Theories, Conceptual Models and Concepts applied to Community Health Nursing.

1. Theories, Conceptual Models and Concepts applied to Community Health Nursing. By Nataliya Haliyash, MD, BSN TSMU, International Nursing School

2. By the end of this lecture you will be able to: • Explain what is meant by a theory and a model of nursing • Discuss the main features of at least two theories of nursing: • Orem’s Theory • Roper, Logan & Tierney • Callister Roy’s model • Characterize the conceptual models: • the Omaha System, • Neuman System Model

3. Theory…… “…is a general statement that summarizes and organizes knowledge by proposing a general relationship between events - if it is a good one it will cover a large number of events and predict events that have not yet occurred or been observed”Robson C.

4. Theories that Define Nursing or Discuss Nursing in a General Sense (Philosophies) • Florence Nightingale • Virginia Henderson • Ernestine Wiedenbach

5. Theories about Broad Nursing Practice Areas: Grand Theories • Myra Estrin Levine's Conservation Model • Betty Neuman's Systems Model • Sister Callista Roy's Adaptation Model • Dorthea Orem's Self-Care Model

6. Theories about Specific Nursing Actions, Processes, or Concepts: Middle-Range Theories • Katharine Kolcaba's Theory of Comfort • Sister Callista Roy's Adaptation Model • Nola Pender's Health-Promotion Model • Hildegard Peplau's Interpersonal Relations in Nursing

7. Theories that Defy Classification • Martha Rogers's Unitary Human Beings • Margaret Newman's Health as Expanding Consciousness

8. A conceptual model… • is the synthesis of a set of concepts and the statements that integrate those concepts into a whole.

9. Theory of Nursing Systems = Orem’s Theory • This is the unifying theory that “subsumes the theory of self-care deficit which subsumes the theory of self-care” (Orem, 1991, p. 66). • The Theory of Nursing Systems attempts to answer the question “What do nurses do?”

10. Dorothea Elizabeth Orem • Dorothea Elizabeth Orem (1914 – June 22, 2007), born in Baltimore, Maryland, was a nursing theorist and founder of the Orem model of nursing, or Self Care Deficit Nursing Theory. • In simplest terms, this theory states that nurses have to supply care when the patients cannot provide care to themselves. • Her Theory is about self-care. It's all about the capacity to recover themselves with a little help of Nurses

11. The nurse determines whether or not there is a legitimate need for nursing care. Is a person able to meet self-care needs? Does a deficit exist? If a deficit exists, then the nurse plans care that identifies what is to be done by whom: the nurse, the client, or other (family or significant other). • Collectively, the actions of all these people are called the nursing system.

12. Orem’s Theory • Orem identified three types of nursing systems: • wholly compensatory, • partly compensatory, and • supportive-educative.

13. Orem’s Theory: compensatory nursing system • In the wholly compensatory nursing system, the nurse supports and protects the client, compensates for the client’s inability to care for self, and attempts to provide care for the client. The nurse would use the wholly compensatory nursing system when caring for a newborn or with a client in a postanesthesia care unit who is recovering from surgery. Both of these clients are completely unable to provide self-care.

14. Orem’s Theory: the partly compensatory nursing system • In the partly compensatory nursing system, both the nurse and client perform care measures. For example, the nurse can assist the postoperative client to ambulate. The nurse may bring in a meal tray for the client who is able to feed self. The nurse compensates for what the client cannot do. The client is able to perform selected self-care activities but also accepts care performed by the nurse for needs the client is unable to meet independently.

15. Orem’s Theory: the supportive-educative nursing system • In the supportive-educative nursing system, the nurse’s actions are to help clients develop their own self-care abilities through knowledge, support, and encouragement. Clients must learn and perform their own self-care activities. The supportive-educative nursing system is being used when a nurse guides a new mother to breastfeed her baby.

16. Interpretation of Orem’s theory through Mandala art • Amy Devis, student

17. Interpretation of Orem’s theory through Mandala art • Self care: The flag design represents independence. People are independent when they do what they can to maintain life, health, and well-being. • Self-care deficit: The handicap symbol, made into a compass, symbolizes dependency of the patient coupled with the guidance, direction, and support of the nurse. • Nursing systems: Represented by the fish and hook because it reminds me of the saying: "Give a man a fish, feed him for a day. Teach a man to fish, feed him for a lifetime." The nurse compensates for what the patient cannot do for himself while teaching how to care for himself. • Nursing Process: All the symbols are encompassed in a larger symbol- an apothecary symbol. This symbol represents diagnosis and prescription, determining why nursing care is needed.

18. Dorthea Orem's Self-Care Model

19. Nursing systems • Nursing systems is conceptualized as the providers, resources, structures, methods and processes essential for the efficient and effective delivery of nursing care to aggregates of individuals. • The concentration is directed toward preparing nurse scientists with expertise in • (1) evaluating theoretical and empirical knowledge about inter-and intra-organizational phenomena relevant to the delivery of nursing care; • (2) developing and validating new theoretical constructs and models that explain nursing phenomena from a systems perspective.

20. Neuman's systems model… • is based on the individual's relationship to stress, the reaction to it, and reconstitution factors that are dynamic in nature. • is a unique, open systems-based perspective that provides a unifying focus for approaching a wide range of international health concerns. • Being universal in nature, it is open to creative interpretation and is widely used throughout the world as a multidisciplinary, wholistic, and comprehensive guide for excellence in nursing practice, education, research, and administration.

21. Betty Neuman is a community health nurse and clinical psychologist who has developed this theory. Betty M. Neuman, R.N., B.S.N., M.S., Ph.D., PLC., FAAN Betty Neuman

22. Neuman's systems model… • The Neuman Systems Model was originally developed in 1970 at the University of California • The model was developed by Dr. Neuman as a way to teach an introductory nursing course to nursing students. • The goal of the model was to provide a wholistic overview of the physiological, psychological, sociocultural, and developmental aspects of human beings.

23. Neuman's systems model… • The model's basic central core consists of • energy resources (normal temperature range, genetic structure, response pattern, organ strength or weakness, ego structure, and knowns or commonalities) • that are surrounded by • several lines of resistance, • the normal line of defense, and • the flexible line of defense.

24. Neuman's systems model… • The lines of resistance represent the internal factors that help the patient defend against a stressor • The normal line of defense represents the person's state of equilibrium • The flexible line of defense depicts the dynamic nature that can rapidly alter over a short period of time.

25. Betty Neuman’s Theory interpreted through Mandala Art • (Created by Amy, undergraduate nursing student Fall 2004)

26. Betty Neuman’s Theory interpreted through Mandala Art (cont) • The large circle in the center is the focal point and includes the symbol for Maslow's hierarchy of needs: Physiological, sociocultural, developmental, spiritual. The concentric circles around the center signify client (brown triangle with a circle on top), environment (blue clouds and yellow circle sunshine), health (red crosses), and nursing (pink hearts).

27. Student’s art

28. The Omaha System • The Omaha System is a research-based, comprehensive practice and documentation standardized classification; • it can be used by multidisciplinary health care practitioners in any setting from the time of client admission to discharge. • http://www.omahasystem.org/

29. The Omaha System • Consists of three relational, reliable, and valid components designed to be used together: • Problem Classification Scheme (client assessment) • Intervention Scheme (service delivery) • Problem Rating Scale for Outcomes (client change/evaluation)

30. The Omaha System • Is a research-based, comprehensive, standardized taxonomy. It is designed to enhance practice, documentation, and information management. It is intended for use with individuals, families, and communities who represent all ages, geographic locations, medical diagnoses, socio-economic ranges, spiritual beliefs, ethnicity, and cultural values. • Its terms are arranged from general to specific, and are intended to be easily understood by health care professionals and the general public. It provides a structure to document client needs and strengths, describe multidisciplinary practitioner interventions, and measure client outcomes in a simple and user-friendly, yet comprehensive, manner.

31. The Omaha System • It enables collection, aggregation, and analysis of clinical data. It supports quality improvement, critical thinking, and communication. It fosters research involving best practices/evidence-based practice. It links clinical data to demographic, financial, administrative, and staffing data. It is a middle range theory that supports other established health care theories. Examples include Donabedian’s structure, process, and outcome approach and the Neuman Systems Model. • It is a framework for integrating and sharing clinical data that has existed in the public domain since 1975.

32. The Omaha SystemProblem Classification Scheme Fourlevels. • Four domains appear at the first level and represent priority areas of practitioner and client health-related concerns. • Forty-two terms (concepts), referred to as client problems or areas of client needs and strengths, appear at the second level. • The third level consists of two sets of problem modifiers: health promotion, potential, and actual as well as individual, family, and community. • Clusters of signs and symptoms describe actual problems at the fourth level. The Problem Classification Scheme provides a structure, terms, and system of cues and clues to help practitioners collect, sort, document, classify, analyze, retrieve, and communicate client needs and strengths.

33. The Omaha SystemProblem Classification Scheme • Environmental Domain: Material resources and physical surroundings both inside and outside the living area, neighborhood, and broader community. • Income • Sanitation • Residence • Neighborhood/workplace safety

34. The Omaha SystemProblem Classification Scheme • Psychosocial Domain: Patterns of behavior, emotion, communication, relationships, and development. • Communication with community resourcesSocial contactRole changeInterpersonal relationshipSpiritualityGriefMental healthSexualityCaretaking/parentingNeglectAbuseGrowth and development

35. The Omaha SystemProblem Classification Scheme • Physiological Domain: Functions and processes that maintain life. • HearingVisionSpeech and languageOral healthCognitionPainConsciousnessSkinNeuro-musculo-skeletal functionRespirationCirculationDigestion-hydrationBowel functionUrinary functionReproductive functionPregnancyPostpartumCommunicable/infectious condition

36. The Omaha SystemProblem Classification Scheme • Health Related Behaviors Domain: Patterns of activity that maintain or promote wellness, promote recovery, and decrease the risk of disease. • NutritionSleep and rest patternsPhysical activityPersonal careSubstance useFamily planningHealth care supervisionMedication regimen

37. The Omaha SystemIntervention Scheme • It consists of three levels of professional actions or activities. • Four broad categories of interventions appear at the first level. • An alphabetical list of 75 targets or objects of action and one “other” appear at the second level. • Client-specific information generated by practitioners is at the third level. Because the Intervention Scheme is the basis for planning and intervening, it enables practitioners to describe and communicate their practice including improving or restoring health, decreasing deterioration, or preventing illness.

38. The Omaha SystemIntervention Scheme Categories: • Teaching, Guidance, and Counseling: Activities designed to provide information and materials, encourage action and responsibility for self-care and coping, and assist the individual/family/community to make decisions and solve problems. • Treatments and Procedures: Technical activities such as wound care, specimen collection, resistive exercises, and medication prescriptions that are designed to prevent, decrease, or alleviate signs and symptoms of the individual/family/community. • Case Management: Activities such as coordination, advocacy, and referral that facilitate service delivery, improve communication among health and human service providers, promote assertiveness, and guide the individual/family/community toward use of appropriate resources. • Surveillance: Activities such as detection, measurement, critical analysis, and monitoring intended to identify the individual/family/community’s status in relation to a given condition or phenomenon.

39. Targets: anatomy/physiologyanger managementbehavior modification bladder care bonding/attachment bowel care cardiac care caretaking/parenting skills cast care communicationcommunity outreach worker servicescontinuity of care coping skills day care/respitedietary management discipline dressing change/wound care durable medical equipment education employmentend-of-life care environment exercises family planning care feeding procedures finances gait traininggenetics growth/development care home homemaking/housekeeping infection precautions interaction The Omaha SystemIntervention Scheme

40. The Omaha SystemProblem Rating Scale for Outcomes • The Scale consists of three five-point, Likert-type scales for measuring the entire range of severity for the concepts of knowledge, behavior, and status.  Each of the sub scales is a continuum providing an evaluation framework for examining problem-specific client ratings at regular or predictable times.  Suggested times include admission, specific interim points, and discharge.  The ratings are a guide for the practitioner as client care is planned and provided; the ratings offer a method to monitor client progress throughout the period of service.  Using the Problem Rating Scale for Outcomes with the other two schemes of the Omaha System creates a comprehensive problem-solving model for practice, education, and research.

41. The Omaha SystemProblem Rating Scale for Outcomes http://www.omahasystem.org/shmrate.htm

42. Roy's Model Of Nursing • Sister Callista Roy developed the Adaptation Model in 1976. • Definition • Roy's model of nursing sees an individual as a set of interrelated systems, biological, psychological, and social. The individual tries to maintain a balance between each of these systems and the outside world. However, there is no absolute level of balance. According to Roy we all strive to live within a band where we can cope adequately. This band will be unique to an individual. The adaptation level is the range of adaptability within which the individual can deal effectively with new experiences.

43. Roy's Model Of Nursing • This model comprises the four domain concepts of • person, • health, • environment, and • nursing and involves a six step nursing process.

44. Roy's Model Of Nursing • Roy's models sees the person as "a biopsychosocial being in constant interaction with a changing environment" (Rambo, 1984). The person is an open, adaptive system who uses coping skills to deal with stressors. • Roy sees the environment as "all conditions, circumstances and influences that surround and affect the development and behaviour of the person" (Andrews & Roy, 1991). • Roy describes stressors as stimuli and uses the term 'residual stimuli' to describe those stressors whose influence on the person is not clear

45. Roy's Model Of Nursing • Roy employs a six-step nursing process which includes: • assessment of behaviour, • assessment of stimuli, • nursing diagnosis, • goal setting, • intervention and evaluation.

46. Roy's Model Of Nursing • In the first step, the person's behaviour in each of the four modes is observed. This behaviour is then compared with norms and is deemed either adaptive or ineffective. • The second step is concerned with factors that influence behaviour. Stimuli are classified as • focal, • contextual or • residual

47. Roy's Model Of Nursing • The nursing diagnosis is the statement of the ineffective behaviours along with the identification of the probable cause. • In the fourth step, goal setting is the focus. • Goals need to be realistic and attainable and are set in collaboration with the person (Andrews & Roy, 1991). • Intervention occurs as the fifth step, and this is when the stimuli are manipulated. It is also called the 'doing phase' (Rambo). • In the final stage, evaluation takes place. The degree of change as evidenced by change in behaviour, is determined. Ineffective behaviours would be reassessed, and the interventions would be revised

48. Sister Callista Roy's Adaptation Model • Mandala Representing Roy’s Adaptation Model • By Noreen Frodella BSN, RN, BC, Graduate student • http://nursing.jbpub.com/sitzman/artGallery.cfm

49. Sister Callista Roy's Adaptation Model • This Mandala, representing Roy’s Adaptation Model, was created to show the grouping of related/connected units which form a unified whole (environment/nature) and the adaptations that human beings undertake while living within an unpredictable natural environment. The “client/client system” is the central or focal point and is represented by the sun, the four modes of adaptation are represented by the four lightening bolts (representative of activity/energy and interaction needed to adapt), the four major concepts are represented by the clouds, the stars represent the nursing process, and the crescent moons represent the ten supporting scientific and philosophical concepts. • This Mandala utilizes symbols from nature to conceptualize Roy’s theory that focuses on human beings as an adaptive system; and as such must also adapt to the environment and the forces of nature. It reveals our continual interaction with environmental stimuli.

50. That’s All Falks