medically prescribed diagnostic, therapeutic and rehabilitative measures4. Being aware of and attending to or regulating the discomforting or deleterious effects of prescribed medical care measures5. Modifying the self – concept in accepting oneself as being in a particular state of health and in need of specific forms of health care6. Learning to live with the effects of pathologic conditions and states of medical diagnostic and treatment measures in a life-style that promotes continued personal developmentReferences:George, Julia B. (1995). Nursing theories: The base for professional practice (4th Ed.) Prentice-Hall International Orem, Dorothea E. (1991). Nursing: Concepts of practice (4th Ed.) St. Loius: Mosby Posted by Rhutzuji at 4:13 AM 0 comments Email This BlogThis! Share to Twitter Share to Facebook Share to Google Buzz Links to this post

Theory of Self-Care Deficit

By Rose Ann Bunye

When there is demand to care for oneself and the individual is able to meet that demand, self-care is possible. If, on the other hand, the demand is greater than the individual’s capacity or ability to meet it, an imbalance occurs and this is called a self care deficit.

The theory of self-care deficit is the core of Orem's grand theory of nursing because it delineates when nursing is needed. Nursing is required when an adult (or in the case of a dependent, the parent or guardian) is incapable of or limited in the provision of continuous effective self-care (George 1995). The term "deficit" refers to a particular relationship between self-care agency and self-care demand that is said to exist when capabilities for engaging in self-care are less than the demand for self-care (Parker, 2005, p. 149).

The self-care deficit may be actual or potential. For example:1. In the case of premature birth, the actual infant-care deficit may be the parent’s lack of knowledge of how to provide care for the preterm infant.2. The potential infant-care deficit could result in increased risk of infant abuse or neglect.

Orem identifies 6 methods of helping:--1. Doing for or acting for another2. Guiding or directing another3. Providing physical support4. Providing psychological support5. Providing an environment supportive of development6. Teaching another Posted by Rhutzuji at 4:12 AM 0 comments Email This BlogThis! Share to Twitter Share to Facebook Share to Google Buzz Links to this post

Dorothea Orem's Theory of Self-Care (Illustrations)

By Russel de Lara

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Theory of Nursing System

By Therese A. Baulita

Theory of Nursing Systems

Refers to a series of actions a nurse undertakes to aid in meeting a person’s self-care needs. Describes nursing responsibilities; roles of the nurse & patient Rationales for the nurse-patient relationship The essential organizing component of the Self-Care Deficit Theory of Nursing because it establishes the form of nursing and the relationship between patient and nurse properties. Focused on person There are three support modalities identified in theory: wholly compensatory; partly compensatory; supportive-educative

Three Support Modalities: The client’s ability for self-care involvement will determine under which support modality they would be considered A person may fluctuate between support modalities at any given time

Wholly compensatory system The patient has no active role in the performance of his care The nurse acts for the patient An individual requires total nursing care to fulfill self-care needs A patient’s self-care agency is so limited that she or he depends on others for well-being The nurse accomplishes patient’s therapeutic self-care; compensates for patient’s inability to engage in self-care; supports and protects patients

Partly compensatory system Both nurse and patient work together to perform activities to achieve desired self-care goals A patient can do some self-care measures but needs a nurse to assist her to meet others It has a give and take relationship between the nurse and the patient The nurse compensates for self-care limitations of patient

Supportive-educative system Requires uses of resources and educational tools to teach the person & family to perform their own self-care Indicates that the patient contributes mostly in his/her self-care and the nurse’s role is merely to monitor & regulate the patient’s self-care The patient accomplishes self-care & regulates the exercise & development of self-care agency The patient is able to perform, or can learn to perform, required measures of therapeutic self-care but cannot do so without assistance A patient can meet self-care requisites but needs help in decision-making, behavior control, or knowledge acquisition

Sources:Theoretical Foundations of Nursing Modulehttp://faculty.ucc.edu/nursing-gervase/orem www.slideshare.net/jben501/dorothea-orem-theoryhttp://jlerner.wordpress.com/2010/04/20/a-look-at-orem’s-self-care-deficit Posted by Rhutzuji at 4:11 AM 0 comments Email This BlogThis! Share to Twitter Share to Facebook Share to Google Buzz

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Orem's Self-Care Deficit Theory: Theoretical Assertions

By Rachelle Dogao

Dorothea Orem's Self Care Deficit Theory encompasses all aspect relating to the patient's health, nursing and all the factors that affect which.

The concepts discussed revolve mainly around self care. It is the patient's ability to care for himself and his dependents as well as others as dictated by the environment he lives in that determines health or the need for assistance in maintaining health. On the other hand, the society plays the major role into regulating the nursing care process as to when nursing care is needed and when and how the nursing system is implemented. It is also the environment and the society that directly affect the nurse-patient relationship and self care agency, which are all interconnected into achieving, restoring, and maintaining health.

As shown in the figure below, health can be achieved if the person has knowledge and resources to perform self care activities to meet self care deficits. On the other side, self care deficit results when self care agency (ability to perform self-care) is not adequate to meet the known self care demand and/or the failure to meet the health care requisites (Kozier et.al, 2002) This then warrants the need for nursing intervention through the nursing system, which in turn is empowered by the nurse-patient relationship. The end result of all of this is the maintenance, restoration, or preservation of health.

references:N207 manual on Theoretical Foundations of NursingFundamentals of Nursing by Kozier et.al Fifth Edition

http://currentnursing.com/nursing_theory/self_care_deficit_theory.htmlDorothea Orem's Self Care Deficit Theory by Jean Bridge et.al, Troy University Posted by Rhutzuji at 4:10 AM 0 comments Email This BlogThis! Share to Twitter Share to Facebook Share to Google Buzz Links to this post

Dorothea Orem's Theory of Self-Care (Illustrations)

By Russel de Lara

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Comparison of Orem’s Nursing Process and the Nursing Process

By Monaliza Pineda

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Five Major Assumptions of Orem’s General Theory of Nursing

By Yosef Brian Villanueva

Five major assumptions of Orem’s general theory of nursing are as follows:

(1) Human beings require continuous deliberate inputs to themselves and their environments to remain alive and functions in accord with natural human endowments.

(2) Human agency, the power to act deliberately, is exercised in the form of care of self and others in identifying needs for and in making needed inputs.

(3) Mature human beings experience privations in the form of limitations or action in care of self and others involving and making of life sustaining and functioning- regulating inputs.

(4) Human agency is exercised in discovering, developing, and transmitting to others ways and means to identify needs for and make inputs to self and others.

(5) Groups of human beings with structures relationships cluster tasks and allocate responsibilities for providing care to group members who experience privation for making required deliberate input to self and others

Self care is a requirement for every personUniversal self-care involves meeting basic human needsHealth-deviation self care is related to disease or injuryEach adult has both the right and the responsibility to care for his/her self in order to maintain rational life and health. He/she also has responsibilities to dependentsSelf-care is learned behavior processed by the ego and influenced by both self-concept and level of maturitySelf-care is a deliberative actionAwareness of relevant factors and their meaning is a prerequisite condition for self-care action

Referenceshttp://prism.troy.edu/~scabell/Orem.pdf (Taylor et al, 1998, p. 179).Theoretical Foundations of Nursing, p46 Posted by Rhutzuji at 4:08 AM 0 comments Email This BlogThis! Share to Twitter Share to Facebook Share to Google Buzz Links to this post

Strengths and Limitations of Orem’s Theory

By Myrene Leviste Buban-Aseron

Strengths

Orem’s theory provide a comprehensive base to nursing practice. It is functional in the different fields of nursing. May it be in clinical setting, education, research or administration. Moreover, this theory is as applicable for nursing by the beginning practitioner as much as the advanced clinician(George JB., 1995). Another major strength of Orem’s theory is it’s advocacy for the use of the Nursing Process (Balabagno, et.al, 2006). Orem specifically identified the steps of this process. She also mentioned that the nursing process involves intellectual and practical phases.

Limitations

The ambiguity of applying theory to nursing practice may lie in the fact that one theory does not always specifically support all aspects of nursing care. Orem’s self care deficit theory may not encompass all aspects of care and needs of a specific client. For instance, some dilemma with Orem’s theory include having an unclear definition of family, the nurse-society relationship and public education areas are weak. These issues are essential in the management and treatment plan in caring for patients. Although the family, community and environment are considered in self care action, the focus is primarily on the individual (Balabagno, et.al, 2006). Another limitation is the definition of health as being dynamic and ever changing with states ranging from health or non health, wellness or illness (Fitzpatrick JJ, 2005). This definition of health directly contradicts the experience of some patients with varying needs and levels of care requirements. One of the most obvious limitations of Orem’s theory is that throughout her work, it can be said that a limited recognition of an individual’s emotional needs is present within the theory (George JB., 1995). It focuses more on physical care and gives lesser emphasis to psychological care. Other theories address this limitation quite adequately such as Jean Watson’s Theory of Caring.

REFERENCES

Fitzpatrick JJ, Whall AL. Conceptual models of nursing, analysisand application. 4th ed. Upper Saddle River, New Jersey:Pearson Prentice-Hall; 2005.

George JB. Nursing theories, the basis for professional nursingpractice. 4th ed. Norwalk: Appleton & Lange; 1995.

Balabagno, et al., Pathophysiology, UP Open University; 2006

Application of Orem’s Self-Care deficit theory in the Nursing Profession

By Rosinee Rosales

As a staff nurse in a medical ward in Riyadh Military Hospital, many of our patients have

respiratory and heart problems. All of them present different health problems and needs, some of them are intubated and some of them are in comatose condition after cerebrovascular accident or cardiac arrest. These patients will not be able to verbalize their concerns and feelings. Orem’s concept of self-care specified different self-care requisites, being acquainted in these concepts, it’s easier for me to assess and recognize the needs of my patients and it will facilitate me in selecting particular nursing interventions based on their needs. Orem’s theory of nursing systems is also evident in my current practice. The concepts of wholly compensatory, partly compensatory, and supportive-educative systems are relevant to various interventions that I perform based on different needs and abilities of my patients thus it creates individualized nursing care. In the case of bedridden patients, wholly compensatory nursing system is appropriate to them, “the nurse is their hands and their feet”. Patients who had liver biopsy are not allowed to ambulate 24 hours after the procedure. In this event, partly compensatory nursing system can be applied. Supportive-educative nursing system is appropriate to patients who have diabetes mellitus, they should be taught to correct their diet and lifestyle and how to check their blood sugar and to administer insulin if needed.These are some of the things how Orem’s theory could be beneficial in my current nursing practice. Her contributions are indeed significant in our nursing profession.

Myra Levine's Conservation Theory

"Ethical behaviour is not the display of one's moral rectitude in times of crisis, it is the day-to-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 Nursing” 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 theory” 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 – 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 interest” (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.” 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 ease—the assurance of integrity…in all the dimensions of life.” 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 together” (Levine, 1973). “Conservation describes the way complex systems are able to continue to function even when severely challenged.” (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 disability” as “... the rules of conservation and integrity hold” in all situation in which nursing is requires” (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.” The wholeness (integrity) of the individual demands that the “individual life has meaning only in the context of social life” (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 adaptation”. 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.” On the other hand, disease is “unregulated and undisciplined change and must be stopped or death will ensue”.

IV. Nursing involves engaging in “human interactions” (Levine, 1973, p.1). “The nurse enters into a partnership of human experience where sharing moments in time—some trivial, some dramatic—leaves its mark forever on each patient” (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: 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 short-term 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 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 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 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

Collection of provocative facts through observation and interview of challenges to the internal and external environment using four conservation principles

Nurses observes patient for organismic responses to illness, reads medical reports. talks to patient and family

Assesses factors which challenges the individual

Trophicognosis Nursing diagnosis-gives provocative facts meaning A nursing care judgment arrived at through the use of the scientific process

Judgment is made about patient’s needs for assistance

Hypothesis Planning Nurse proposes hypothesis about the problems and the solutions which becomes the plan

of care

Goal is to maintain wholeness and promoting adaptation

Interventions Testing the hypothesis Interventions are designed based on the conservation principles

Mutually acceptable

Goal is to maintain wholeness and promoting adaptation

Evaluation Observation of organismic response to interventions It is assesses whether hypothesis is supported or not supported

If not supported, plan is revised, new hypothesis is proposed

***

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.

REFERENCES

Websites:

Current Nursing. (n.d.). Nursing theories: Levine’s four conservation principles. Retrieved from http://currentnursing.com/nursing_theory/Levin_four_conservation_principles.htm on July 2009.

Leach, M.J. (n.d.) Wound management: Using Levine’s Conservation Model to guide practice. Vol. 52, Issue No. 8. Retrieved from: http://www.o-wm.com/article/6024 on July 2009.

Sitzman, K. & Eichelberger, L.W. (2009). Understanding the work of nurse theorists: A creative beginning. Retrieved from http://nursing.jbpub.com/sitzman/artGallery.cfm on July 2009. Jones and Bartlett Publishers.

Yeager, S. (2002). Overview of nurse theorist: Myra Levine’s conservation model. Retrieved from: http://www4.desales.edu/~sey0/levine.html on July 2009.

www.google.com

www.yahoo.com

Books:

Añonuevo, C. A., et al. (2005). Theoretical foundations of nursing. University of the Philippines Open University: Quezon City, Philippines.

George, J. B. (2001). Nursing theories: Base for professional nursing. (5th ed). Pearson Education.

Levine, M. E. (1973). Introduction to clinical nursing. F. A. Davis Company: Philadelphia, PA.

Parker, M. E. (2001). Nursing theories and nursing practice. F. A. Davis Company: Philadelphia, PA.

Schaefer, K. M., Pond, J. B., et al. (1991). Levine’s conservation model: A framework of nursing practice. F.A. Davis Company: Philadelphia, PA.

Tomey, A. M. & Alligood, M. R. (2006). Nursing theorists and their work. (6th ed.). Elsevier Health Sciences.

Comfort Theory: An Overview

In the light of current nursing shortage, health care system should find the means to address this problem in order to continue achieving the goal, which is to provide the optimum level of health of a person or client. 

During the 1900’s, comfort is considered the goal of both nursing and medicine because it is believed that comfort will lead to recovery. Comfort is a complex term and titled as one of the distinguishing characteristic of the nursing profession yet, it has never been conceptualized, studied and researched in the field.

In this part of the blog, you will notice that we include certain terms about the theory in which you may get confused of but don’t worry because each will be discussed further as you read the other posts in this blog.

Pioneering the work on theory of comfort in nursing is Dr. Katharine C. Kolcaba PhD, RN, an American nursing scholar, a clinical nurse specialist who attained several scholastic awards and achievements. With her collated

readings, knowledge, experiences and researches... she was able to provide a holistic definition for comfort not only in nursing but for the whole health care team.

The theory of comfort is one of the many middle range nursing theory because it is focused on a limited dimension of the reality of nursing. It is formulated to provide guidance for everyday practice and scholarly research rooted in the discipline of nursing. 

According to Kolcaba, Comfort has 3 existing forms... Relief, Ease and Transcendence. It also includes 4 contexts in which patient comfort can occur... Physical, Psycho-spiritual, Environmental and Socio-cultural.

Similar to all other Nursing Theories, Kolcaba was also able to apply the 4 concepts in the metaparadigm of nursing (Person, Health, Nursing and Environment) according to her theory.  In this theory, she proposed that the term “Nursing Interventions” should be changed to “Comfort Interventions” as to broaden its application and not specify the work only to nurses.  

Her theory also talked about comfort considered to be a positive concept and is associated with activities that nurture and strengthen patients. Kolcaba’s Theory of Comfort has a real potential to direct the work and thinking of all health care providers within one institution since, it appears that the concept of comfort is universally present in all culture and appropriate universal goal for healthcare. 

As her study continues, it is speculated that if Comfort Theory is adapted to include all health care providers and implemented as an institution-wide framework for practice... Comfort for patients will be enhanced further, thus, increasing their health-seeking behaviour--- A win-win situation for the patient, the hospital/institution and the society.

There are a lot of benefits we can get in learning and applying Kolcaba’s Theory of Comfort as it promotes greater understanding and collaboration between health care team members addressing the current shortage in health care team. In addition, it will improve societal acceptance and appreciation of the health institution and increase patient satisfaction.

References:

March, A., & McCormack, D., (April 2009). Nursing theory-directed healthcare: Modifying kolcaba's comfort theory as an institution-wide approach. Holistic Nursing Practice. 23(2). Retrieved from http://www.nursingcenter.com/prodev/ce_article.asp?tid=851431

Smith, M., & Liehr, P. (2008). HMiddle range theory for nursing second edition. Retrieved from www.springerpub.com/samples/9780826119162_chapter.pdf

MARGARET NEWMAN, RN, PHD, FAAN

Saturday, July 18, 2009 11:26 PM

Bibliography

-Margaret Newman was born on October 10, 1933 in Memphis Tennessee.

In 1954 She earned her first Bachelors degree in Home Economics and English from Baylor University in Waco, Texas

-Margaret Newman felt a call to nursing for a number of years prior to her decision to enter the field.

-During that time she became the primary caregiver for her mother, who became ill with Lou Gehrig's Disease.

-Upon entering nursing at the University of Tennessee, Memphis, Dr. Newman knew almost immediately that nursing was right for her

Education

• In 1962 she received her Bachelors degree in Nursing from the University of Tennessee, Memphis.

• In 1964 she received her Masters Degree of Medical-Surgical Nursing and Teaching at the University of California in San Francisco.

• In 1971 she completed her Doctorate of Nursing Science and Rehabilitation at New York University

Employment

Ø 1971 to 1976- She completed her graduate studies at New York University. She also worked and taught alongside nursing theorist Martha Rogers.

Ø Rehabilitation Nursing stemmed her interest in health, movement & time.

Ø 1977- Professor in charge of graduate study in nursing at Pennsylvania State.

Ø 1984- Nurse theorist at the University of Minnesota.

Ø 1996- Retired from teaching.

HEALTH AS AN EXPANDING CONSCIOUSNESS

Newman's Health as Expanding Consciousness was influenced by Martha Rogers. Newman (2003) writes:

The theory of health as expanding consciousness stems from Rogers' theory of Unitary Human Beings. Rogers' assumptions regarding patterning of persons in interaction with the environement are basic to the view that consciousness is a manifestation of an evolving pattern of person-environment interaction...Consciouness includes not only the cognitive and affective awareness normally associated with consciousness, but also the interconnectedness of the entire libing system, which includes physiochemical maintenance and growth processes as well as teh immune system. This pattern of information, which is the consciousness of the system, is part of a larger,undivided pattern of an expanding universe

Newman’s theory of pattern recognition provides the basis for the process of nurse-client interaction. Newman suggested that the task in intervention is a pattern recognition accomplished by the health professional becoming aware of the pattern of the other person by becoming in touch with their own pattern. Newman suggested that the professional should focus on the pattern of the other person , acting as the “reference beam in a hologram”.

Relationship to the Metaparadigm Concepts

Newman has designated “caring in the human health experience” as the focus of nursing discipline and has specified the focus as the metaparadigm of the discipline.

Nursing

-to help clients get in touch with the meaning of their lives by the identification of their patterns of relating

-Intervention is a form of non intervention whereby the nurse’s presence assists clients to recognize their own patterns of interacting with the environment.

-facilitates pattern recognition in clients by forming relationships with them at critical points n their lives and connecting with them in an authentic way.

-The nurse-client relationship is characterized by “a rhythmic coming together and moving apart as clients encounter disruption of their organized predictable state.”

-Nurses are seen as partners in the process of expanding consciousness.

Person

-Person as individuals are identified by their individual patterns of consciousness.

-Persons are further defined as “centers of consciousness” within an overall pattern of expanding consciousness”

-The definition of person has also been expanded to include family and community.

Environment

-Environment is not explicitly defined but is described as being the larger whole, which is beyond the consciousness of the individual.

Health

-A fusion of disease and non-disease creates a synthesis that is regarded as health.

-Disease and non-disease are each reflections of the larger whole; therefore a new concept “pattern of the whole” is formed.

-Newman has stated that pattern recognition is the essence of the emerging health. Manifest health, encompassing disease and non-disease can be regarded as the explication of the underlying pattern of person-environment.

Essence of Margaret Newman's Theory:

• An individual person in each situation, no matter how disordered and hopeless, is part of the universal process of expanding consciousness.

• The expanding consciousness is a process wherein an individual becomes more of his real self, as he finds greater meaning in his life and the lives of those people around him.

• In his/her search for his/her real self, the individual's awareness expands to include the interests of those people around him and the rest of the world.

• Self-awareness may eventually lead to acceptance of one's self and one's circumstances and limitations.

• With self-awareness and self-acceptance, an in-depth understanding of one's condition may pave the way for a person to engage into activities leading to positive progression transcending

Supporting Theory

• The health of a human being is a unitary phenomenon, an evolving pattern of human-environment (Rogers, 1970).

• Life is a process of expanding consciousness. Consciousness is the informational capacity of the system and can be seen in the quality of interaction of the system with the environment (Bentov, 1978).

• The explicate order is a manifestation of the implicate order (Bohm, 1980).

Assumptions

1. Health encompasses conditions heretofore described as illness, or, in medical terms, pathology

2. These pathological conditions can be considered a manifestation of the total pattern of the individual

3. The pattern of the individual that eventually manifests itself as pathology is primary and exists prior to structural or functional changes

4. Removal of the pathology in itself will not change the pattern of the indivdual

5. If becoming ill is the only way an individual's pattern can manifest itself, then that is health for that person

6. Health is an expansion of consciousness.

Critique

Clarity

Semantic clarity is evident in the definitions, descriptions, and dimensions of the concepts of the theory.

Simplicity

The deeper meaning of the theory of health as expending consciousness is complex. The theory as a whole must be understood, nut just the isolated concepts. If an individual wanted to use a positivist approach, Newman’s original propositions would serve as guides for hypothesis development. However, researchers who tried that approach have concluded that it is inadequate to study the theory. As Newman have advocated in the 1994 edition of her book, Health as Expanding Consciousness, the holistic approach of the hermeneutic dialectic method is consistent with the theory and requires a high level of understanding the theory in praxis research.

Generality

The concepts in Newman’s theory are broad in scope because they all relate to health. The theory has been applied in several different cultures and is applicable across the spectrum of nursing care situations. This renders her theory generalizable.

Empirical Precision

In the early stages of development, aspects of the theory were operationalized and tested within a traditional scientific method. However, quantitative methods are inadequate in capturing the dynamic, changing nature of this theory.

Derivable Consequences

The focus of Newman’s theory of health as expanding consciousness provides an evolving guide for all health-related disciplines. In the quest for understanding the phenomenon of health, this unique view of health challenges nurses to make a difference in nursing practice by the application of this theory.

Margaret Newman UPOU N207_09_groupF

Case Study/ Application

Alice is an 80-year old widow who has lived alone in a low-income apartment complex in a small rural town since her husband’s death 8 years ago. She has one surviving family member, a granddaughter who lives 30 miles away. Alice has never learned to drive and depends on her granddaughter for all transpiration to physician appointments, shopping and getting medications. Her income is $824 monthly, and she requires several expensive prescriptions for arthritis, hypertension, and cardiac problems. She has osteoarthritis in her knees and requires a quad cane for support and safety when getting around her apartment. A visiting nurse stops by weekly to check her blood pressure and give her an injection for her arthritis. The visiting nurse notes that Alice’s BP is elevated, and Alice states that she has been unable to get her medication because her granddaughter’s car is broken. Alice also mentions that she is running low on food in the apartment because she can’t go out to shop.

Alice admits that she hardly knows or speaks to her neighbours despite having lived there for 8 years, and she still feels like a stranger and doesn’t want to “push myself in.” She says that she hates to bother people and “won’t hardly unless I just have to.” She says that sometimes she gets lonely for “her people” who are all deceased.

The visiting nurse, in working with Alice, recognized the current situation as a choice point, with potential for increased interaction with other and increased interaction with others and increased consciousness. The old ways no longer work for Alice and new ways relating are necessary. The nurse incorporates the elements of Newman’s method to assist Alice in pattern recognition for the purpose of discovering new potentials for action. As the nurse has Alice relate her story, through dialogue and

interacting with Alice, she helps Alice recognize past patterns of relating and how present circumstances have changed those patterns. Alice talks about how she and her husband lived for 56 years in a rural mountain cabin with few neighbours except for two sisters and their sole daughter. They were very self-sufficient, grew large gardens, had their own livestock, and rarely went to town. All these family members are now deceased except the granddaughter, who insisted that Alice leave the cabin and move into town after the death of her husband. It is apparent that Alice’s past patterns have been those of independence and limiting social contact mainly to family members.

The nurse shares her perceptions with Alice and verifies the pattern identification. Alice states, “I just don’t know long I am going to manage by myself anymore.” The nurse helps her explore sources of help, besides the granddaughter, that will help Alice remain in her apartment as independently as possible. Alice relates that there is one man, a few doors away who has stopped several times to ask if she needed anything from the grocery store, but she hadn’t asked him because she hates to bother him and doesn’t want to be “beholden.”

After further discussion, she decides that she will ask him to pick up staples and medications for her and pay him back by baking some bread saying, “I just love to bake anyway and haven’t had anyone much to bake for.”

In subsequent weekly visits, Alice and the nurse explore the possibility of getting medications at a reduced price through the local nurse-managed clinic. Alice states that she might try getting to know some of her neighbours. The nurse helps Alice make arrangements to be picked up by the Senior Van for physician appointments. As Alice begins to build her own support system, she finds that she relies on the nurse less for help with maintain her independence and they resume their previous pattern of simply checking her BP and giving her injections weekly.

HTML Codes

Sources:

1.Tomey, A. M. & Alligood., M. R., (2006). Nursing Theorists and Their Work. 6th edition. Mosby Inc.

2.George, Julia B. (1995) Nursing Theories - the base for professional nursing practice. Norwalk, Connecticut. Appleton & Lange

3.Weingourt, Rita(1998) Using Margaret A. Newman's theory of health with elderly nursing home residents. Perspectives in Psychiatric Care. http://findarticles.com/p/articles/mi_qa3804/is_199807/ai_n8795466

4.http://books.google.com.ph/books?id=pe4wvuhT01UC&dq=margaret+newman+nursing&printsec=frontcover&source=in&hl=en&ei=sbxNSr2vDobq7APCm9yBBA&sa=X&oi=book_result&ct=result&resnum=12

5.Picard, C and Jones, Dorothy (2004). Giving Voice to What We Know: Margaret Newman’s Theory of Health as Expanding Consciousness in Nursing Practice, Research, and Education, Jones and Bartlett Publishing.

6.http/www.healthasexpandingconsciousness.org/Downloads/HECPresentation.pdf

7.www.scrbd.com/doc/5611804/Models -and- Theories-of-Nursing

8.www.scrbd.com/doc/10899031/nursing-Theory

9.http://library.utmem.edu/exhibits/newman/

10.http://escholarship.bc.edu/dissertations/AAI3008589

11.http://wps.prenhall.com/chet_george_nurstheory_5/0,2535,88787,00.htm

12.http://www.healthasexpandingconsciousness.org/home/

13.http://www.enursescribe.com/nurse_theorists.htm

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Changing The World... One Step At A Time (Faye G. Abdellah)

Friday, August 28, 2009 5:44 AM

Faye Glenn Abdellah was one of the most influential nursing theorist and public health scientist in our era. It is extremely rare to find someone who has dedicated all her life to the advancement of the

nursing profession and accomplish this feat with so much distinction and merit. In fact, when she was inducted into the National Women's Hall of Fame in 2000, Abdellah said, "We cannot wait for the world to change.… Those of us with intelligence, purpose, and vision must take the lead and change the world. Let us move forward together! … I promise never to rest until my work has been completed!"

And she couldn’t have said it any better. Let us get to know this extraordinary theorist by understanding her theory, appreciating how her life story influenced her scientific pursuit, and discerning how her theory can be applied in the ever-dynamic field of nursing.

BIOGRAPHY

Faye Glenn Abdellah was born on March 13, 1919, in New York City. Years later, on May 6, 1937, the German hydrogen-fueled airship Hindenburg exploded over Lakehurst, New Jersey, where 18-year-old Abdellah and her family then lived, and Abdellah and her brother ran to the scene to help. In an interview with a writer for Advance for Nurses, Abdellah recalled: "I could see people jumping from the zeppelin and I didn't know how to take care of them, so it was then that I vowed that I would learn nursing."

Educational Achievements

In 1942, Abdellah earned a nursing diploma and is magna cum laude from Fitkin Memorial Hospital's School of Nursing New Jersey (now Ann May School of Nursing).

She received her Bachelor of Science Degree in 1945, a Master of Arts degree in 1947 and Doctor of Education in Teacher’s College, Columbia University. In 1947 she also took Master of Arts Degree in Physiology. With her advanced education, Abdellah could have chosen to become a doctor. However, as she explained in her Advance for Nurses interview, "I never wanted to be an M.D. because I could do all I wanted to do in nursing, which is a caring profession.”

As an Educator and Researcher

Abdellah went on to become a nursing instructor and researcher and helped transform the focus of the profession from disease centered to patient centered. She expanded the role of nurses to include care of families and the elderly.

In 1957 Abdellah headed a research team in Manchester, Connecticut, that established the groundwork for what became known as progressive patient care. In this framework, critical care patients were treated in an intensive care unit, followed by a transition to immediate care, and then home care. Abdellah is credited with developing the first nationally tested coronary care unit as an outgrowth of her work in Manchester.

Abdellah's first teaching job was at Yale University School of Nursing. At that time she was required to teach a class called "120 Principles of Nursing Practice," using a standard nursing textbook published by the National League for Nursing that included guidelines that had no scientific basis. After a year Abdellah became so frustrated that she gathered her colleagues in the Yale courtyard and burned the textbooks. As she told Image: "Of the 120 principles I was required to teach, I really spent the rest of my life undoing that teaching, because it started me on the long road in pursuit of the scientific basis of our practice."

Established Nursing Standards

In another innovation within her field, Abdellah developed the Patient Assessment of Care Evaluation (PACE), a system of standards used to measure the relative quality of individual health-care facilities that was still used in the health care industry into the 21st century. She was also one of the first people in the health care industry to develop a classification system for patient care and patient-oriented records.

Military Nursing Service

Abdellah served for 40 years in the U.S. Public Health Service (PHS) Commissioned Corps, a branch of the military. In 1981 she was named deputy surgeon general, making her the first nurse and the first woman to hold the position and hold the position for eight years. As deputy surgeon general, it was Abdellah's responsibility to educate Americans about public-health issues, and she worked diligently in the areas of AIDS, hospice care, smoking, alcohol and drug addiction, the mentally handicapped, and violence.

She was also the former Chief Nurse Officer for the U.S. Public Health Service, Department of Health and Human Services, Washington D.C. She was one of the first to talk about gerontological nursing, to conduct research in that area, and to influence public policy regarding nursing homes. She was responsible for establishing nursing-home standards in the United States.

Abdellah has frequently stated that she believes nurses should be more involved in public-policy discussions. In her government position, Abdellah also continued her efforts to improve the health and safety of America's elderly.

What has influenced Faye Abdellah in the development her own model of nursing?

1937 – She wanted to be a nurse on the day she saw Hindenburg explode. In this time she was 18 years old on an outing with her family in New Jersey. The fire and injuries that resulted from this horrific event inspired in her wish to never again be helpless when people needed assistance.

1949 – She spent 40 years in Public Health Service where she first became involved in research, being assigned to perform studies to improve nursing practices.

1960 – She was influenced by the desire to promote client-centered comprehensive nursing care. Abdellah described nursing as a service to individuals, to families and therefore to, to society. Acknowledging the influence of Henderson, expanded Henderson's 14 needs into 21 problems that she believed would serve as a knowledge base for nursing. Throughout her career, she strongly supported the idea that nursing research would be the key factor in helping nursing to emerge as a true profession. The research done regarding these common needs and problems has served as a foundation for the development of what is now known as nursing diagnosis.

Now that we have learned her influences, let’s get to know her concepts on the nursing concepts of man, health, environment, and nursing:

MAN/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, sociological and interpersonal needs- which are often missed and perceived incorrectly. The patient is described as the only justification for the existence of nursing. The individuals (and families) are the recipients of nursing, and health, or achieving of it, is the purpose of nursing services

HEALTH

Abdellah’s concept of health maybe defined as the dynamic pattern of functioning whereby there is a continued interaction with internal and external forces that results in the optimal use of necessary resources that serve to minimize vulnerabilities (George, 1990).

In Patient–Centered Approaches to Nursing, Abdellah describes health as a state mutually exclusive of illness. Emphasis should be placed upon prevention and rehabilitation with wellness as a lifetime goal. Holistic approach must be taken by the nurse to help the client achieve state of health (George, 1990). However in order to effectively perform these services, the nurse must accurately identify the lacks or deficits regarding health that the client is experiencing. These lacks or deficits are the client’s health needs.

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

ENVIRONMENT/SOCIETY

The environment is implicitly defined by Abdellah as the home or community from which patient comes. Society is included in “planning for optimum health on local, state, national and international levels.” However, as Abdellah further delineated her ideas, the focus of nursing service is clearly the individual. Society is integrated when she discusses the implementation.

NURSING

GOAL OF NURSING:

To Abdellah, nursing is a service to individuals, to families and therefore to society. The goal of nursing according to Abdellah is the fullest physical, emotional, intellectual, social and spiritual functioning of the client which pertains to holistic care.

She stated that nursing is based on an art and science that molds 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 (George, 1990). These would mean a comprehensive nursing service, this would include:

1. Recognizing the nursing problems of the patient.

2. Deciding the appropriate actions to take in terms of relevant nursing principles.

3. Providing continuous care of the individual’s total health needs.

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

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

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

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

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

9. Working with allied health professional in planning for optimum health on local, state, national and international needs.

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

Nursing care for Abdellah is doing something to or for the person or providing information to the person with the goals of meeting needs, increase or restoring self-help ability or alleviating impairment.

Her theory also stated that the nurse needs knowledge on basic science and specific nursing skills, as well as knowledge skills in the communication, psychology, sociology, growth and development and interpersonal relations. These 11 nursing skills that a nurse must possess includes the following:

1. Observation of health status

2. Skills of communication

3. Application of knowledge

4. Teaching of patients and families

5. Planning and organization of work

6. Use of resource materials

7. Use of personnel resources

8. Problem-solving

9. Direction of work of others

10. Therapeutic use of the self

11. Nursing procedures

Nursing is broadly grouped into the 21 problem areas to guide care and promote use of nursing judgment. These deals with biological, psychological, and social areas of individuals.

KEY CONCEPTS AND MODEL

Faye Abdellah proposed a classificatory framework for identifying nursing problems, based on her idea that nursing is basically oriented to meeting an individual client’s total health needs. Her major effort was to differentiate nursing from medicine and disease orientation.

Abdellah’s patient-centred approach to nursing was developed inductively from her practice and is considered a human needs theory. Although it was intended to guide care of those in the hospital, it also has relevance for nursing care in community settings. Abdellah was clearly promoting the image of the nurse who was not only kind and caring, but also intelligent, competent, and technically well prepared to provide service to the patient.

ABDELLAH'S TYPOLOGY OF 21 NURSING PROBLEMS

1. To maintain good hygiene and physical comfort.

2. To promote optimal activity: exercise, rest, and sleep.

3. To promote safety through prevention of accident, injury, or other trauma and through the prevention of the spread of infection.

4. To maintain good body mechanics and prevent and correct deformity.

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

6. To facilitate the maintenance of nutrition of all body cells.

7. To facilitate the maintenance of elimination.

8. To facilitate the maintenance of fluid and electrolyte balance.

9. To recognize the physiological responses of the body to disease conditions—pathological, physiological, and compensatory.

10. To facilitate the maintenance of regulatory mechanisms and functions.

11. To facilitate the maintenance of sensory function.

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

13. To identify and accept interrelatedness of emotions and organic illness.

14. To facilitate the maintenance of effective verbal and nonverbal communication.

15. To promote the development of productive interpersonal relationships.

16. To facilitate progress toward achievement of personal spiritual goals

17. To create and/or maintain a therapeutic environment.

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

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

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

21. To understand the role of social problems as influencing factors in the cause of illness.

Abdellah's typology was divided into three areas:

1. Physical, sociological,and emotional needs of the patients;

2. Types of interpersonal relationship between the nurse and the patient;

3. Common elements of patient care.

Theoretical Assertions

Several assertions were repeatedly stated by Abdellah although they were not labeled as such. These assertions are:

1. The nursing problem and nursing treatment typologies are the principles of nursing practice and constitute the unique body of knowledge that is nursing.

2. Correct identification of the nursing problem influences the nurse's judgment in selecting steps in solving the patient's problem.

3. The core of nursing is patient/client problems that focus on the patient and his/her problems.

With this knowledge, how, then, can we apply Abdellah’s theory in our field of practice?

Nursing Practice

First and foremost, Abdellah’s main goal is the improvement of the nursing education. She believed that as the education of nurses improves, nursing practice improves as well.

The most important impact of Abdellah’s theory to the nursing practice is that it helped transform the focus of the profession from being “disease-centered” to “patient-centered.” The patient-centered approach was constructed to be useful to nursing practice as it helped bring structure and organization to what was often been a disorganized collection of nursing care experiences. She categorized nursing problems based on the individual’s needs and developed a typology of nursing treatment and nursing goals which served as a basis for determining and organizing nursing care.

Her twenty one nursing problems made nurses look at patients’ problems and come up with nursing plan of care in a thorough and organized way. Abdellah’s identification of health needs as overt and covert assists nurses in exploring unmasked conditions about the client and plan appropriate interventions to address them. Client centered care emphasizes the principle that every nursing goal should be geared towards treating the patient and not just the mere illness. It has been viewed that if all 21 problems are investigated, the patient would be likely to be thoroughly assessed and thus will aid the nurse organize appropriate nursing strategies. Currently, the 21 nursing problems have been updated to focus on the patient and nursing diagnosis. It has ultimately helped nurses develop their individual critical-thinking skills leading to increase in job satisfaction and more productive nurse-patient and nurse-family interaction.

The application of Abdellah’s theory in nursing practice is greatly attributed to its strong influence to a patient-centered nurse-focused problem-solving approach. Abdellah’s problem-solving process of identifying the problem, selecting pertinent data, formulating hypotheses through collection of data, and revising hypotheses on the basis of conclusions obtained from the data parallels the steps of the nursing process of assessment, diagnosis, planning, implementation and evaluation (Abdellah and Levine, 1986; George, 1995). Because of the strong nurse-centered orientation in the 21 nursing problems, their use in the nursing process is primarily to direct the nurse; indirectly, the client benefits (George, 1995). If the nurse assists the client in meeting the goals states in the nursing problems, then the client will be moved toward good, optimum health.

In the end, Abdellah’s theory helps the practicing nurse organize the administration of care, nursing strategies and provides a scientific base for making decisions. As a theorist who was actively involved on nursing and health care internationally, Abdellah gave credence to the use of the model and is an advocate of applying new knowledge to improve practice.

Nursing Education

Abdellah’s theories and concepts were developed in the 1950’s to present a comprehensive clinical record for nursing students, thus, providing structure to the nursing curriculum. The patient-centered approach that was based from her concepts supported and facilitated the move from the medical model that was used at the time to a nursing model. The major focus of her book, Patient-Centered Approaches (Abdellah, et al., 1960), was on the implementation of the model in baccalaureate, associate degree and diploma nursing programs. Abdellah’s extraordinary researches, publications and other works and her worldwide reputation have been instrumental in disseminating the patient-centered approach to educational programs around the world.

Abdellah’s typology of twenty one nursing problems was an awakening call for revisions and amendments of the nursing educational system in her era. Professors and educators realized the importance of client centered care rather than focusing on medical interventions. Nursing education then slowly deviated its concentration from the complex, medical concepts, into exercising better attention to the client as the primary concern.

One of Abdellah’s theory’s major limitation—it’s very strong nurse-centered orientation—is, on the other hand, it’s major contribution to nursing education. With this orientation, the theory can be used

to organize teaching contents for nursing students, to evaluate a student’s performance in a clinical area, or both (George, 1995).

Nursing Research

Research played a great part in the selection of the 21 problem classifications. Her researches were actually the major strengths of her works. In fact, her framework continues to stimulate research about the role and responsibilities of the nurse. The broad nature of the concepts in her framework offers opportunities to identify directional relationships in nursing interventions. Her theories continue to guide researchers to focus on the body of nursing knowledge itself, the identification of patient problems, the organization of nursing interventions, the improvement of nursing education, and the structure of the curriculum.

Abdellah strongly believed the idea that nursing research would be the key factor in helping nursing emerge as a true profession. The extensive research done regarding the patient’s needs and problems has served as a foundation for the development of what is now known as nursing diagnoses.

Her Typology gave birth to more nursing research and studies. The concepts are very precise and straight forward, making it simple and applicable, thus, stimulating similar disciplines and researches. Her typology was also utilized by some clinical institutions in establishing their staffing outline, namely, the intensive care, intermediate care, long term care, self care and home care units. These were identified according to how Abdellah ideates patient’s needs in her concept of care. Now patients in varied medical institutions are categorized with similar client needs, than by their medical diagnosis and diseases. Also it helped nurses provide better patient care and improve critical thinking skills.

Let us see how nurses in various settings can use Abdellah’s Typology of Needs Theory in their own work settings.

From an ICU nurse:

Ruff Joseph Cajanding, RN

As an ICU nurse, Abdellah's model of nursing care equips me with specific guidelines as to how I can better manage various patient conditions with adeptness and grace. The spectrum of cases I have and will handle in the ICU is diverse and multidimensional, ranging from the extremely common myocardial infarction, up until the most devastating Stevens-Johnson Syndrome, or porphyria, and their management could not get any more complicated. However, in planning for their care, I could utilize the principles underlying Abdellah's Typology inasmuch as it is synonymous to Maslow's hierarchy of needs. I will be guided by the fact that the basic needs should be met first (oxygenation, hydration, nutrition, etc.) before proceeding to higher level needs. Moreover, I will utilize the principle of treating patients in holistic manner, minding their psychosocio-spiritual needs inasmuch as I cater to their physical needs. Ultimately, Abdellah's typology provides nurses a framework as to how we can better organize our work in order to deliver quality nursing care to our clientele—the individual, the family, and the community in general.

From an OR nurse:

Francis Lloyd Borcelas, RN

“As an OR suite nurse, my responsibilities are not only confined on being a scrub, circulating, or anesthetist nurse in the PACU. Managing the OR is a big responsibility, and we do function similarly to the bedside nurses in the ward. Once the patient is scheduled for a procedure, an hour should be rendered for pre-operative preparation including giving of pre-operative medications, performing physical as well as emotional, psychological and spiritual assessment, and reviewing the patient’s history and laboratory results, referrals and co-management needed. In this manner, we learn more about the patient through our review of relevant data and consequently uncover nursing problems presented by the patient. Through this, we will be able to identify the therapeutic plan of care that needs to be delivered pre-operative, intra-operative and post-operatively. The applicability of Abdellah’s nursing theory is of valuable to patient care and management, and this allows nurses to manage patients in a holistic manner.

From a medical-surgical nurse:

Mae Claire N. Cabatania, RN

I would like to cite a case of my client (a stroke patient) in the medical-surgical ward. He is 45 year old male patient diagnosed with CVA and was a trans-out from ICU. He is receiving oxygen therapy via nasal cannula and hooked to NGT for feeding, and there are times when the client would be restless. Upon receiving the client during endorsement I have identified the possible nursing problems of my client.

First thing on the line is the performance of self care needs and safety. Self care needs such as personal hygiene is very important for client to maintain their integrity and enhance their recovery. Another nursing problem identified is the risk for injury. At times the patient is restless, raising of side rails is very important to prevent falls and injuries. Stroke patients are at risk for falls due to altered level of consciousness. To maintain my client’s nutrition to support his recovery, he is fed via nasogastric tube as prescribed by physician. Also, my patient is at risk for aspiration that is why before feeding it is a must to check for the placement of nasogastric tube to avoid aspiration during feeding.

From a medical-surgical nurse ward:

Patricia Cornejo, RN

In this setting where clients receive direct nursing care, nurses provide a variety of measures to maintain good hygiene and physical comfort. For clients who are totally dependent and require total hygiene care such as clients with alteration in level of sensorium, a complete bed bath is rendered. While bathing the client, exposing only the areas being bathed, closing the door or pulling room curtains around the bathing area promote physical comfort. Clients in a hospital setting have their normal rest and sleep routine disrupted, which generally leads to sleep problems. The nurse can control the hospital environment in several ways. As an example, the nurse can close the curtains between clients in semiprivate rooms. Lights on the nurse’s station and client’s room can be dimmed at night. To reduce noise, nurses can conduct conversations and reports in a private area away from the client’s rooms and keep necessary conversations to a minimum, especially at night. Keeping bed clean and dry and in a comfortable position may help clients relax. Some clients suffer painful illnesses requiring special comfort measures such as application of dry or moist heat, use of supportive dressings or sprints, and proper positioning before retiring. In the rehabilitation unit, the nurse, in collaboration with other health care professionals such as physical therapists, promotes activity and exercise by teaching the use of canes, walkers, or crutches, depending on the assistive device most appropriate for the client’s condition. Nursing interventions to facilitate supply of oxygen to all body cells include positioning and coughing techniques. Initially placing a dyspneic client in high-fowlers position can relieve dyspnea whereas deep breathing and coughing techniques for postoperative client prevent further complications such as pneumonia. To create and/or maintain a therapeutic environment, a nurse can allow relatives to remain at client’s bedside during hospitalization. To facilitate the maintenance of sensory function in the older adult clients, it helps to reduce any background noise by turning off or lowering the volume of any TV, appliance, or radio during a conversation. Since bedridden clients are at risk for sensory deprivation, a nurse routinely stimulates them through range-of-motion exercises, positioning, and self-care activities (as appropriate). To prevent the spread of infection, nurses can teach aseptic practices. Medical asepsis, which includes hand hygiene and environmental cleanliness, reduces the transfer of microorganisms. Proper disposal of body secretions such as sputum should be taught as well. Safety bars on toilets, locks

on beds and wheelchairs, and call lights are examples of safety features found in the hospital to prevent accident, injury, or other trauma.

To further examine how Abdellah’s Typology of 21 Nursing Problems can individually be applied in a specific nursing area, the following scenario is presented:

In my experience as a staff nurse in the endoscopy unit, Faye Abdellah's 21 nursing problems were applied in the following ways:

Katherine D, RN

1. To maintain good hygiene and physical comfort – After colonoscopy, patients are usually soiled from the procedure. It is therefore important to clean them properly and change their diapers if applicable. Physical comfort through proper positioning in bed, adjusting the air-conditioning unit, as well as proper lighting are also provided to the patient, especially if they were sedated and have to stay in the unit.

2. To promote optimal activity: exercise, rest, and sleep – Patients who were sedated during the procedure stay in the unit until the effect of the sedation has decreased to a safe level. During this time, patients are allowed to stay in the room and rest. As a nurse, I make sure the patients are able to rest and sleep well by providing a conducive environment for rest, such as decreasing environmental noise and dimming the light if necessary.

3. To promote safety through prevention of accident, injury, or other trauma and through the prevention of the spread of infection – Making sure the siderails are always up when leaving the patient keeps them from fall accidents. In our unit, one way we prevent the spread of infection is through proper disinfection of the equipments we use. We use products such as Cidezime to disinfect the instruments.

4. To maintain good body mechanics and prevent and correct deformity – Positioning the patient properly, allowing for the normal anatomical position of body parts.

5. To facilitate the maintenance of a supply of oxygen to all body cells – when patients manifest breathing problems, oxygen is attached to them, usually via nasal cannula. Sedated patients are

attached to cardiac monitor and pulse oximeter while having the oxygen delivered. When the oxygen saturation falls below the normal levels, the rate of oxygen is increased accordingly, as per physician's order.

6. To facilitate the maintenance of nutrition of all body cells – patients undergoing endoscopic procedures are on NPO. For this reason it is important to monitor the blood glucose level through HGT. When the patient's blood glucose falls from the normal value, we inject D50W to the patient or we change the patient's IVF to a dextrose containing fluid.

7. To facilitate the maintenance of elimination – Providing bedpans or urinals to patients and at times, insertion of foley catheter when the patient is not able to void

8. To facilitate the maintenance of fluid and electrolyte balance – Proper regulation of the intravenous solutions as well as proper incorporations it may have. An example is when patients have low serum potassium, KCl is incorporated in the solution

9. To recognize the physiological responses of the body to disease conditions—pathological, physiological, and compensatory – it is important to check the patients for signs of internal gastrointestinal bleeding by monitoring the blood pressure and cardiac rate.

10. To facilitate the maintenance of regulatory mechanisms and functions – When a patient has a difficulty in breathing and is showing an increase respiratory rate, elevating the head part of the bed is done to facilitate the respiratory function.

11. To facilitate the maintenance of sensory function – Sometimes there are semi-conscious patients, in these cases, it is still necessary to talk to them while performing nursing interventions to maintain their auditory sense

12. To identify and accept positive and negative expressions, feelings, and reactions – most patients feel anxious before undergoing the procedures. It is necessary to listen to the patients' expressions and allow them to ask questions. To decrease their anxiety, proper instructions are given, what they are to expect, how long the procedure will take, what they should do during and after the procedure as well as other concerns.

13. To identify and accept interrelatedness of emotions and organic illness – Encourage patients to verbalize their feelings and allow them to cry when they have the need to do so will help them emotionally. Some patients are diagnosed with malignancy after the procedure and during this time the emotional needs of the patient is a priority.

14. To facilitate the maintenance of effective verbal and nonverbal communication – when patients are not able to express themselves verbally, it is important to assess for nonverbal cues. For instance when patients are in pain, assessing for facial grimacing. Touch and eye contact are also done for a good patient care.

15. To promote the development of productive interpersonal relationships – allow the patient's significant others to stay with the patient before and after the procedure. This allows for bonding and promotes interpersonal relationship.

16. To facilitate progress toward achievement of personal spiritual goals – our supervisor is a nun and she usually visits the patients in the unit. Catholic patients may benefit from this, allowing them time to practice their faith

17. To create and/or maintain a therapeutic environment - providing proper lighting, proper room temperature, a quiet environment are done to patients staying in the unit.

18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs – care to patients vary according to their developmental needs. Allowing the parents to stay during the procedure help the pediatric patients in their emotional and developmental needs.

19. To accept the optimum possible goals in the light of limitations, physical, and emotional – The goals for each patient vary depending on the capability of the patient. The nutritional goal for a patient with a PEG tube for instance will be different, knowing that the patient has limited feeding options.

20. To use community resources as an aid in resolving problems arising from illness – Some patients live far from the city and thus referral to health centers is sometimes done

21. To understand the role of social problems as influencing factors in the cause of illness – Some patients who are diagnosed with amoebic colitis for instance are advised to avoid buying street foods to which the preparation they are not sure of, and also avoid drinking water that are not safe.

***

In conclusion, 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 the health needs of people. From this framework, 21 nursing problems, which are comparable to Henderson’s 14 components of nursing and Maslow’s hierarchy of needs, are developed. Her theory and framework provides a basis for determining and organizing nursing care. It is anticipated that by solving the nursing problems through appropriate and organized nursing strategies, the client will be moved towards ultimate health.

Isn’t health everything that we all aspire for?

Sources:

Abdellah, F. G. & Levine, E. (1965). Better patient care through nursing research. New York: Macmillan.

George, J. (2002). Nursing Theories: The Base for Professional Nursing Practice. Upper Saddle River, NJ: Prentice-Hall, Inc.

George, J. (1995). Nursing theories: The base for professional nursing practice, 4th ed. USA: Prentice-Hall Intl.

George, J.B. (1990). Nursing theories: The base for professional nursing practice 3rd edition. Norwalk, CN: Appleton and Lange.

_____________. (1998). Image. USA: ____________.

Johnson, B. & Webber, P. (2005). An Introduction to Theory and Reasoning in Nursing 2nd Ed. Philadelphia, PA: Lippincott Williams and Wilkins.

Octaviano, O. & Balita, C. (2000). Theoretical Foundations of Nursing: The Philippine Perspective. Philippines: ___________.

_____________. (2000). Advance for Nurses. USA: ___________.

Parascandola, J (1994). "Women in the Public Health Service". Leadership in Public Health. Chicago: Illinois Public Health Leadership Institute.

Submitted by Group B: UPOU N207 batch 2009 group B.

THE QUEEN WHO IS KING

Friday, July 17, 2009 12:13 PM

IMOGENE KING: The Queen of Goal Attainment Theory

A little Man in the Making

An Application of King’s Theory

By Melvina Ceceilia R. Manayan and Karen Katrina A. Manlapaz

Young boys playing happily in a park… a lovely picture to glance at. Their youth, energy and innocence seem to linger through my veins- a feeling that I have been longing to sense for a while now. One boy was kicking the soccer ball with great confidence that he would reach the goal. Another was manning him, preparing all his might to block the kick. There was one who was just running around the field with bare feet, enjoying the strokes of the grass on his soles. It seemed that their world evolves only on what they were doing, so soft and gullible.

This is the vision that I saw before I went to work one day, a perfect image of how children should be. They play, enjoy life and do not have any struggles. At their very young age, they are supposed to be just “kids”.

Little did I know that at that same day I would change my usual perception about children.

Randolf was this first patient that I attended to. He was 10 years old, incidentally, just came from a soccer tryout where he injured his left knee after hitting another kid. He was sitting on a stretcher and was sobbing. As I approached to attend to him, I was sure that he was crying because of the excruciating pain brought about by his injury. “Piece of cake,” I thought to myself. I was to assess him first and provide some comfort measures. Then, he would surely be better. But, after doing what I thought would make him well- wound care and antiseptics, and some pain medications, he still went on with his crying.

I decided to pull a chair and started talking to him. He managed to look at me and said “the pain is still there but it isn’t as intense as before you gave me some medications. That’s a relief. But… will I ever play again?”

With his tear drenched face he continued, “My leg never hurt that much before. I’m scared that I won’t be able to play. You see, I have always dreamt of being a famous soccer player. My dad used to say that if I would just put my heart into it, master the rules, have discipline and relate with my peers well, it wouldn’t be hard to reach for my dream…but this morning.. it was just my first day at soccer tryout. And everything went wrong. Not to mention missing school and my friends… I’ll be left behind!”

I froze for a moment. I never thought that at a very young age, a child would say those words. He speaks of his concerns and his plans. I underestimated him. He wanted to get involved in a team and is willing to play by the rules. I was too judgmental. He speaks about not wanting to miss school. He wanted to learn and do his homework. I was enlightened. He is a little man in the making.

I didn’t realize, until then, that I had to include Randolf’s concerns in the plan of his care. He wanted to play again, to go to school and to reach for his dreams. He wanted his leg to be better. I continued to sit with Randolf to indentify his other concerns. We talked, exchanged some views and planned his rehabilitation schedule before I discharged him. As he left the emergency room, I felt that he lightened up—seeing a bit of hope for his concerns. He left with a smile painted on his face.

A few months later, a familiar face greeted me in the emergency room. He wasn’t in any way ill- no pain neither any injury. He was wearing a medal and was holding a soccer ball. It was Randolf and he got his first medal as his team won 3rd in the soccer competition.

“I forgot to say thanks the last time.” He went on talking proud about his accomplishments after completing the rehabilitation program. He was happy.

Children, as little and innocent as they seem, are not kids anymore. They are slowly exploring their self, learning the social rules and capable of decision- making. They are not that responsible enough thus guidance is still needed. They have needs to be helped with. They have lots of things to learn. With the proper assistance, they will be self directed.

Kids will not be kids forever. They will be a man soon.

HERE’S A GLIMPSE OF THE LIFE OF IMOGENE KING…

BIBLIOGRAPHY

(January 30, 1923 – December 24, 2007)

* Imogene King completed her diploma nursing education in 1945, at St. John's Hospital in St. Louis, Mo.

* She received her BS and MS in nursing from St. Louis U. in 1957,

* She obtained her Doctorate in Education from Columbia U. N.Y.

* She has practiced as a staff nurse, nurse educator, and nurse administrator.

* She formulated her theory while she was an associate professor of nursing at Loyola U. in Chicago.

* This was at the time nursing was emerging as a profession and some nurses sought to challenge the existing role of nurses.

* King began her work in nursing theory with a conceptual framework.

* King considers her theory as a deviation from systems theory, with emphasis on interaction theory.

* In 1981 she refined her concepts into a nursing theory that consisted of the following basis:

1. An open system framework as the basis of goal attainment.

2. Nursing as a major system within the health care system.

3. Nursing process emphasis on interpersonal processes.

HER THEORY…

Goal Attainment Theory

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

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

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

From the theory of goal attainment king developed predictive propositions, which includes:

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

• If nurse and client make transaction, goal will be attained

• If goal are attained, satisfaction will occur

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

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

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

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

Many people believe King's theory of goal attainment to be a productive and empowering way for nurses and patients to interact. There has been some discussion about how well the theory applies across all groups of patients, as it is necessary for the patient to be able to interact with the nurse to develop and agree on goals, and on ways to work toward those goals. Others contend that King's theory can be applied to all groups because a large portion of communication involves nonverbal behavior, so being able to communicate through spoken language is not a prerequisite for transactions to occur.

Goal Attainment Theory Conceptual Framework

It includes:

• Several basic assumptions

• Three interacting systems

• Several concepts relevant for each system

Basic assumptions

• Nursing focus is the care of human being.

• Nursing goal is the health care of individuals & groups.

• Human beings: are open systems interacting constantly with their environment.

• Interacting systems: Personal system, Interpersonal system, Social system

• Concepts are given for each system :

o Concepts for Personal System: Perception, Self, Growth & development, Body image, Space, Time

o Concepts for Interpersonal System: Interaction, Communication, Transaction, Role, Stress

o Concepts for Social System: Organization, Authority, Power, Status, Decision making

The theory of goal attainment, which lies at the heart of King's theory of nursing, exists in the context of her conceptual framework. The essence of goal attainment theory is that the nurse and the patient work together to define and reach goals that they set together. The patient and nurse each perceive, judge, and act, and together the patient and nurse react to each other and interact with each other. At the end of this process of communication and perceiving, if a goal has been set a transaction is said to have occurred. The nurse and patient also decide on a way to work toward the goal that has been decided upon, and put into action the plan that has been agreed upon. King believes that the main function of nursing is to increase or to restore the health of the patient, so then, transactions should occur to set goals related to the health of the patient. After transactions have occurred and goals have been defined by the nurse and patient together, both parties work toward the stated goals. This may involve interactions with other systems, such as other healthcare workers, the patient's family, or larger systems.

After the transaction has occurred, and the goal has been set, King believes that it is important for good documentation to be practiced by the nurse. She believes that documenting the goal can help to streamline the process of goal attainment, making it easier for nurses to communicate with each other and other healthcare workers involved in the process. It also helps to provide a way to determine if the goal is achieved. This assessment of whether or not the goal has been successfully achieved plays an important end stage in King's goal attainment theory.

Theoretical Framework

Dynamic Interacting System

The essence of Goal Attainment Theory is for the nurse to promote health by using initially the nurse's personal system. It begins with self-awareness of all the components of his personal self. It is only after self awareness that the nurse will be effective in the assessment of the client.

The nurse then interacts with the client and begins communicating. Upon communicating, the interpersonal system will then exist, which is basically the overlap of the personal system of the nurse and the client. It is imperative then that the nurse has a solid awareness of himself before communicating with the client so that the interpersonal system will be created in a sense that the nurse provides confidence to the care that he will be providing.

The Social System then builds up from the interaction that was created. It is where clear and distinct roles will be defined and the client will realize that he is a patient who, with his actions; permitted himself to be in an institution that has the same goal as what he wants. The client wants to get well or be healthy that is why he is in a caring institution (e.g. hospital, clinic, etc) where he has to follow certain rules as well as to communicate his needs to the nurse; which is a part of the caring social system. It is then when transaction occurs; which is the process of purposeful, goal-directed interaction with the environment to achieve mutually acceptable goals.

APPLICATION – FROM THEORY TO PRACTICE…

Imogene King’s Goal Attainment Theory in Application to the Care of the Elderly in the Emergency Room

Situation: An 80-year-old female patient came in the Emergency Room lying on a stretcher. She was brought to the hospital by her son because she was no longer responding to verbal stimulations. She had a nasogastric tube because she is no longer capable of feeding orally. Upon assessment, we found out that she responded to pain stimulation. Her vital signs were BP-140/60, RR-25, PR-108 and T- 38.2. The patient’s Glasgow Comma Scale was 8.

Application of Imogene King’s Theory

In this situation, the patient can no longer speak or decide for herself, so her son can provide the necessary information and decisions for both of us to formulate goals that are necessary for the patient’s care and later on act on them. Through proper interaction and effective communication with the patient’s son, we were able to understand each others ideas and concerns and we came up with the goals (for their time being at the ER) : to stabilize the patients situation, preserve the patients integrity and carry out necessary laboratory examinations to know the underlying cause of the patient’s current problem.

In the care of my elderly patient, I was very careful with the procedures that I executed especially with the invasive ones such as IV insertion, since elderly patients are very susceptible to infection. Through this, I can prevent doing further harm to her.

I then promoted an environment where I maintained the patient’s integrity through providing her physiologic needs. I also interacted with the patient despite the fact that she is unconscious because I believe that by doing such, I acknowledge and respect the value of my client. Not only that, I allowed her significant others to be involved in the assessing, planning and execution of the plan of care for the patient.

After carefully assessing the status of my client, interacting with his son and formulating goals, I started deliberating on what nursing procedures are best for the patient while at the emergency room. So I decided to carry out the physician’s orders (medications, laboratories, IV fluids, etc.). Then I promoted a safe and clean environment for the patient. And since the patient can no longer provide her basic physiologic needs, I fed her via the nasogastric tube and changed her diapers and clothing to maintain her body’s integrity despite her disability. I also allowed her son to participate in the planning and intervention so that she may feel loved and well taken cared of.

After 3 hours of attending to the patient at the Emergency Room, the patient’s vital signs were stable, the laboratory examinations necessary for knowing the client’s status were executed, and the patient was transported safely to the ward department. I then endorsed the care of my patient to the ward nurse.

Imogene King’s Goal Attainment Theory in Application to the Primary Health Care setting

Imogene King's model is a model of three interacting systems: personal, interpersonal, and social. In her theory of goal attainment, she states that client goals are met through the transaction between nurse and client. The model can be applied to all settings. King describes her model as a conceptual system and the goal of nursing as bringing a person closer to a healthy state (King, 1997, 2001). The nurse and the person interact toward a goal. The end-point of this interaction, which occurs over time, is transaction, at which the person's goal is met.

Working as a staff nurse in a Primary Health Center, Imogene’s theory is realized through the importance of interaction, perception, communication, transaction, self, role, stress, growth and development, time, and personal space with our patients. Most of them are for regular check-up and follow ups which give us opportunity to plan nursing care and set goals to be achieved by the patients for a certain period of time. Middle-East countries especially gulf area are known to have one of the highest mortality and morbidity rates in Diabetes. Most of them are obese, non-working, and has inactive lifestyle. Diabetic patients are carefully managed in our diabetic clinic. Each of them are given monthly appointments to follow up with the nurse and the doctor to evaluate the care that is planned both by the nurse and the patient to establish a controlled blood sugar, prevent diabetic foot and engage patients in healthy lifestyle. Patients are encouraged and motivated to participate in the care of plan that is most comfortable with them and most importantly within the norms of their society and acceptable to their culture and tradition. They are usually taught to self-inject themselves with insulin or a family member is asked and taught to give insulin to the patient. Patient or a family member is also taught to check and record the blood sugar everyday and to keep a record about the food that the patient has eaten. During their monthly appointment we evaluate all that is taught to the patient and revise everything if it is important and necessary for the health of the patient or we refer them to Hamad General Hospital if it is deemed necessary. Each of them has a registration book where we document everything and where all records are kept. Patients are involved and empowered in a way that they get to have a chance to participate in deciding the plan of care for them. Since working in a primary health care, prevention and health education are strengthened and greatly emphasized to the patients and interaction is necessary to set goals and prioritize plan of care.

Imogene King’s Goal Attainment Theory in Application to the care of the Child

King’s Goal Attainment Theory emphasized the ten concepts as the essential knowledge that nurses must use in concrete nursing situations. In the community setting, some of these concepts are applicable: perception, growth and development, time, communication and interaction. They are useful in promoting and preventing occurrence of health problems which is the prime focus of community health nursing.

In care of children in the community setting, promotion of health activities is of priority. Handwashing and cough etiquette lectures are very timely activities today because of the pandemic spread of Influenza A (H1N1).

In interacting with children, we utilized colorful instructional materials and terms appropriate for their ages for easier comprehension. Children are encouraged to participate and are recognized when they are able to do the procedures properly.

Time is also a basic consideration; lectures were conducted at the early part of the day to assure that there energy levels are still high and that they are prepared mentally.

In applying King’s theory, nurses must understand the extent of the children’s understanding about the importance of handwashing and cough etiquette practice. It is also important that nurses must have self-awareness on how he/she perceives the health behavior as well.

In dealing with children, the supporting persons are part of the decision making process because children are not yet capable of making decisions concerning their care. If the child and their support system together with the nurse mutually agree to meet a certain goal, then the process outcome will be goal attainment like in our case practice of handwashing and cough etiquette is achieved.

Imogene King’s Goal Attainment Theory in Application to the care of the Adult

Working as a staff nurse in a Primary Health Center, Imogene’s theory is realized through the importance of interaction, perception, communication, transaction, self, role, stress, growth and development, time, and personal space with our patients. Most of them are for regular check-up and follow ups which give us opportunity to plan nursing care and set goals to be achieved by the patients for a certain period of time. Middle-East countries especially gulf area are known to have one of the highest mortality and morbidity rates in Diabetes. Most of them are obese, non-working, and has inactive lifestyle. Diabetic patients are carefully managed in our diabetic clinic. Each of them are given monthly appointments to follow up with the nurse and the doctor to evaluate the care that is planned both by the nurse and the patient to establish a controlled blood sugar, prevent diabetic foot and engage patients in healthy lifestyle. Patients are encouraged and motivated to participate in the care of plan that is most comfortable with them and most importantly within the norms of their society and acceptable to their culture and tradition. They are usually taught to self-inject themselves with insulin or a family member is asked and taught to give insulin to the patient. Patient or a family member is also taught to check and record the blood sugar everyday and to keep a record about the food that the patient has eaten. During their monthly appointment we evaluate all that is taught to the patient and revise everything if it is important and necessary for the health of the patient or we refer them to Hamad General Hospital if it is deemed necessary. Each of them has a registration book where we document everything and where all records are kept. Patients are involved and empowered in a way that they get to have a chance to participate in deciding the plan of care for them. Since working in a primary health care, prevention and health education are strengthened and greatly emphasized to the patients and interaction is necessary to set goals and prioritize plan of care.

----------

I was able to understand that Imogene King’s conceptual system was used to build a world community of nurses who respect cultural differences and share the mutual goal of health in each nation. Last July 2008, I was given the opportunity to join a Medical Mission held in Phnom Penh, Cambodia for 1 week. It was organized by Youth With A Mission (YWAM), a Christian organization. Together with the health team, we were able to know what the main problem of the community was after the ocular survey. Khmer people living in the slum area were not particular with their hygiene. They don’t have proper clothing, took a bath in a muddy river, and they don’t brush their teeth. Henceforth, dealing with them was not that easy because of language barrier and culture differences. They don’t know how to speak English and part of their culture is to take a bath in the Mekong River from time to time because they believed that the said river can heal their disease. The truth is they don’t have enough knowledge and understanding of what could happen to them if they continue it. To solve this matter, we planned to coordinate with their town leader and did some health teachings to the community with the help of an interpreter. We gave them much information about the diseases they could get when they immersed with that kind of water. We also taught them how to brush their teeth properly. Clothes were given and some vitamins as well. We talked with several people and fortunately, they gave us good feedbacks. They were able to understand that the health team had no intention to disrupt their culture but instead, showed them a better way of having healthy bodies through clean-living lifestyle. Through that, I was also able to appreciate one of Imogene King’s assumptions of an individual: that they have the capacity to think, to know, to make choices, and to select alternative courses of action. It was such a great experience as a nurse!

Imogene King’s Goal Attainment Theory in Application to the care of the Elderly

Caring for the elderly must be done with love and respect. It is a skill that may or may not come naturally to an individual, but either way, members of the family move ahead and do the best they can for their loved one.

Three years back, I have a patient who had Alzheimer’s disease for two years already. As for me, it is one of the difficult patient to encounter since the disease is incurable, degenerative and terminal. She has been in and out of the hospital for several months due to complications of the disease. It has been stressful on the part of the family, looking at the patient day and night suffering from the dreaded disease. One could only imagine how many nights they could not sleep well worrying what will happen the next day. Despite all of what they are facing, they should stay strong. In the midst of what happened those days, I could remember some of the things that I have done for the patient. I

can remember the way she greeted me with a smile and simply say hi every time I entered the room. Although sat times she’s cranky. I can remember the way she tells stories with enthusiasm. And I can remember the way her family showed their love and affection to her. They hug and kiss her. They try to give the best for her. And I salute them for their patience, love, and generosity. As a nurse and as a person, I never thought I could encounter such patient. I never imagined that it was difficult to approach and manage a patient with Alzheimer’s. I was depressed then that I could not do anything about the disease. But then again on second thought, why think of the things that I could not even answer?! What I did was, I talked to her family instead. I reached out to her family because I understand what they feel...and I sympathize with them even if I know that this is not good and not a therapeutic way of communicating. I tried my best to attend to the needs of the patient, may it be in physical, emotional, spiritual, and intellectual aspect. Day by day I was beginning to understand the disease per se and eventually the patient. I thought of making a plan and set goals for the patient. My problem then was the patient cannot follow the things that I have to tell her for us to be able to attain our goals. So, I thought of another plan, why not involve the entire family in rendering care to the patient. I told the folks about these and they gladly said yes. Although I could not change the status of the patient in relation to the disease itself, I manage to somehow change a little bit the condition of the patient. Physically, she was able to move some parts of her body to prevent muscle atrophy through the simple exercises and massage that we do to her every morning. Somehow we managed to talk to her even at the peak of her mood swings and let her tell stories of her past experiences as a wife and mother. We managed to let her out of the bed hassle free for quite some time. For some, this might be insignificant changes, but for me and for the family as well, meant a lot already. At times we cannot do all the activities for the day because of her mood swings. We can only react to what actions she showed to us. If she does not pull her hands and shout at you during the massage of the hands then we continue the massage. If she does not grab the blanket and cover herself during the exercises then we continue the exercise until we’re done. There are days that we cannot do anything at all. But there are days that we fortunately finish all the activities for the day. These is the way I together with her family, manage the patient.

REFERENCES

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

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

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

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

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

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

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

8. http://www.muw.edu/nursing/tupelo/NU433KING%27S.htm

9. Kozier, Barbara et. al. (2004). Fundamentals of Nursing: Concepts, Process and Practice (7th Ed). Philippines: Pearson Education South Asia PTE LTD.

10. http://www.novelguide.com/a/discover/genh_0002_0003_0/genh_0002_0003_0_00487.html

11. http://www.sandiego.edu/nursing/theory⟩

12. Murray, Ruth L.E. and Marjorie Baier. "King's Conceptual Framework Applied to a Transitional Living Program." Perspectives in Psychiatric Care 32: 15-20.

Martha Rogers

Saturday, July 18, 2009 9:47 PM

Welcome to N207_2009_Group E's Headquarters. You came just in time! We nurse detectives were just about to start an investigation on one of the theories of nursing and it would be great if you could join us! Our main objective would be to know what the Science of Unitary Human Beings theory is all about.

Are you ready?

Let's begin by getting to know some facts about the main proponent of the theory,

Dr. Martha Elizabeth Rogers

Whew! Now that was a lot of useful information. We're getting to know more and more about the theory. Before we move on with our investigation, let's take a breather! Time for an intermission brought to you by our very own team members! Just click on the slide below to start the show!

Create Your Own GushyGram

Visit MushyGushy.com

A round of applause for our performers!*CLAP* *CLAP* *CLAP* Now back to work guys. So far we've learned about the author of the theory, her theoretical sources and her major concepts and definitions. Now it's time to learn more about the theory.

Major Concepts and Theoretical Assumptions

So now we know about the theory. We need to find out what the community thinks about it. How did the nursing community accept this theory?

Group E

We're almost done! Here are a few insights from the detectives in our headquarters.

(if you can't see the picture clearly, CLICK HERE.)

EUREKA! We've received word from our intelligence

unit that there is a way to communicate with the main proponent of the theory!

Thanks to the University of Pennsylvania School of Nursing,

for interviewing Martha Rogers for us! Let's hear what she has to say.

Who better to get insights about the theory

than the theorist herself!

Now let's STOP for a moment.

Before we draw our conclusion,

let's review a few of the facts that we know so far.

More flashcards, word search, and hangman provided by StudyStack.com

Did you get the answers correctly? Great! Have you figured it out already? Gathering all the data we've acquired, we are now ready to make our conclusion. We have a guest detective, Afaf ibrahim Meleis, the author of Theoretical Nursing: Development & Progress, who will help us in closing our investigation. He states:

"In addition to Florence Nightingale, who introduced nursing to the notion of the centrality of environment in nurses' domain of practice, Martha Rogers is the person-environment relationship guru.

Furthermore, her theory supports the essentiality of patterns and patterning in understanding the experiences in health and illness. She also reinforced the idea that nursing is based on science. She pioneered the connection between physics and nursing, and she provided the optimistic view of health that empowers the individual as well as the professional nurse. She was a visionary thinker, an inspiring leader, and a theorist who was ahead of her time. She saw the world of nursing very differently, and provided a framwork for others ot experience this perspective. Despite many critics, many of her concepts and propositions continue to stimulate innovative nursing research."

CONGRATULATIONS! You've made it to the end! We hope you learned a lot about this case as we did. Because you did a good job, we have a game for you to enjoy! =)

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And now, Ladies and Gentlemen, it is with great pleasure to present to you the Group E detectives!!!

PEPLAU's LEGACY

Monday, July 21, 2008 10:20 AM

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Monday, July 21, 2008 1:45 AM

TO BE OF SERVICE: Team E Utilizing

The Three C’s of Lydia Hall

(Introduction by Rose de Leon)

It was the 1st week of July 2008 when we had the chance to introduce ourselves in the group. It amazes me that we will have this actual grouping to be able to work together interactively, though a little bit hesitant at first, if this could really work for us and if we can really hang-on with each other. Thus, I grab this opportunity with a delightful heart to introduce my team members for our Group Blog, FMA 1 for N207. Most of my team mates are located in our beloved native land. Truly, one of the best countries where an excellent foundation for Nursing Education could exists nowadays. And also highly diversified in experience with each of us coming from different fields yet we shared one common vision…to come-up with a substantive output and to fulfill our nursing dream. The team, although far from ideal, showed their best efforts in putting the blog together, not minding the hindrances such as work schedules, family and personal lives. These are the talented and hardworking people of Team E:

ROSE: An offshore student who works as a Nursing Service Director, coordinates all group activities, and yes, even posting forums in MOODLE, just to keep everyone updated.

SHANDZ: Working as a CI in one of the nursing schools in Rizal, she took the challenge to become the group’s first Team Manager and formulated a questionnaire to help us ponder deeply into our assigned theory.

JOY: also an offshore student taking up graduate studies in London, through communication by far hinders, she made he way to make it up with the team through technical layout support and collaborative idea of its final picture that comes to reality.

ANNA: A bank executive from the South, she took the challenge of being the secretary, buzzing everyone in time for the conferences; and she does it even while working overtime!

CAYE: Despite working 2 shifts in the Neonatal Intensive Care unit of one of the country’s top hospital, took the challenge of being the team editor (in between naps).

DOC LOREL: A physician and a nurse, shared very clear and interesting point of view about the CURE model. Truly, she’s heaven-sent.

ELOISE: Shares with Rose the same operating room experiences, putting the theory to use in their perioperative patients.

JAN: A dialysis nurse on training, inspired the team to come up with the best that it can do, challenging the limitations to be able to present a blog that is short, concise and unique.

RANDULF: Together with Jan, he injected some masculinity in the predominantly woman team and encouraged everyone to come up with a personalized insight on the applicability and relevance of Lydia Hall’s theory in our practice.

These are the team members, and this is our TEAM BLOG.

ON LYDIA HALL AND HER THEORY: BY ANNA ESTOY and NHINA DE ROSAS

Lydia Hall was born in New York City on September 21, 1906 and grew up in Pennsylvania. She was an innovator, motivator, and mentor to nurses in all phases of their careers, and advocate for the chronically ill patient. 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. These experiences might have given her insight in on the distinct roles of nurses in providing care for the patients and how the nurses can be of utmost importance in caring for these patients.

The theory of all, as they say, contains of three independent but interconnected circles—the core, the care and the cure. But what do these terms mean? According to the theory, the core is the person or patient to whom nursing care is directed and needed. The module has mentioned that the core has goals set by himself and not by any other person, and that these goals need to be achieved. 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 module has been explicit in stating that the cure circle is shared by the nurse with other health professionals. These are the interventions or actions geared on treating or “curing” the patient from whatever illness or disease he may be suffering from. Some interventions I can think of in relation to this are the surgeries performed to treat a tumors or other malignancies, prescribing pharmacologic therapies and performing diagnostic tests. The highlight, however is the care model. This is the part of the model reserved for nurses, and focused on performing that noble task of nurturing the patients, meaning the component of this model is the “motherly” care

provided by nurses, which may include, but is not limited to provision of comfort measures, provision of patient teaching activities and helping the patient meet their needs where help is needed.

That means that if all three circles exhibit harmony and balance, the patient will be the one to benefit from it all since his needs are being put into priority but the meeting of it depends on which circle of the model is responsible for meeting such activities. It was hard not to see that in all of the circles of the model, the nurse is always presents, but 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.

THE THEORY AT WORK: APPLICATION TO OUR INDIVIDUAL PRACTICE

ELOISE ENCARNACION AND ROSE DE LEON, Operating Room Nurses:

The theory can be applied in all the phases of the operative experience. The CARE can be utilized when providing patient care and teaching at each phase of the surgery, providing comfort both physiologically and psychosocially. The CORE model can be realized when he patient is able to express his feelings about the procedure and participates in exploring these feelings, helping him towards a faster recovery. The CURE model is used when we provided medication therapy to the patient, nurses assuming our roles as either scrub or circulating nurse.

CAYE ELLIMA, Critical Care/NICU Nurse: The patient with congestive heart failure usually has health problems related to the ineffective pumping mechanism of the blood, pooling of the blood in the lower extremities and a vast array of systemic symptoms. The cure model can be applicable in this case when the nurse would perform assessment and formulate care plans based on the patient’s needs and against limitations set by the physicians. The cure model will also require the nurse to closely monitor the patient’s response to the treatments and any untoward symptoms and relay these with the other members of the health team. In the care model, the nurse can help the patient or the family in accepting and adapting to the emotional and other stresses the condition may bring. It will be the nurse’s task to open channels of communication to allow expression of feelings and help the patient/family work out through it. It is also in this model that health teachings are imparted. The core model dominates when the patient and/or family are able to address the emotional concerns and issues related to the perception of the effects of the disease process such as activity restrictions. It will be, therefore, the sole role of the nurse to help the patient/family maintain or achieve his sense of balance.

NHINA SANDEEP DE ROSAS, Nursing Education/Clinical Instructor: The core, care and cure model can be applied into nursing education by utilizing its concepts in the mode of instruction given to students. The care model can be materialized in education by having clinical instructors provide “real-world” learning experiences to students. This would provide the students more opportunities for learning and encourages feedbacks about learning topics. Doing this would institute measures to further explore learning needs and help students develop confidence in assuming their roles as nurses. The cure model can be used by nursing educators when they plan for learning activities for their students. This can be done through implementation of diagnostic examinations to ascertain the students’ learning needs not only on nursing practice but also on other fields of science affecting the practice of nursing. The core model can be fully realized only when the clinical instructors are successful in helping the student meet his learning needs and thus providing him with an increased sense of accomplishment in terms of knowledge.

RANDULF ERGUIZA, Community Health Nursing/Clinical Instructor: Care becomes effective when we show sincerity and genuineness in out approach not only towards students but also to patients. We listen, we communicate and we make them feel a part helping the patients. Core is strengthened when we make them (students and patients) realize their potentials as individuals by reflecting not only on things that they can do but also on things that they were not able to do, and what things they still can do. Cure is provided when measures such as encouraging people in the community to utilize the services offered by the health centers and; and teaching them compliance to treatment regimens.

JAN STANLEY DIARESCO, Dialysis Nurse: Lydia Hall’s Care, Core and Cure theory can also be seen and identified in this kind of setting. Patients undergoing hemodialysis experiences problems such as physical vulnerability, feeling of being a burden to the family and being hopeless. Being a nurse one should use therapeutic communication when dealing with the patient, and family, provide proper care to the client as he or she undergoes dialysis and create an environment that would promote holism as the procedure is being done.

As soon as the patient arrives in our unit we explain the treatment and how would it benefit her and the risks involve so that he/she would be ready once the consent is being explained to her the physician. The therapeutic use of self of a nurse is shown here. As a practitioner in the Kidney Unit, we perform dual responsibility, one as nurse and the other as a technician. Being a nurse technician, we provide care to our clients by understanding the concept of dialysis with the use of the machine, how to troubleshoot technical problems, understanding water treatment, cannulation and priming the machine When priming the machine we wash out the renalin and residues present in the dialyzer to protect the client from its harmful effects that could lead to anaphylactic shock. Injecting innohep and heparinizing the tubings makes it safer for the client since clotting will be prevented, which could cause blood loss or wastage. Monitoring vital signs of the client 15 min for the first hour and 30 min thereafter to check for hypotension or hypertension (common complications during HD) would easily alert the nurse to provide initial interventions such as positioning, flushing and notifying the physician for medications to be given or any procedure to be carried out. Upon removal of the cannula’s from the patient site, the nurse should properly apply pressure dressing on the site so as to prevent blood loss and promote healing of the site. Educating the client not to scratch the site, exercise her are so that the fistula site would be bigger and prevent any injury to the site would be ways of preventing future complications to the site.

References:

Anonuevo, et al., Theoretical Foundations of Nursing; UP Open University Press; 2005

Potter and Perry; Fundamentals of Nursing, Fifth Edition; Mosby Publishers; 2001

George, J.B.; Nursing Theories: The Base for Professional Nursing Practice; 2000

http://www.napnes.org/practice/news/clinical_articles/care_of_the%20_congestive_heart_failure_patient.html

AND THIS IS OUR TEAM…

Shandz, Anna, Caye, Rhose, Eloise, Doc Lorel, Joy, Jan, & Randulf

Betty Neuman's Systems Model

Monday, July 21, 2008 12:32 AM

Betty Neuman

"Health is a condition in which all parts and subparts are in harmony

with the whole of the client.”

BIOGRAPHY

1924 - Born in Lowell, a village in Washington County, Ohio, United States, along the Muskingum River

1947 - Obtained her Registered Nurse Diploma from the Peoples Hospital School of Nursing, in Akron Ohio. After that, she went to California where she worked in a hospital as a staff nurse, and eventually became the head nurse. She also explored other fields, and experienced being a school nurse, industrial nurse, and clinical instructor.

1957 - She went to the University of California at Los Angeles (UCLA) and took a double major in psychology and public health. She received her BS Nursing from this institution.

1966 - She completed her Masters degree in Mental Health, Public Health Consultation, also at UCLA. She became recognized as a pioneer in the field of nursing involvement in community mental health.

1970 - Started developing The Systems Model as a way to teach an introductory nursing course to nursing students. The goal was to provide a Holistic overview of the physiological, psychological, sociocultural, and developmental aspects of human beings.

1972 - After a two-year evaluation of her model, it was eventually published in Nursing Research.

1985 - She completed her doctorate in Clinical Psychology from Pacific Western University.

1988 - She founded the Neuman Systems Model Trustee Group, Inc. They are dedicated to the support, promotion and integrity of the Neuman Systems Model to guide nursing education, practice and research.

1992 - She was given an Honorary Doctorate of Letters, at the Neumann College, Aston, Pennsylvania.

1993 - Because of her important contributions to the field on Nursing, Dr. Neuman was named Honorary Member of the Fellowship of the American Academy of Nursing.

1998 - Received an Honorary Doctorate of Science from the Grand Valley State University in Michigan. For the past years, Dr. Betty Neuman has continuously developed and made famous the Neuman systems model through her work as an educator, author, health consultant, and speaker. Her model has been very widely accepted, and though it was originally designed to be used in nursing and is now being used by other health professions as well.

As keynote speaker at the University of Maine (2004)

INFLUENCES

Betty Neuman took inspiration in developing her theory from the following theories/ philosophers:

1. Pierre Tielhard deChardin : a philosopher-priest that believed human beings are continually evolving towards a state of perfection – an Omega Point

2. Gestalt Theory : A theory of German origin which proposes that the dynamic interaction of the individual and the situation determines experience and behavior.

3. General Adaptation Syndrome mainly talks about an individual’s reaction to stress on the 3 levels a) alarm b) resistance c) exhaustion

4. General Systems Theory postulates that the world is made up of systems that are interconnected and are influenced by each other.

The Neuman System Model

KEY CONCEPTS

*

Viewed the client as an open system consisting of a basic structure or central core of energy resources which represent concentric circles

*

Each concentric circle or layer is made up of the five variable areas which are considered and occur simultaneously in each client concentric circles. These are:

1.

Physiological - refers of bodily structure and function.

2.

Psychological - refers to mental processes, functioning and emotions.

3.

Sociocultural - refers to relationships; and social/cultural functions and activities.

4.

Spiritual - refers to the influence of spiritual beliefs.

5.

Developmental - refers to life’s developmental processes.

Basic Structure Energy Resources

This is otherwise known as the central core, which is made up of the basic survival factors common to all organisms. These include the following:

1.

Normal temperature range – body temperature regulation ability

2.

Genetic structure – Hair color and bodily features

3.

Response pattern – functioning of body systems homeostatically

4.

Organ strength or weakness

5.

Ego structure

6.

Knowns or commonalities – value system

*

The person's system is an open system - dynamic and constantly changing and evolving

*

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

*

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

Flexible Lines of Defense

*

Is the outer boundary to the normal line of defense, the line of resistance, and the core structure.

*

Keeps the system free from stressors and is dependent on the amount of sleep, nutritional status, as well as the quality and quantity of stress an individual experiences.

*

If the flexible line of defense fails to provide adequate protection to the normal line of defense, the lines of resistance become activated.

Normal Line of Defense

*

Represents client’s usual wellness level.

*

Can change over time in response to coping or responding to the environment, which includes intelligence, attitudes, problem solving and coping abilities. Example is skin which is constantly smooth and fair will eventually form callous over times.

Lines of Resistance

*

the last boundary that protects the basic structure

*

Protect the basic structure and become activated when environmental stressors invade the normal line of defense. An example would is that when a certain bacteria enters our system, there is an increase in leukocyte count to combat infection.

*

If the lines of resistance are effective, the system can reconstitute and if the lines of resistance are not effective, the resulting energy loss can result in death.

Stressors

*

Are capable of producing either a positive or negative effect on the client system.

*

Is any environmental force which can potentially affect the stability of the system:

1.

Intrapersonal - occur within person, example is infection, thoughts and feelings

2.

Interpersonal - occur between individuals, e.g. role expectations

3.

Extrapersonal - occur outside the individual, e.g. job or finance concerns

*

A person’s reaction to stressors depends on the strength of the lines of defense.

*

When the lines of defense fails, the resulting reaction depends on the strength of the lines of resistance.

*

As part of the reaction, a person’s system can adapt to a stressor, an effect known as reconstitution.

Reconstitution

*

Is the increase in energy that occurs in relation to the degree of reaction to the stressor which starts after initiation of treatment for invasion of stressors.

*

May expand the normal line of defense beyond its previous level, stabilize the system at a lower level, or return it to the level that existed before the illness.

*

Nursing interventions focus on retaining or maintaining system stability.

*

By means of primary, secondary and tertiary interventions, the person (or the nurse) attempts to restore or maintain the stability of the system.

Prevention

*

Is the primary nursing intervention.

*

Focuses on keeping stressors and the stress response from having a detrimental effect on the body.

1.

Primary prevention focuses on protecting the normal line of defense and strengthening the flexible line of defense. This occur before the system reacts to a stressor and strengthens the person (primarily the flexible line of defense) to enable him to better deal with stressors and also manipulates the environment to reduce or weaken stressors. Includes health promotion and maintenance of wellness.

2.

Secondary prevention focuses on strengthening internal lines of resistance, reducing the reaction of the stressor and increasing resistance factors in order to prevent damage to the central core. This occurs after the system reacts to a stressor. This includes appropriate treatment of symptoms to attain optimal client system stability and energy conservation.

3.

Tertiary prevention focuses on readaptation and stability, and protects reconstitution or return to wellness after treatment. This 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.

Betty Neuman's System Model

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APPLICATION

The main use of the Neuman Model in practice and in research is that its concentric layers allow for a simple classification of how severe a problem is. For example, since the line of normal defense represents dynamic balance, it represents homeostasis, and thus a lack of stress. If a stress response is perceived by the patient or assessed by the nurse, then there has been an invasion of the normal line of defense and a major contraction of the flexible line of defense. Infection or other invasion of the lines of resistance indicates failure of both lines of defense. Thus, the level of insult can be quantified allowing for graduated interventions. Furthermore each person variable can be operationalized and the relationship to the normal line of defense or stress response can be analyzed. The drawback of this is that there is no way to know whether our operationalization of the person variables is a good representation of the underlying theoretical structures.

For example, Eileen Gigliotti published a research article in 1999 based on the Neuman Systems Model. The study investigated the relationship of multiple role stress to the psychological and sociocultural variables of the flexible line of defense. If multiple role stress had occurred, then the normal line of defense had been invaded. Questionnaire instruments were used to operationalize the psychological

component with perceived role as a student and as a mother; the sociocultural component with social support, the normal line of defense as perceived multiple role stress.

Upon analysis, no conclusions could be made about the normal line of defense simply on the basis of the psychological component and sociocultural component. By dichotomizing the data by median age, however, a relationship between them could be described. Thus the relationship between the normal line of defense and the psychological and sociocultural components could only be described by taking into account the developmental component. It indicates that the components of the flexible line of defense interact in very complex ways and it may be difficult and dangerous to overgeneralize their interaction.

PERSONAL EXPERIENCES

Experience #1

I’m assigned at the service/charity ward of PDMMMC few months ago. As a staff in the ward of a government hospital, I noticed many weaknesses and shortcomings in the medical management and nursing care as well maybe due to the city government’s not prioritizing health care. They say it is maybe due to “lack of budget” but I really don’t believe in that same old music. I know there is, but the question is where is it going? We are badly lacking of resources, instruments and material so we need to improvise. And most of all, we are under staff so proper nursing care is compromised to every patient plus the fact that the environment is not conducive to the nurses and the patients. At that time, a 25 year old female patient was transferred to our ward from the ICU. The case was PTB advanced and heart problem. I was very curious why? They said that the patient is stable but the catch is she was admitted to the isolation room of the charity ward together with other PTB cases and with minimum nursing care because of the overwhelming census. Based on my own assessment, the patient is not yet stable, I think the true reason for transfer is that the patient can no longer withstand the demands for her medication in ICU because she is the one who is availing that, or maybe there is a much priority patient who will be placed in ICU, because it is only two – bed capacity so they need to manage and decide very well on admissions and discharge. And if they want to transfer the patient post ICU, why in service ward that is not so conducive? Of course the patient is financially incapable to be admitted to pay ward.

The client’s flexible line of defense is compromised here; she had a hard time resting because the temperature in the isolation room is very warm and humid even if she has an electric fan. Her nutritional level is also not good and quantity of stress increases. Her normal line of defense is also unstable, she is not well and we can assess she is not. And her line of resistance is severely debilitated; she has PTB infection and dyspnea. Her environment to isolation room further worsens her condition.

Extrapersonal stressors like the isolation room environment where infection is floating around the room and also the nursing care that nurses wasn’t able to render because of the nurse to patient ratio of 1:30 which is not very ideal. She also has interpersonal stressors like the problem of broking up with his husband and for not having the opportunity to see her son because children are restricted to ward premises especially in isolation room. And her intrapersonal stressors like disturbed emotional status, deteriorating physical ability and financial problems.

These factors disrupted the reconstitution of the patient. In this situation, primary prevention is not given priority, because her admission to charity ward, isolation room increases her risk to infection and stress and limited nursing care. In secondary prevention, we succeed in the first part in ICU but wasn’t able to continue in the ward because of many factors as stated above. Even the prescribed medications are not purchased because of financial constraints. In tertiary prevention, sometimes we nurses do our best, but fate will still prevail. Patient died that evening during endorsement before we receive her case. Nursing goal is not met. And lessons are learned.

Neuman system model is a delicate tool to be used in nursing care especially in identifying the stressors, the interventions, and the affectation in the line of defenses of the client that we must protect to maintain quality of life, reconstitution and optimum level of functioning of our clientele and much better in disease prevention. Holistic care should be given to all of our patients at all times in any setting.

Experience #2

About a week ago I had in my care the wife of the captain of the ill-fated Princess of the Stars. In this case, I was able to identify the following stressors:

1. Psychological-Emotional:

*

Anxiety which stemmed from the uncertainty about the fate of her husband.

*

A sense of guilt because relatives of the passengers are blaming her husband for the tragedy.

*

Ambivalence in the sense that she would be happy if her husband survived and at the same time worried too that if he did survive he would be subjected to court litigation.

2. Financial Stress: Her husband is the breadwinner of the family and in a brood of 5 children, only one is employed; the rest are still in school.

3. Physical Stress manifested as:

a. Insomnia

b. Elevated blood pressure unresponsive to maintenance medications

c. Persistent chest pains

Nursing interventions are carried out on three preventive levels:

*

Primary Prevention would not be applicable because the accident causing the stressors has already occurred and the patient has already developed the reactions/symptoms of stress.

*

Secondary Prevention is applicable in this case. Because of the persistent elevated blood pressure ( above 200/110) accompanied by severe chest pains, the patient was admitted to the hospital for both diagnostic and therapeutic management. Nursing intervention centered initially on the round the clock monitoring of the blood pressure and giving of the ordered anti- hypertensive drugs. Since the EKG showed ischemia, the patient was closely watched for worsening of the pain because of the possibility of a myocardial infarction. Immediate referral of the patient to the resident physician is to be made if chest pain persisted despite giving isosorbide dinitrate for proper evaluation. Aside from giving anxiolytics to decrease the anxiety of the patient, I have to warn visiting relatives to refrain from talking about the tragedy. Sedatives were given before bedtime to prevent insomnia.

*

Tertiary Prevention: Upon discharge, I gave the patient and the immediate family members the following advice:

1. If possible to stay in a relative’s house for a few weeks because they were being hounded by media who were camped outside their home.

2. Regular monitoring of the patient’s blood pressure by a daughter who is a student-nurse who should also monitor her intake of medications as prescribed by the physician.

3. Avoid watching TV shows that mention about the tragedy.

4. Avoid answering the phone.

5. She should have a close relative with her aside from the children who will manage their affairs in the meantime.

Experience #3

In the Community...

In one of the rotations of my students in the community, we encountered this very interesting newly married young couple (both are 18 years old). They have been married only for 3 months, but the supposed to be happy pair is already facing a lot of stressors.

One condition that brings extrapersonal stress is the unemployment of the husband. Their financial source is not enough to meet their needs. The woman somzd enough for her son. This relationship poses as an interpersonal stress to her.

The wife is also pregnant at that time, and her poor nutritional (underweight) and emotional status (sadness and anger at her mother-in-law) create intrapersonal stresses.

We know, based on Neuman’s Systems Model, that the reaction to stressors would depend on the strength of the lines of defense. The woman, due to financial constraints, is suffering from poor nutritional status. She usually lacks enough sleep due to the nature of her work. This creates a breach to her flexible line of defense. The normal line of defense also becomes unreliable because of her uncaring attitude toward her pregnancy and sexual behaviors that predispose her to a lot of possible illnesses. Her coping abilities are also affected because she is sometimes preoccupied with her relationship problems with her mother-in-law.

These conditions put not only our client but also her unborn child on the verge of developing various illnesses. Hence, our interventions focused on restoring system stability, by helping the client’s system adapt to the stressors.

Starting with primary prevention, we tried to educate their family on the importance of having good nutrition. We suggested some nutritious but cheap food choices. We also tried to advice her on possible alternative jobs that would not jeopardize her health and that of her unborn baby.

For the secondary prevention, we advised that she seek pre-natal check-up, and make use of the available services of the nearby health center.

After about 1 month of constant visits to these clients, we really observed noticeable improvements in their health conditions. The woman began to show weight gains consistent with her age of gestation. The couple has also learned to plant and eat nutritious food such as fruits and vegetables. The husband started to work as a production operator in a nearby factory, allowing his wife to take a break from her old job.

Before our duty in the community ended, we were able to initiate tertiary prevention by supporting and commending the positive behavioral changes exhibited by the couple. We also dwelt on strengthening the positive attributes of the family, such as their unwavering faith in God, and their strong devotion to each other. We learned from this experience that no problem is unsolvable with the use of consistent and well-contemplated nursing care.

REFERENCES:

Websites:

http://www. google.com

http://www.neumansystemsmodel.org

http://www.neumansystemsmodel.org/NSMdocs/nsm_powerpoint_overview.htm

http://www.patheyman.com/essays/neuman/index.htm

Patrick Heyman and Sandra Wolfe, University of Florida, April 2000 http://www.patheyman.com/essays/neuman/implications.htm

Books

Añonuevo, C. et. Al (2000). N207 Theoretical Foundations of Nursing. Philippines: UP Open University

Balita, Carlito E. (2005). Ultimate Learning Guide to Nursing Review. Ultimate Learning Series

Kozier, B. et. Al (2004). Fundamentals of Nursing: Concepts, Process, and Practice (4th ed.) New Jersey: Pearson

Marriner-Tomey, A. (1994). Nursing Theorists and Their Work (2nd edition). St. Louis: Mosby

Octaviano, Eufemia F. and Balita, Carlito E. Theoretical Foundations of Nursing: The Philippine Perspective. Ultimate Learning Series, 2008

CONTRIBUTORS

Reyes, Jose Richard III

Ricana, Ryan

Rico, Ron Paulo

Rimas, Ma. Filipina

Rosales, Ava

“Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.”

Sunday, July 20, 2008 5:11 PM

A Close Encounter: Orlando's Dynamic Nurse-Patient Relationship

Monday, July 21, 2008 3:32 PM

"I can't move, I can't speak, I need help..."

An origami design is used to express Orlando-Pelletier’s Nursing Theory. The three large folds represents the three steps or processes of patient behavior, nurse reaction, and nurse action.

Subsequent smaller folds would include the assumptions associated with the theory. The finished object might resemble a silhouette of two people connected to one another, alluding to the ongoing nurse and client interaction required for deliberative care to effectively take place.

Understanding Ida Jean Orlando-Pelletier’s

Dynamic Nurse-Patient Relationship

Know the THEORIST

Ida Jean Orlando, a first-generation American of Italian descent was born in 1926. She received her nursing diploma from New York Medical College, Lower Fifth Avenue Hospital, School of Nursing, her BS in public health nursing from St. John's University, Brooklyn, NY, and her MA in mental health nursing from Teachers College, Columbia University, New York. Orlando was an Associate Professor at Yale School of Nursing where she was Director of the Graduate Program in Mental Health Psychiatric Nursing. While at Yale she was project investigator of a National Institute of Mental Health grant entitled: Integration of Mental Health Concepts in a Basic Nursing Curriculum. It was from this research that Orlando developed her theory which was published in her 1961 book, The Dynamic Nurse-Patient Relationship. She furthered the development of her theory when at McLean Hospital in Belmont, MA as Director of a Research Project: Two Systems of Nursing in a Psychiatric Hospital. The results of this research are contained in her 1972 book titled: The Discipline and Teaching of Nursing Processs. Orlando held various positions in the Boston area, was a board member of Harvard Community Health Plan, and served as both a national and international consultant. She is a frequent lecturer and conducted numerous seminars on nursing process. She is married to RobertPelletier and lives in the Boston area. She passed away on November 28 , 2007.

Distinguish the THEORY

Case Scenario

“Nurse, can you give me my morphine,” cried out Mrs. So. “Can you tell how painful it is using the 0 10 ‐pain scale, where 0 being not painful and 10 being severely painful?”replied the nurse. “Ummm... I think it’s about 7. Can I have my morphine now?” “Mrs. So, I think something is bothering you besides your pain. Am I correct?” Mrs. So cried and said, “I can’t help it. I’m so worried about my 3 boys. I’m not sure how they are or who’s been taking care of them. They’re still so young to be left alone. My husband is in Yemen right now and he won’t be back until next month.” “Why don’t we make a phone call to your house so you could check out on your boys?” Mrs. So phoned his sons. “Thank you nurse. I don’t think I still need that morphine. My boys are fine. Our neighbour, Mrs. Yee, she’s watching over my boys right now.”

The focus of Orlando’s paradigm hubs the context of a dynamic nurse-patient phenomenon constructively realized through highlighting the key concepts such as : Patient Behavior, Nurse Reaction , Nurse Action.

1. The nursing process is set in motion by the Patient Behavior. All patient behavior, verbal ( a patient’s use of language ) or non-verbal ( includes physiological symptoms, motor activity, and nonverbal communication) , no matter how insignificant, must be considered an expression of a need

for help and needs to be validated . If a patient’s behavior does not effectively assessed by the nurse then a major problem in giving care would rise leading to a nurse-patient relationship failure. Overtime . the more it is difficult to establish rapport to the patient once behavior is not determined. Communicating effectively is vital to achieve patient’s cooperation in achieving health.

Remember : When a patient has a need for help that cannot be resolved without the help of another, helplessness results

2. The Patient behavior stimulates a Nurse Reaction . In this part, the beginning of the nurse-patient relationship takes place. It is important to correctly evaluate the behavior of the patient using the nurse reactions steps to achieve positive feedback response from the patient. The steps are as follows:

The nurse perceives behavior through any of the senses -> The perception leads to automatic thought -> The thought produces an automatic feeling ->The nurse shares reactions with the patient to ascertain whether perceptions are accurate or inaccurate -> The nurse consciously deliberates about personal reactions and patient input in order to produce professional deliberative actions based on mindful assessment rather than automatic reactions.

Remember : Exploration with the patient helps validate the patient’s behavior.

3. Critically considering one or two ways in implementing Nurse Action. When providing care, nursing action can be done either automatic or deliberative.

Automatic reactions stem from nursing behaviors that are performed to satisfy a directive other than the patient’s need for help.

For example, the nurse who gives a sleeping pill to a patient every evening because it is ordered by the physician, without first discussing the need for the medication with the patient, is engaging in automatic, non-deliberative behavior. This is because the reason for giving the pill has more to do with following medical orders (automatically) than with the patient’s immediate expressed need for help.

Deliberative reaction is a “disciplined professional response” It can be argued that all nursing actions are meant to help the client and should be considered deliberative. However, correct identification of actions from the nurse’s assessment should be determined to achieve reciprocal help between nurse and patient’s health. The following criterias should be considered.

o

Deliberative actions result from the correct identification of patient needs by validation of the nurses’s reaction to patient behavior.

o

The nurse explores the meaning of the action with the patient and its relevance to meeting his need.

o

The nurse validates the action’s effectiveness immediately after compelling it.

o

The nurse is free of stimuli unrelated to the patient’s need (when action is taken).

Remember : for an action to have been truly deliberative, it must undergo reflective evaluation to determine if the action helped the client by addressing the need as determined by the nurse and the client in the immediate situation.

Learn more about the THEORY

METAPARADIGM CONCEPTS

Human/Person An individual in need. Unique individual behaving verbally or nonverbally. Assumption is that individuals are at times able to meet their own needs and at other times unable to do so.

Health Assumption is that being without emotional or physical discomfort and having a sense of well-being contribute to a healthy state. She further assumed that freedom from mental or physical discomfort and feelings of adequacy and well being contribute to health. she also noted that repeated experiences of having been helped undoubtedly culminate over periods of time in greater degrees of improvement

Environment Orlando assumes it as a nursing situation that occurs when there is a nurse-patient contact and that both nurse and patient perceive, think, feel and act in the immediate situation. any aspect of the environment, even though

its designed for therapeutic and helpful purposes, can cause the patient to become distressed. She stressed out that when a nurse observes a patient behavior, it should be perceived as a signal of distress.

Nursing A distinct profession "Providing direct assistance to individuals in whatever setting they are found for he purpose of avoiding, relieving, diminishing, or curing the individual's sense of helplessness" (Orlando, 1972, p. 22). Professional nursing is conceptualized as finding out and meeting the client’s immediate need for help.

Cite the Applications of the THEORY

In Nursing Research

1. In a Veterans Administration (VA) ambulatory psychiatric practice in Providence, RI Shea, McBride, Gavin, and Bauer (1987) used Orlando’s theoretical model with patients having a bipolar disorder.Their research results indicate that there were: higher patient retention, reduction of emergency services, decreased hospital stay, and increased satisfaction. They recommended its use throughout the VA system.Currently Orlando’s model is being used in a multi-million dollar research study of patients with a bipolar disorder at 12 sites in the VA system (McBride, Telephone interview, July, 2000). McBride and colleagues continue its use in practice and research at the Veteran Administration Hospital in Providence, RI.

2. In a pilot study, Potter and Bockenhauer (2000) found positive results after implementing Orlando’s theory. These included:positive, patient-centered outcomes, a model for staff to use to approach patients, and a decrease in patient’s immediate distress. The study provides variable measurements that might be used in other research studies.

in Nursing Education

1. Orlando's theory has a continuing influence on nursing education. Through e-mail communication it was found that the Midwestern State University in Wichita Falls, Texas, is using Orlando's theory for teaching entering nursing students. According to Greene (e-mail communication, June, 2000) she became aware, when taking a doctoral course about nursing theories, that it was Orlando theory used by its school.

2. Through networking the author found that for over 10 years South Dakota State University in Brookings, SD has been using Haggerty’s (1985) description of the communication based on Orlando’s theory for entering nursing students as well as re-enforcing it in their junior year (e-mail communication, (J. Fjelland, June, 2000). Joyce Fjelland, MS, RN. After working with Schmieding at Boston City Hospital, Lois Haggerty used Orlando’s theory in her teaching of students and in conducting a research study of students’ responses to distressed patients at BostonCollege in Chestnut Hill, Massachusetts.

in Nursing Practice

From an ICU nurse: “Patients have an initial ability to communicate their need for help”. Consider a case of an immediate post Coronary Artery Bypass Graft (CABG) patient. Once relieved from the effects of anesthetic sedation, though intubated, you would realize his excruciating retort from the sternotomy incisional pain through implicit cues. Morphine Sulfate 1 to 2 mg To be given via slow IV push every 1 to 2 hours or Ketorolac 15 mg IV every 6 hours is the typical pro re nata (PRN) order of a cardiac intensivist to relieve the client from pain. Automatic response of a nurse is to calm the client and encourage relaxation through deep breathing while splinting the chest with a pillow. Being Deliberate in your actions include knowing the pharmacokinetics of an ordered drug in relation to the client’s physiologic standing. If the creatinine level were elevated, would you administer ketorolac? If the client is on respiratory precaution, would you administer Morphine? You would ask yourself, what other alternatives do I have to ease my client from pain? “The client’s behavior is meaningful”. If such “need” would be fittingly dealt with, the intervention is thriving. “When patient’s needs are not met, they become distressed.”

Analyze the THEORY

Case Study

A relative of a patient at the emergency room went to the nurse’s station and began complaining in a loud shouting voice that their patient being a charity case is not being given the same quality of care as that of the other patients who are under private consultants. He claimed that their patient who was hyperventilating and was complanining of difficulty of breathing due to neurocirculatory astheinia was just forced to sit in the cubicle, while the rich-looking patient was a gomey.

Question

How will you handle this kind of situation and avoid conflict? How can Orlando’s dynamic nurse-patient interaction theory be utilized in this type of situation?

This Group Blog is Submitted to Ms. Sheila Bonito, FIC,

in Partial Fulfillment of the Requirements in N207.

Manager: Aux Lizares

Editor: Maria Mae Juanich

Contributors:

Katrina Anne Limos

Ginno Paulo Maglaya

Diana Jasmin Lee

Acknowledgment

We would like to acknowledge the following people: Ma’am Shiela Bonito, for coming up with this group work which really challenged not only our knowledge, understanding and creativity but also our ability to stay connected despite the distance, Ms. Aux Lizares, for diligently sorting out the articles, Ms. Maria Mae Juanich, for organizing the articles into a working blog, and for Ms. Katrina Anne Limos, Mr.

Gino Paulo Maglaya, and Ms. Diana Jasmin Lee, for tirelessly contributing their thoughts, ideas, and resources. Without all of you, this blog would have never been possible. Thank you very much!!!

Dear classmates,

Let us learn together. Have we done justice to Ida J. Orlando in presenting her theory this way? We would like to invite you to share with us your thoughts, feelings, comments or reactions on our blog entitled, “Understanding Ida Jean Orlando-Pelletier’sDynamic Nurse-Patient Relationship.” Thank you for your participation!

Regards,

Group G

Reference:

Orlando, I. J. (1972). The discipline and teaching of nursing process: An evaluative study. New York: G. P. Putnam.

http://www.enursescribe.com/orlando.htm

George, J.B. (2002). Nursing Process Discipline: Ida Jean Orlando. In George, J.B. (Ed.). Nursing Theories: the Base for professional nursing practice (5th Ed.). Upper Saddle River, New Jersey: Prentice Hall, pp. 189-208.

Schmieding, N.J. (2002). Ida Jean Orlando (Pelletier): Nursing Process Theory. In Tomey, A.M., & Alligood, M.R.. Nurse theorists and their work (5th Ed.). St. Louis: Mosby, pp. 399-417.

http://www.uri.edu/nursing/schmieding/orlando/

Orlando, I.J. (1961). The dynamic nurse-patient relationship, function, process and principles. New York: G. P. Putnam.]

Haggerty, L.A. (1985). A theoretical model for developing students’ communication skills. Journal of Nursing Education, 24(7), 296-298.

Haggerty, L.A. (1987). An analysis of senior nursing students’ immediate responses to distressed patients.. Journal of Advanced Nursing, 12, 451-461.

Nancy M. Shea, Linda McBride, Christopher Gavin, and Mark Bauer

Bauer, M. S. (2001). The collaborative practice model for bipolar disorder-Design and implementation in a multisite randomized controlled trial. Bipolar Disorders 3(5), 233-244. Bauer, M.S., & McBride, L.(2002). Structured group psychotherapy for bipolar disorder (2nd Ed). New York: Springer Publishing Co. Shea, N. M., McBride, L. Gavin, C., & Bauer, M. (1997). The effects of ambulatory collaboration practice model on process and outcome of care for bipolar disorder. Journal of the American Psychiatric Nurses Association 3(2), 49-57. Mertie. L. Potter, ND, ARNP, CS and Barbara Jo Bockenhauer, MS, RNC

Potter, M.L. & Bockenhauer, B.J. (2000). Implementing Orlando’s nursing process theory: A pilot study. Journa

l of Psychosocial Nursing nd Mental Health Services, 38(3), 14-21

DULCIUS EX ASPERIS--(sweetness after difficulties)

Saturday, July 19, 2008 5:46 PM

‘Use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet — all at the least expense of vital power to the patient.’

Florence Nightingale--Notes on Nursing (1860)

The Lady with the Lamp and the Nursing Profession

The Nursing profession—a science and an art practiced by both man and women—Tiring, arduous, demanding, tough, eye-bag forming, yet fulfilling, a vocation of honor and dignity entwined with humility.

When??...

It was in mid 1800’s with the leadership of Florence Nightingale that organized nursing started. Before her era, nursing care was done by paupers and drunkards: persons unfit for any type of work. Hospitals were placed where the poor frequently suffered more from the environment than from the disease that brought them there.

‘No man, not even a doctor, ever gives any other definition of what a nurse should be than this — 'devoted and obedient'. This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman.’

Nightingale’s efforts to uplift the nursing profession were indeed admirable. At that time, nursing was viewed as a kind of work that requires menial tasks or routinely actions but Nightingale saw it as a vocation aided by proper use of assessment and empowered by skills, knowledge and attitude acquired from proper schooling. In her book, she takes limelight away from the Physicians, and places it on the nurses.

Notes on Nursing—What It is and What It is not

Her most frequently cited work, Notes on Nursing, was written not as a nursing text but to “give hints for thoughts of women who have personal charge of the health of others.”

Nightingale’s notes on nursing covers all the basic necessities of human lives. It explains how to deal with sick people which can be applied not just to simple cough, colds and flues but to all types of human illnesses. And yes if one can read between the lines (as we always do), the book offers tips on how to survive a hospital experience.

Nightingale’s environmental model has always been applied in the hospital setting. One setting would include the care of our patients in the Intensive Care Unit wherein all chapters of the book can be applied—ventilation and warming, noise management, observation of the sick etc. And even if we are not in the hospital setting whether we are just in our office or at home, Nightingale’s vision of nursing is always present. We can even relate it to a song by Chris Brown and Jordin Sparks entitled No Air… and the lyric goes like this

“Tell me how I’m supposed to breathe with no air? Can’t live, can’t breath with no air That’s how I feel whenever ain’t there There’s no air, no air”

See? Nightingales contribution is so wide that the realization of her vision is not only limited to us nurses. And with that, her vision should inspire, motivate and direct every interaction we make and every intervention we do to be able to provide a wholistic nursing care to our patients and help them in their need for identifying their health concerns without them telling us what we can do for them but doing it automatically.

………………

Although Nightingale’s book was more of a lecture, a sermon, or even a plea put into writing, she backed up her concepts with well researched studies to prove her points.

She is also a skilled statistician- used statistics to present her case for hospital reform. According to Cohen, “the idea of using statistics for such a purpose- to analyze social conditions and the effectiveness of public policy- is common place today, but at that time it was not” (Marie L. Lobo: NURSING THEORIES; The Base for Professional Nursing Practice; Fourth Edition; 1995)

The notes on nursing by Nightingale repeatedly emphasize on its aim to empower women to take control of the care not only the sick but also the healthy members of the family especially the children. We understand that this highlight is because the children are ought to be the foundation of the future. She used statistics to support her claims. These lines are lifted from the first pages of Notes on Nursing to show how extensive Nightingale’s research is for her to come up with such data; “--- do you know that in every seven infants in this civilized land of England perishes before it is one year old? That in London, two in every five die before they are five years old? And, in the other great cities of England, nearly one out of two?----More than 25,000 children die every year in London under 10 years of age” These are just some but they prove that Nightingale’s craft is based on thorough research and statistics.

Basing on today’s world, though advance techniques are being used in the nursing profession, still Nightingales thoughts are being applied. In a hospital in Dubai where one of our groupmates work (Ms. Elvie Abanico), still-life paintings are displayed in the patient’s room and nurses look at how long tentatively patients will stay in the hospital, the longer they stay the nurses will plan to give a room with a view—where flowers and tress can be seen from the patients window since basing on research variety of colors and pictures can help to make a patient feel well. As supported by Nightingales Notes on Nursing variety section page 44: "Variety of form and brilliancy of colors in objects presented to patients are actual means of recovery and that "Variety is just like food for a starving stomach, just like a sick patient who wants to see a variety, just like a starving eye”.

Indeed, one could simply say that Florence Nightingale is Nursing and Nursing is Florence Nightingale. So would it not be sensible if we also try to looked at her well-known work—‘Notes in Nursing’, in a whole new perspective that goes beyond the scope of Nursing?

No Place for a Woman: The Femme Fatal

During Nightingales time, women are considered second class in short they have no right to assert something—near helpless with lethargic lifestyle—a life of thoughtless comfort for the world of social service. During her time, she encountered a lot of problem just because she is a woman. Though she took part on influencing the decisions of the War Department by providing information to Sir Sidney Herbert by giving any of the position papers and reports, because of the position of women in Victorian England, she was not permitted to submit her findings under her own name.

(-Marie L. Lobo: NURSING THEORIES; The Base for Professional Nursing Practice; Fourth Edition; 1995)

In her book entitled Cassandra, she wrote:

“Women are never supposed to have any occupation of sufficient importance not to be interrupted, except ‘suckling their fools’; and women themselves have accepted this”

The above quote shows the displeasure of Nightingale on how women of her times accepted their roles at the society without even exerting an effort to show what they are capable of. In fact, she stated that there were even books written on the acceptance of role that women play in the society then. But Nightingale never conformed to the society nor did she accept. In fact, her writings as well as actions

showed her firm disagreement with how society regarded women. So Nightingale was also one of great women in history who did her part to lobby for the rights of women.

Nightingale had a strong conviction that woman have the mental capacities to achieve whatever they wish to achieve. Out of this conviction came her resolve and action to establish nursing as a profession wherein women could develop the intellectual abilities to contribute meaningful service to society.

With her book—Notes on Nursing, a glimpse of feminism can be seen since the book empowers women to have personal charge of the health of others though it does not teach them how, but it asks women to teach herself. Thanks to Florence Nightingale, women now realize that they must gain control over their own time in order to change the social and political structures over their lives—it can be observed that majority of the nurses of today are women living what Florence Nightingale had stated in her book though it is a fact that men also share her vision of what nursing is.

Voluminous texts were written on Florence Nightingale and her contribution to the Nursing profession. What many nurses fail to realize is that she did more than just that. We hope our little blog could help them see and appreciate another aspect of her life and her contributions not just to nursing, but to the world.

“Nurses we are love serves—this is the essence of nursing. For what ever reason we pursue this course, regardless of where we practice it, the essence of nursing should be internalized…”

Jordin Sparks duet with Chris Brown - No Air

SISTER CALLISTA ROY: ADAPTATION THEORY

Saturday, July 19, 2008 5:08 PM

“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. Adapting the course to be congruent with the Roy model,

2. Developing teaching tools suitable for student learning.

3. Sequencing of content for student learning

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.

GROUP D

Cortez, Joyzen

Cutay, Rose Ann

Cristobal, Maureen

De Jesus, David

Daniel, Jane

Dayao, Genevieve

Thank you for your contributions.

Group K:Transcultural Nursing...... a bridge to reach clients globally

Saturday, July 19, 2008 11:07 AM

Transcultural Nursing...... A bridge to reach clients globally

Madeleine M. Leininger

PhD, LHD, DS, CTN, RN, FAAN, FRCNA

Madeline Leininger was a pioneer nurse anthropologist. Appointed dean of the University of Washington, School of Nursing in 1969, she remained in that position until 1974. Her appointment followed a trip to New Guinea in the 1960’s that opened her eyes to the need for nurses to understand their patients’ culture and background in order to provide care. She is considered by some to be the "Margaret Mead of nursing" and is recognized worldwide as the founder of transcultural nursing, a program that she created at the School in 1974. She has written or edited 27 books and founded the Journal of Transcultural Nursing to support the research of the Transcultural Nursing Society, which she started in 1974.

Every human race has his/her different beliefs and culture may it be taught and passed on from one generation to the other. Even if we have the same language or dialect spoken we all have different

culture and beliefs being followed as one of the norms in our society. And a part of our culture was our health beliefs and practices. In our group we categorize some of the health beliefs and practices into different age group based on experiences and research. This will give us awareness on how we could be able to render effective care to our clients, with certain age and background.

PRESCHOOL AND SCHOOL AGE

An ethnographic study of Latino pre-school children’s oral health in rural California revealed that, Latino children experienced a higher prevalence of caries than do children in any other racial groups in the U.S. The study conducted in 2005 focus on both recent immigrants and longer term residents of a small agricultural town in the central valley of California. Around 95% of the population of approximately 9,000 is of Latino largely Mexican origin.

Rural immigrant parents tend not to recognize dental caries in their children as a disease, but rather classified as visible discoloration on teeth and tend not to seek help unless this were accompanied with swelling and pain. Because tooth decay is viewed as a stain, when treatment is sought, parents often requested and expected cleaning. The high cost of restorative work therefore, is a surprise.

The mothers were educated by health care workers about baby bottle decay but claimed that the problem is the bottle nipple and not the sweet fluid content of the bottle. Many mothers claimed that as adults they never had a dental treatment nor dental caries when young and now their children have dental caries and they are unsure how to prevent it.

Migrant parent also reported major changes in diet since moving to the U.S., and also commented on how different their children’s diet is from their own when growing up. Major differences between their diets were the high consumption of sugar, sodas, and less access to fresh fruits and vegetable. Parents did not specifically associate these broad dietary changes with their children’s problems although they did connect the consumption of sweet substances with the subsequent advent of dental caries. Collectively all these understanding and actions on the part of care givers sets up Latino children for high rates of unrecognized and untreated oral disease.

ADOLESCENT

As depicted in Leininger’s Sunrise model culture, worldview, and social structure influences the individual’s care behaviors and beliefs which in turn affects their health and illness status. The nurse needs to clearly understand universal and specific cultural views of adolescents and clarify values in order to promote wellness in a culturally acceptable manner.

One of the most pressing problems of adolescence in many societies is engaging in risky sexual behaviors at an early age. In some societies, adolescent participation in risky sexual behaviours are treated as a measure of ‘manhood’, a sense of ‘belongingness’, a sign of ‘friendship’. The nurse through applying transcultural care concepts of Leininger should bear in mind these problems and study the deeply rooted societal and cultural origins of these.

Cultural beliefs and practices leading to risky sexual behavior do not only lead to this specific problem but to a myriad of problems related to such health practice including teenage pregnancy, sexually transmitted diseases, poor maternal and child health, etc. The nurse in these situations should devise a strategy in teaching adolescents about the effects of risky sexual behavior and actions to curb such incidents in ways that are meaningful to them.

There are a lot of universal and culture-specific issues concerning adolescents today. It is very important for a nurse applying transcultural care concepts to be sensitive not just to cultural and social background but also to the adolescent’s developmental issues and concerns.

Being an adolescent is indeed a big transition in our lives from an adventurous kid to a growing up girl/boy. We experience a lot of challenges like peer pressure and a lot of changes in our body. One of the things as an adolescent is when I have my menarche my mother asked me to jump in the stairs 3 times ,a part of our family’s culture I guess which I find very amusing.

As adolescents, we are expected to mingle with other person with the same age but some of us have a different upbringing so some tend not to "go with the flow" wherein others tend to be depressed and commit irrational behavior like suicide. Some committed suicide because of family problems, school, and failed relationships. Aside from personal and social challenges an adolescent faces, he/she also learn a lot of new things like drinking alcohol and smoking but it depends on how he/she will handle this, the parent's guidance will be of important issue here. Because not only this will affect personal relationships but also their health is at risk. I have this patient, 17 year old male who seek treatment in the emergency room who attempted to commit suicide by drinking sleeping pills because of a failed relationship with his girlfriend. As nurses we should understand them what they are experiencing now. We should treat them with empathy. Our responsibility is teaching them the importance of life and health. We should understand them because they behave differently depends on their family values, personal experiences and beliefs.

ADULTHOOD

A common theory is that adulthood is the real test of life, to experience the world from a first-person standpoint instead of through the parents. Then the adult can pass those experiences down to younger people and they can experience them when they become adults. In this stage, there are noticeable changes in how adults view on their careers / finances and Marriage/ family. Most of these adult live their life in a fast pace. As a nurse I encounter clients who are an American businessman who is an

occasionally smoker and drinker for annual physical check up. Despite admitted in the hospital he’s still focusing his attention on his work rather than his health. He’s the breadwinner of the family. He has 4 kids studying in a private school and his wife works as a cashier in a grocery store I didn’t stopped him in doing his work but when laboratory test and physical assessment will be given to him I just told him to stop for a while and cooperate. I oriented him the importance of annual check-up and having a healthy lifestyle.

Another situation experienced among expectant mothers in Filipino-Chinese women they consult a Chinese conception calendar because some would like to have their first born to be a boy. An experience of one of our groupmates also told us when she was caring for a Filipino-Chinese woman who had been admitted to their floor. She asked her to contact her obstetrician because she have to give birth before lunch even if she’s not in active labor, as one of the many beliefs that Chinese have about labor and delivery. She was quite surprised by her request but she found out that it was just one of the many beliefs that the Chinese have about labor and delivery. She was brought to the delivery room before 10 am.

Some would like their first born to be a boy, others say that they consult a Chinese conception calendar for this. The calendar is supposed to predict whether you will have a girl or boy. Personally she was able to consult this when she was pregnant with my first born, the sex of my baby was accurately predicted.

OLDER ADULTHOOD/ GERIATRIC

The theory of Leininger paved its way in the study of human culture. Culture of an individual shapes ones view of aging. Which explains that older adult is also a heterogeneous group of people. With the increasing population of baby boomers, nurses should expand their roles in the care of individual or group of older adults not only in the hospital but in the community as well. As you read the succeeding text of my blog, I hope this will make you understand why older adults behave the way they do and how nurses should deliver personalized care.

Among older adults, one of us had been able to care for a 70 y/o white American client who was due for a cataract extraction. She oriented the client with the physical set-up and hospital policy. Her wife visited her and left after 2 hours. The client told me that in the United States visitors do not stay for a long time on the patient’s room in which he is fine with it. Looking at this patient we will notice that as long as they can do things by themselves they won’t bother in asking for assistance. In this situation older people experience a feeling of fulfillment if they can have a sense of control even with alteration in health condition.

Another adult patient she had was a 69 y/o who is due for CABG, three days prior to operation he was already admitted in the hospital to undergo clearance before he undergo surgery. She oriented him with the physical setup and rules. She discussed to the client visiting hours and number of visitors and companionallowed. He asked if he could have some considerations because he is expecting a lot of relatives. The request was granted. In this scenario as nurses we act as advocate of our clients, though there are rules to follow sometimes we will have to bend some as long as we are not bypassing any authority. We should know how to assert ourselves in behalf of our patients. Her Filipino client was used

to that culture wherein there is strong family ties especially in times of health illness the presence provides comfort and security being the head of the family.

REFERENCES:

Isaacs B. An introduction to geriatrics. London: Balliere, Tindall and Cassell, 1965

Geiger, J.N. & Davidhizar, R.E. (1991). Transcultural nursing: assessment in intervention. St. Louis: Mosby-Year Book.

Leininger, M. (1991). Transcultural nursing: the study and practice field. Imprint, 38(2), 55-66.

Merck $ Co. The Merck Manual of Geriatrics.1995-2007 Merck & Co., Inc., Whitehouse Station, NJ, USA

www.baby-talk.co.uk/chinese_calendar.htm

http://www.tcns.org/

Andrews,M. and Boyle,J. "Competence in Transcultural Nursing Care" The American Journal of Nursing vol 97 no.8 august 1997.pp16AAA,16BBB,16DDD,Lippincott Williams and Wilkins

Silvestri,L. (2006). Saunders Comprehensive Review for the NCLEX-RN Examination. 3rd Edition. Singapore :Elsevier.

Añonuevo,C.et al(2000).Theoretical Foundations of Nursing.Philippines:UP Open University.

Group members: Cherry Sagge, Marlon Salazar, Michael San Juan, Jay Ar Santiguel, Laarni Sarad, Marie Jam Separa, Clarisse Elise Sintor, Ma. Cristina Setubal, Elsie Santiago

Health Promotion Model: Heuristic Device for Health Care Professionals

Friday, July 18, 2008 6:11 PM

Ourselves, our body, our health….. enhancing self usage towards prevention of illnesses & promoting well-being.

Nora J. Pender developed the Health Promotion Model that is proposed as a holistic predictive model of health-promoting behavior for use in research and practice. She is Professor Emeritus in the School of Nursing at the University of Michigan, and an advocate of health promotion.

“I committed myself to the proactive stance of health promotion and disease prevention with the conviction that it is much better to experience exuberant well-being and prevent disease than let disease happen when it is avoidable and then try and cope with it.”

Nola J. Pender, PhD, RN, FAAN

Health Promotion Model has given health care a new direction. According to her, Health Promotion and Disease Prevention should be the primary focus in health care, and when health promotion and prevention fail to prevent problems, and then care in illness becomes the next priority. She defined 2 concepts: health promotion & health protection.

Health promotion is defined as behavior motivated by the desire to increase well-being and actualize human health potential. It is an approach to wellness. On the other hand, health protection or illness prevention is described as behavior motivated desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness. (Kozier, 2004)

Figure 1 – Health Promotion Model

This model (Figure 1) is moving towards understanding multi-faceted nature of persons correlating with their interpersonal nature and interacting with their interpersonal & physical environments as they trail towards health.

Because of the model, nurses have already advanced their health approaches, addressing not only the curative side, but as well as prevention of diseases & promotion of well-being. Application of this theory is varied and substantive on its own.

Applications

Nursing Practice

“We are moving toward an era of science-based practice in nursing that incorporates the latest findings from the behavioral and biological sciences into practice to assist people of varying cultural backgrounds to adopt healthy lifestyles.” – Pender

As what they say, prevention is better than cure. Thus, health promotion is valued much. But how? Question seems hard…hard as if you don’t know how to solve the problems of the world…But how, again? If super heroes could save life using their super powers, we nurses could do more by using our caring touch, and therapeutic talks. Health teachings are always part of nurses’ experience in the workplace. Despite of various clinical & community health care settings, we nurses are always interacting with our patient/client.

Community health care setting is the best avenue in promoting health & preventing illnesses. Using Pender’s Health Promotion Model, community program may be focused on activities that can improve the well-being of the people. Health promotion and disease prevention can more easily be carried out in the community, as compared to programs that aim to cure disease conditions. This is because the people in the rural area tend to veer away from modern medical methods. Most of them, due to financial reasons, choose to avail of the services offered by “herbolarios” and other folk healers. In our local setting, promoting health to our fellow Filipinos is very crucial. Though, there are campaigns provided by our government’s health agency, which is the Department of Health (DOH), there’s still a big percentage in the population who live unhealthily and many are suffering from different type of diseases.

Nurses, though are scattered in different fields, have common primary concern: to promote health to every individual. The following are just examples of methods on how to promote health to our fellows.

Insight from an Academe nurse teaching CHN… A group of students taught the families the value of eating a balanced diet. They introduced the concept of including the different food groups in all their

meals. They also stressed the benefits and advantages of the various vitamins and minerals found in those food. Another group encouraged the community to practice lifestyle modification. They discussed the disadvantages of vices such as smoking and drinking alcoholic beverages. For disease prevention and health protection, one group tried to inculcate the importance of early detection of illnesses. They taught the women the proper way and timing of self-breast examination. The mothers were also encouraged to avail of the vaccination services offered by the nearby health center. These programs proved to be very beneficial to the community. Because one can truly build a healthier tomorrow through good community health practice.

Insight from an ICU nurse… Although most patients admitted in the ICU are experiencing health problems, Health Promotion Model may still be applied in one way or another. This is projected towards improving health condition and prevention of further debilitating conditions. Diet modifications and performing passive & active range of motion exercises are examples of its application.

Nursing Education

“I believe that the future will be very bright and productive for nurses who direct their careers toward understanding disease prevention and health promotion processes.” – Pender

Nurses are expected to be adaptive. Indeed, changes are always constant. In health care settings, patients come & go. Meet & greet. Recover or expire. As this theory advocated, we should not allow our patients to experience severe conditions if we could only prevent them from encountering such. We are expected to know, if not in depth, the disease processes. Because of this know-how, we could apply health promotion and worsening prevention before the hands of the clock stop moving.

Percentage of nurses is geared towards continuing professional education. Attending seminars & conventions. Enrolling to masteral & doctoral classes. All are goaled towards becoming competent nurses. Nursing education is not a one-phase process. It does not end after passing the licensing exam. It is continuous. Unending. Ever changing. We must be abreast with new technologies, new approaches,

and new techniques. Because of this theory, we nurses could address more the needs and problems of the client before it progresses to exacerbation. This model could be a basis for structuring nursing protocols and interventions.

Nursing Research

“I was committed to health promotion and encouraged other scholars to move in that direction long before health promotion and risk reduction became popular.” - Pender

Research help Health Care provider to develop a systematic problem-solving approach to improve and develop strategies to promote good health to individuals. Through research we will be able to clarify and verify the phenomenon.

Evidenced-based practice is fast emerging because of its factual and substantive results. These researches yield fruitful outcome that of great help in addressing arising problems and in setting nursing protocols. Much more research must be done to tailor interventions to individuals rather than to group stereotypes.

If we could remember, common research topics in our nursing college days are health promotion techniques and disease prevention. To name a few, some geared their research on effectiveness of Expanded Program on Immunization, others on health practices of mothers and families, some on efficiency of early detection of common illnesses. These are all but few of the model’s application to research.

Of all the theories presented in the module, Health Promotion Model is the easiest of them, yet substantive & useful. In our day-to-day experiences as nurses, we are always promoting health, preventing illnesses, and upholding well-being. We are seen by the public as health advocates. We have knowledge on health & illnesses, thus, we are expected to share this to laymen and contribute to their well-being. As what Pender said, “We cannot continue to let people become ill when we have the means

to keep many people well--particularly when problems are environmentally and behaviorally induced”. Thus, the theory of Pender on Health Promotion is indeed a great to advocate to prolong and preserve life. This theory really manifests the noble work of a NURSE. Remember, nurses we are LOVE SERVES.

JEAN WATSON'S THEORY OF HUMAN CARING

Friday, July 18, 2008 11:03 AM

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References:

George, J. (1990). Nursing Theories: The Base for Professional Nursing Practice; 4th Edition. London: Prentice-Hall International, Inc. p. 317.

McEwen, M. & Wills, E. (2007). Theoretical Basis for Nursing; 2nd Edition. Philadelphia, USA: Lippincott Williams & Wilkins. p. 191.

Tomey, A.M. & Alligood, M. (2002). Nursing Theorists and their Work; 5th Edition. Singapore: Mosby, Inc. p. 145.

Tomey, A.M. & Alligood, M. (2006). Nursing Theory Utilization and Application; 3rd Edition. Missouri, USA: Mosby, Inc. p. 103

Watson, J. (1985). Nursing: Human Science and Human Care. Connecticut, USA: Appleton-Century-Crofts.

http://www2.uchsc.edu/son/caring/content/evolution.asp

CONTRIBUTORS:

MARIABELEN QUIZON

ARIANE PANGANIBAN

ALLAN PECSON

CHARMAINE PECSON

JUDY PEDALIZO

LAARNI PICZON

Thank you for taking time in reading our blog. We hope you learned something from it. Have a nice day. Take care!!! :)