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THEORETICAL FOUNDATION (NCMA110) Coverage: − Her theory focuses nursing interventions on the patient well -being overall and o Martha Rogers...

THEORETICAL FOUNDATION (NCMA110) Coverage: − Her theory focuses nursing interventions on the patient well -being overall and o Martha Rogers not just their disease state o Dorothy Orem − It encourages the use of guided imagery, relaxation, therapeutic touch, and o Imogene King meditation. o Myra Estrin Levine Analysis of the theory o Betty Neuman Clarity o Dorothy Johnson − It is difficult-to-understand principles, lack of operational definitions, and o Sister Callista Roy inadequate tools for measurement. Model has passed the test of time for the o Anne Boykin and Savina O. Schoenhofer development of nursing science as nursing matured as a science o Afaf Ibrahim Meleis Simplicity o Nola J. Pender − when the model is examined in total perspective, some still classify it as complex. With its continued use in practice, research, and education, nurses will come to o Madeleine Leininger appreciate the model’s elegant simplicity o Margaret Newman Generality o Rosemarie Rizzo Parse − Rogers’ conceptual model is abstract and therefore generalizable and powerful. o Helen C. Erickson, Evelyn M. Tomlin, Mary Ann P. Swain It is broad in scope, providing a framework for the development of nursing o Ramona Mercer knowledge through the generation of grand and middle-range theories o Merle Mishel Importance o Pamela Reed − Rogers’ science has the fundamental intent of understanding human evolution o Carolyn Wiener & Marylin Dodd and its potential for human betterment. The science “coordinates a universe of open systems to identify the focus of a new paradigm and initiate nursing’s Martha Rogers identity as a science.” (Science of Unitary Human beings) Background Dorothy Orem Martha E. Rogers was born in 1914 in Dallas, Texas. (Self care deficit) She received her nursing diploma from the Knoxville General Hospital School of Background Nursing in 1936, then earned her Dorothea E. Orem (1914-2007), one of the prime US theorists born in Baltimore, Public Health Nursing degree from George Peabody College in Tennessee in Maryland 1937. She began her nursing career at Providence Hospital School of Nursing in Her Master’s degree was from Teachers College at Columbia University in 1945, Washington, DC, where she received a diploma of nursing in the early 1930s. and her Doctorate in Nursing was Obtain her basic diploma in nursing at School of Nursing Washington, BSN earned from Johns Hopkins University in Baltimore in 1954. Rogers died on (1939) and MSN in 1945 from Catholic University of America, and Doctorate March 13, 1994. degrees (honorary Doctorates awarded from different Universities). Rogers worked as a professor at New York University’s School of Nursing. She published her theory in 1959 for the first time and revised in 1971, 1983, She was also a Fellow for the American Academy of Nursing. 1987, and 2001. Her contributions enabled her to achieve Excellency from Her publications include: prominent societies like Sigma Theta Tau International Society, the National ✓ Theoretical Basis of Nursing (1970) League for Nursing, and the American Academy of Nursing. ✓ Nursing Science and Art: A Prospective (1988) ✓ Nursing: Science of Unitary, Irreducible, Human Beings Update (1990) OREM PHILOSOPHY ✓ Vision of Space Based Nursing (1990). Assumptions: “Nursing is the ability to care for another human Wholeness: human being is considered as united whole being, most importantly when they are unable to Openness: A person and his environment are continuously exchanging energy care for themselves. The ultimate goal is achieving an optimal level of with each other health and wellness for our patients”. Orem (1971) Unidirectionality: the life process of human being evolves irreversibly and unidirectional i.e from birth to death Pattern and organization: pattern identifies individuals and reflects their Concepts of Orem’s Model innovative wholeness 1. The Self-Care Deficit Theory developed as a result of working toward her goal of improving the quality of nursing in general hospitals in her state. Sentence and thought: humans are the only organisms able to think, imagine, 2. The model interrelates concepts in such a way as to create a different way of have language and emotions looking at a particular phenomenon. HOMEODYNAMIC PRINCIPLES 3. The theory is relatively simple, but generalizable to apply to a wide variety of Resonance - is an arrangement for human and environment that undergo patients. transformation. 4. It can be used by nurses to guide and improve practice, but it must be consistent Helicy - is the nature of change is unpredictable, continuous and innovative. with other validated theories, laws and principles Integrality - is the energy fields of human and environment in a continuous Concepts and definition mutual process The Self-Care Deficit Nursing Theory is a general theory composed of the Roger’s Nursing Metaparadigm following four related theories: Unitary Human being − one of wholeness and continuity as well as dynamic and creative change The theory of self-care, which describes why and how people care for Health themselves. − symbolize wellness and the absence of disease and major illness. The theory of dependent-care, which explains how family members Environment and/or friends provide dependent-care for a person who is socially − defines as irreducible pan dimensional energy field identified by pattern and dependent. manifesting characteristics different from those of the parts. The theory of self-care deficit, which describes and explains why Nursing people can be helped through nursing − both art and science and the nurse is a factor in healing environment. The theory of nursing systems, which describes and explains Implications of Rogers theory relationships that must be brought about and maintained for nursing to Nursing Practice be produced. − Evaluative and diagnostic phase includes determining the patients’ and their family’s wellbeing status at the time − Interventive how the nurse will go about implementing nursing interventions for Theory of self-care the patient “Self –care comprises the practice of activities that maturing and mature persons Education initiate and perform, within time frames, on their own behalf in the interest of − That students have individual personalities and patterns to their work. maintaining life, healthful functioning, continuing personal development and − They are all unitary human beings and should be interacted with differently wellbeing through meeting known requisites for functional and developmental − Culture, family, and experiences affect their reasons and motives to become a regulations. nurse The Theory of Self-Care has three components: − Beings focuses on “the integrality of person and environment, the individual’s 1. universal self-care needs active participation in change, and each person’s individual pattern. 2. developmental self-care needs Research 3. health deviation − It was found that the theory applies to any environment that contains human beings. Universal Self Care Needs ✓ Air ✓ Food TRANSCRIBED BY: EIZEL ABARENTOS | BSN 1 – Y1 – 8  THEORETICAL FOUNDATION (NCMA110) ✓ Water − It uses the SCDNT or components, Biggs (2008) found more than 800 ✓ elimination/excretion references. Berbiglia identified selected practice settings and SCDNT ✓ activity & rest conceptual foci from a review of more than 3 decades of use of the SCDNT in ✓ solitude/social interaction practice and research and publicized selected international SCDNT practice ✓ functioning/well being models for the twenty-first century. ✓ Normalcy Analysis of the theory Clarity Developmental Self Care Requisites: − Orem defined the term and elaborated the substantive structure of the concept More specific to the process of growth and development and are influenced by what in a way that is unique while also congruent with other interpretations is happening during the life cycle. It can be positive or negative. Simplicity Health Deviation Self Care Requisites: − Orem’s theory is expressed in a limited number of terms. These terms are defined When a condition.permanently or temporarily alters structural, physiological or and used consistently in the expression of the theory. Orem’s general theory, the psychological function. SCDNT, comprises the following four constituent theories: self-care, dependent- care, self-care deficit, and nursing systems Self care Generality Self Care Agent - provides the foundation for understanding the action − As a general theory, it serves nurses engaged in nursing practice, in development requirements and action limitations of persons who may benefit from nursing. and validation of nursing knowledge, and in teaching and learning nursing. Theory of dependent care - “explains how the self-care system is modified when Accessibility it is directed toward a person who is socially dependent and needs assistance in − As a general theory, the SCDNT provides a descriptive explanation of why meeting his or her self-care requisites” persons require nursing and what processes are needed for the production of Therapeutic self-care - demand is the totality of self-care actions to be performed required nursing care for some duration in order to meet self-care requisites by using valid methods and related sets of operations and actions. − The SCDNT differentiates the focus of nursing from other disciplines. Although other disciplines find the theory of self-care helpful and contribute to its Theory Of Dependent Care development, the theory of nursing systems provides a unique focus for nursing Dependent care refers to the care that is provided to a person who, because of age or related factors, is unable to perform the self-care needed to maintain life, healthful functioning, continuing personal development, and well-being. Imogene King (Goal attainment theory) Dependent-Care Self-Care Agency Dependent-Care Demand Agency Background Summation of care The self-care agency is Refers to the acquired born in 1923 measures at a specific a complex acquired ability of a person to Bachelor in science of nursing from St. Louis University in 1948 point in time or over a ability of mature and know and meet the duration of time for maturing persons to therapeutic self-care Master of science in nursing from St. Louis University in 1957 meeting the know and meet their demand of the Doctorate from Teacher’s college, Columbia University. dependent’s therapeutic continuing requirements dependent person Theory describes a dynamic, interpersonal relationship in which a person grows self-care demand when for deliberate, purposive and/or regulate the his or her self-care action to regulate their development and and develops to attain certain life goals. agency is not adequate own human functioning exercise of the Factors which affects the attainment of goal are: or operational. and development. dependent’s self-care ✓ Roles agency. ✓ Stress ✓ Space Theory Of Self-Care Deficit ✓ Time A self-care deficit occurs when an individual cannot carry out self-care requisites. KING’S OPEN SYSTEM FRAMEWORK Orem identifies method of helping: Nursing Focus is the care of human being 1. Acting for and doing for others Nursing Goal is the health of the individual and health care for the group 2. Guiding and directing Human Beings are open system in constant interaction with the environment. 3. Providing Physical and Psychological support 4. Environment of promoting personal development 5. Teaching Examples of self-care requisites are: 1. Wound care 2. Activities of Daily Living 3. Bowel program 4. Glucose monitoring Theory Of Nursing Systems Wholly compensatory support - patient is unable to complete any self-care independently; nursing compensates for patient’s inability to perform self-care. Partial compensatory support - patient is able to perform self-care tasks with Assumptions Partial or no assistance from nursing. The basic assumption of Nursing Process is that the nurse and patient Supportive/educative compensatory - patient able to perform tasks communicate information, set mutual goal, and act to achieve these goals. independently. Nursing provides ongoing education and support. Each human being perceives the world as a total person in making transaction Four Major Concepts of Orem with individual and things in the environment. Person NURSE PATIENT TRANSACTION MODEL − viewed biologically, symbolically and socially but still as a whole person. This person is Action is a means of behavior or activities that are towards the considered to be able to provide self-care accomplishments of certain act. It is both physical and mental. Health Reaction - is a form of reacting or a response to a certain stimuli. − state characterized by soundness or wholeness of developed human Interaction - is any situation wherein the nurse relates and deals with a structures and of bodily and mental functioning. clientele or patient. Environment Transaction - is a unique observable in which human being communicate with − physical, chemical, biologic and social factors that makeup who a person is. the environment. Nursing King’s Goal attainment metaparadigm − how a healthcare professional develops a plan of care to meet the patient’s self- Person care needs − existing in an open system who makes choices and select alternative action. Significance of the theory Health Nursing Practice − continuous adjustment to stress in the internal and external environment. − It has achieved a significant level of acceptance by the international nursing Environment community, as evidenced by the magnitude of published material and − process of balance involving internal and external interactions inside the social presentations at the International Orem Society World Congresses. system. Education Nursing − The SCDNT was introduced as the basic structure for nursing management in − an observable behavior found in the health care systems in society”. The goal German hospital DRG (diagnosis-related group) implementation. The of nursing “is to help individuals maintain their health so they can function in their movement toward SCDNT-based nursing management. roles”. − The influence of Orem’s SCDNT has continued at the international level Significance of the theory through the translation of Nursing Concepts of Practice into several languages. Nursing Practice Research TRANSCRIBED BY: EIZEL ABARENTOS | BSN 1 – Y1 – 8  THEORETICAL FOUNDATION (NCMA110) − Individualized the plans of care while encouraging active participation from injury that is repaired but the person himself or herself... It is not merely the clients healing of an afflicted part. It is rather a return to self hood, where the − The profession of nursing function through individuals and groups within the encroachment of the disability can be set aside entirely, and the individual is environment. free to pursue once more his or her own interests without constraint." Education − disease is "unregulated and undisciplined change and must be stopped or − It is used in curriculum design in nursing programs death will ensue" − It provides a systematic means of viewing nursing as profession, an organized Environment body of knowledge and clarifying nursing as discipline. − completes the wholeness of the individual. Research − The individual has both an internal and external environment − It is design and conducted to implement this system in hospital, ambulatory, Nursing community and home care nursing. − Nursing involves engaging in "human interactions" "The nurse enters into a Analysis of the theory partnership of human experience where sharing moments in time-some trivial, Clarity some dramatic-leaves its mark forever on each patient". The goal of nursing is − Theory of Goal Attainment is the ease with which it can be understood by nurses. to promote adaptation and maintain wholeness (health). Concepts are concretely defined and illustrated Simplicity − King’s definitions are clear and are conceptually derived from research literature. Internal Environment Generality ✓ Homeostasis − It has been criticized for having limited application in areas of nursing in which − Stable state normal alterations in physiologic parameters respond to patients are unable to interact competently with the nurse. environmental changes; an energy sparing state, a state of conservation. ✓ Homeorrhesis Accessibility − orchestrated or coordinated control in metabolism of body tissues necessary − descriptive study was conducted to identify the characteristics of transaction and to support a physiological state whether nurses made transactions with patients Three Aspects of External Environment Drawn upon Bates’ Importance (1967) − middle-range Theory of Goal Attainment focused on all aspects of the nursing ✓ Perpetual process: assessment, planning, implementation, and evaluation. The body of − consists of information that is recorded by the sensory organs. literature clearly establishes King’s work as important for knowledge building in ✓ Operational the discipline of nursing − consists of the undetected natural forces and that impinge on the individual. ✓ Conceptual Myra Estrin Levine − influenced by language, culture, ideas, and cognition (Conservation Model) Background CONSERVATION MODEL After earning an MS in nursing at Wayne State University in 1962, she authored 77 published articles which included “An Introduction to Clinical Nursing” with multiple publication years in 1969, 1973, and 1989. She also received an honorary doctorate from Loyola University in 1992. She died in 1996.. Conservation Model The core of the conservation model is to improve a person’s physical and emotional well-being by considering the four domains of conservation she set out. Nursing’s role in conservation is to help the person with the process of “keeping together” the total person through the least amount of effort. Under Conservation model: Adaptation − 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. Three characteristics of adaptation: o Historicity - Adaptation is a historical process. Responses are based on past Conservation of energy experiences both personal and genetics o It refers to balancing energy input and output to avoid excessive fatigue. It o Specificity - Adaptation is also specific. It refers to the individual responses includes adequate rest, nutrition and exercise. and their adaptive pattern, which varies on the basis of specific genetic o Examples: Availability of adequate rest; Maintenance of adequate nutrition structure. Conservation of structural integrity o Each system has particular responses. The physiologic responses that “defend o It refers to maintaining or restoring the structure of body preventing physical oxygen supply to the brain are distinct from those that maintain the appropriate breakdown and promoting healing. blood glucose levels.” (Levine, 1989) o Examples: Assist patient in ROM exercise; Maintenance of patient’s personal o Redundancy - represents the fail-safe options available to the patient to hygiene ensure continued adaptation. Conservation of personal integrity Wholeness o It recognizes the individual as one who strives for recognition, respect, self − Levine stated that "the unceasing interaction of the individual organism awareness, selfhood and self determination. with its environment does represent an 'open and fluid' system, and a o Example: Recognize and protect patient’s space needs condition of health, wholeness, exists when the interaction or constant Conservation of social integrity adaptations to the environment, permit ease-the assurance of integrity..in o An individual is recognized as some one who resides with in a family, a all the dimensions of life.” community, a religious group, an ethnic group, a political system and a nation. Conservation o Example: Help the individual to preserve his or her place in a family, community, − product of adaptation. and society. − Latin word conservatio, meaning "to keep together" Assumptions About Individuals − Conservation describes the way complex systems are able to continue to − Each individual "is an active participant in interactions with the environment.. function even when severely challenged. Through conservation, constantly seeking information from it." (Levine, 1969) individuals are able to confront obstacles, adapt accordingly, and maintain − The individual "is a sentient being, and the ability to interact with the environment their uniqueness. "The goal of conservation is health and the strength to seems ineluctably tied to his sensory organs." confront disability" as the rules of conservation and integrity hold" in all − "Change is the essence of life, and it is unceasing as long as life goes on. situation in which nursing is requires". − Change is characteristic of life." (Levine, 1973) Conservation model metaparadigm Assumptions About Nursing Person − "Ultimately, the decisions for nursing intervention must be based on the unique − a holistic being who constantly strives to preserve wholeness and integrity and one "who behavior of the individual patient." is sentient, thinking, future-oriented, and past-aware." − "Patient-centered nursing care means individualized nursing care. It is predicated − The wholeness (integrity) of the individual demands that the "individual life has meaning on the reality of common experience: every man is a unique individual, and as only in the context of social life" The person is also described as a unique individual in such he requires a unique constellation of skills, techniques, and ideas designed unity and integrity, feeling, believing, thinking and whole system of system. specifically for him."(Levine, 1973) Health − Levine (1991) 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 TRANSCRIBED BY: EIZEL ABARENTOS | BSN 1 – Y1 – 8  THEORETICAL FOUNDATION (NCMA110) Betty Neuman Health - a continuum of wellness to illness that is dynamic in nature. Optimal wellness - exists when the total system needs are being completely met; (Systems model) Wellness - exists when all system subparts interact in harmony with the whole Background system and all system needs are being met born in 1924 (Ohio). Illness - exists at the opposite end of the continuum from wellness and represents Her rural background helped her develop a compassion for people in need, which a state of instability and energy depletion has been evident throughout her career. Stressors - are tension-producing stimuli that have the potential to disrupt system She completed her initial nursing education with double honors at Peoples stability, leading to an outcome that may be positive or negative Stressors may Hospital School of Nursing arise from the following: Baccalaureate degree in public health and psychology with honors (1957) ✓ MA in mental health, public health consultation (1966), (UCLA) − Intrapersonal Forces ✓ PhD in clinical psychology at Pacific Western University in 1985 − Interpersonal Forces Systems model − Extrapersonal Force a unique, open systems-based perspective that provides a unifying focus for Degree of Reaction - The degree of reaction represents system instability that approaching a wide range of concerns. occurs when stressors invade the normal line of defense; A system acts as a boundary for a single client, a group, or even a number groups Prevention As Intervention - Interventions are purposeful actions to help the client It can also be defined as a social issue retain, attain, or maintain system stability. They can occur before or after protective A client system in interaction with the environment delineates the domain of lines of defense and resistance are penetrated. Interventions are based on the nursing concerns possible or actual degree of reaction, resources, goals, and anticipated outcomes. a dynamic, open, systems approach to client care originally developed to provide Neuman identifies three levels of intervention: a unifying focus for defining nursing problems and for understanding the client’s − Primary Prevention - used when a stressor is suspected or identified. A interaction with the environment. reaction has not yet occurred. The purpose is to reduce the possibility of The client as a system may be defined as a person, family, group, community, encounter with the stressor or to decrease the possibility of a reaction. Taken or social issue. consideration the risk factors. Outer prevention − Secondary Prevention - involves interventions or treatment initiated after symptoms from stress have occurred. Disease is already in you but you are not showing any symptoms. Stop to protect the entire organism to have totally sick − Tertiary Prevention - occurs after the active treatment or secondary prevention stage. It focuses on readjustment toward optimal client system stability. The goal is to maintain optimal wellness by preventing recurrence of reaction or regression. The disease is already in you and you are prevented for further damage. Ex, death Reconstitution - occurs after treatment for stressor reactions. It represents return of the system to stability, which may be at a higher or lower level of wellness than before stressor invasion. When you recover from serious disease Systems Model Metaparadigm Person Dynamic – constantly changing based on its stimulus provided of the internal − “the client” ( individual, family, group, community, or social issue). and external factors − Client – normal people to be checked up The basic structure – the core of the living substance of that particular − The client system is a dynamic composite of interrelationships among physiological, organism. Composed of normal temperature, genetics, dna, and all that psychological, sociocultural, developmental, and spiritual factors. contributes to life. Health Major Concepts & Definitions − a continuum of wellness to illness that is dynamic in nature and is constantly Wholistic Approach changing. − Clients are viewed as wholes whose parts are in dynamic interaction. − continue – you can move to one part of a period of time. Ex. Pwedeng may − The model considers all variables simultaneously affecting the client system: sakit ka ngayon then mawawala mamaya physiological, psychological, sociocultural, developmental, and spiritual. − “Optimal wellness or stability indicates that total system needs are being met. − She changed the spelling of the term holistic to wholistic in the second edition to A reduced state of wellness is the result of unmet systemic needs” enhance understanding of the term as referring to the whole person Environment Open System - there is a continuous flow of input and processes, output, and − all the internal and external factors that surround and influence the client feedback. Stress and reaction to stress are basic components of an open system system. Stressors (intrapersonal, interpersonal, and extrapersonal) are Input and Output - are the matter, energy, and information that are exchanged significant to the concept of environment and are described as environmental between the client and the environment forces that interact with and potentially alter system stability Feedback - output in the form of matter, energy, and information serves as future − whatever stresses you, whatever triggers you to behave input for corrective action to change, enhance, or stabilize the system Nursing Negentropy - The process of energy conservation that assists the system in the − concerned with the whole person. She views nursing as a “unique profession in progression toward stability or wellness is negentropy; that it is concerned with all of the variables affecting an individual’s response to Stability - Stability is a dynamic and desirable state of balance in which energy stress” exchanges can take place without disruption of the character of the system, which Example: Health teaching on proper nutrition and exercise points toward optimal health and integrity Immunization Environment - Internal and external forces surrounding the client, influencing, and Pap Smear being influenced by the client, at any point in time. Case Finding Created Environment - is developed unconsciously by the client to express system Blood examination of cholesterol every 6 months wholeness symbolically. Its purpose is to provide protection for the client’s system Advising the client to quit smoking in order to prevent respiratory diseases functioning and to insulate the client from stressors Speech therapy after throat surgery Client System - a composite of five variables (physiological, psychological, Conducting a seminar for dietary modifications sociocultural, developmental, and spiritual) in interaction with the environment. Rang-of-motion exercises for a post accident patient Basic Structure - The client as a system is composed of a central core surrounded Handwashing teaching among patients by concentric rings. Lines of Resistance - rings represent resource factors that help the client defend against a stressor; serve as protection factors that are activated by stressors Dorothy Johnson penetrating the normal line of defense (Behavioral system / model) Normal Line of Defense - It represents the adaptational level of health developed Background over the course of time and serves as the standard by which to measure wellness Born on August 21, 1919, (Savannah, Georgia); deviation. A.A. (Associate of Arts) from Armstrong Junior College in Savannah, Georgia Flexible Line of Defense - It is perceived as serving as a protective buffer for (1938); preventing stressors from breaking through the usual wellness state as represented B.S.N, - Vanderbilt University in Nashville, Tennessee (1942); by the normal line of defense. M.P.H. - Harvard University in Boston (1948). − represents the openness of the system. Staff nurse at the Chatham-Savannah Health Council from 1943 to 1944 − Why is line broken – so that the substances for nourishment can come in and Instructor and an assistant professor in pediatric nursing at Vanderbilt University waste product can exit School of Nursing (Tennessee) , from 1949 until her retirement in 1978 TRANSCRIBED BY: EIZEL ABARENTOS | BSN 1 – Y1 – 8  THEORETICAL FOUNDATION (NCMA110) Key Largo, Florida, assistant professor of pediatric nursing, an associate − She also acknowledged that prior experience, learning, and physical and social professor of nursing stimuli also influence behavior. UCLA (University of California Los Angeles) Professor of Nursing − She noted that a prerequisite to using this model is the ability to look at a Behavioral System Theory person as a behavioral system, observe a collection of behavioral subsystems, Johnson’s Behavioral System Model (JBSM) was heavily influenced by and be knowledgeable about the physiologic, psychological, and sociocultural Florence Nightingale’s book, Notes on Nursing factors operating outside them She accepted Nightingale’s belief that the first concern of nursing is with the Health “relationship between the person who is ill and their environment, not with the − as an elusive, dynamic state influenced by biological, psychological, and social illness” factors; reflected by the organization, interaction, interdependence, and Johnson used the work of behavioral scientists in psychology, sociology, and integration of the subsystems of the behavioral system ethnology to develop her theory − An individual attempts to achieve a balance in this system, which will lead to The interdisciplinary literature cited focused on observable behaviors that were functional behavior. of adaptive significance. This body of literature influenced the identification and − A lack of balance in the structural or functional requirements of the subsystems the content of her seven subsystems. leads to poor health. Observable − Thus, when evaluating “health,” one focuses on the behavioral system and Behavior is observed in the beginning system balance and stability, effective and efficient functioning, and behavioral system imbalance and instability Environment − consists of all the factors that are not part of the individual’s behavioral system, but that influence the system. − The nurse may manipulate some aspects of the environment so the goal of health or behavioral system balance can be achieved for the patient. Nursing − aim to maintain and restore the person’s behavioral system balance and stability or to help the person achieve a more optimum level of balance and functioning. Sister Callista Roy Major Concepts & Definitions (Adaptation Model) Behavior - the output of intra organismic structures and processes as they are coordinated and articulated by and responsive to changes in sensory stimulation. Thus, nursing, as perceived by Johnson, is an external force acting to preserve Johnson focused on behavior affected by the actual or implied presence of other the organization and integration of the patient’s behavior to an optimal level by social beings that has been shown to have major adaptive significance. means of imposing temporary regulatory or control mechanisms or by providing System – Johnson (1980) stated, “A system is a whole that functions as a whole by resources while the patient is experiencing stress or behavioral system virtue of the interdependence of its parts” imbalance. Behavioral System - encompasses the patterned, repetitive, and purposeful ways of behaving. − These ways of behaving form an organized and integrated functional unit that Background determines and limits the interaction between the person and his or her “God is intimately revealed in the diversity of creation and is the common environment and establishes the relationship of the person to the objects, events, destiny of creation; persons use human creative abilities of awareness, and situations within his or her environment. enlightenment, and faith; and persons are accountable for the process of Subsystems - “a mini system with its own particular goal and function that can be deriving, sustaining, and transforming the universe” maintained as long as its relationship to the other subsystems or the environment is member of the Sisters of Saint Joseph of Carondelet not disturbed”. There are seven identified subsystems which are: was born on October 14, 1939, in Los Angeles, California. − Attachment-Affiliative Subsystem She received a bachelor’s degree in nursing in 1963 from Mount Saint Mary’s − Dependency Subsystem College in Los Angeles − Ingestive Subsystem master’s degree in nursing from the University of California, Los Angeles, in − Eliminative Subsystem 1966. − Sexual Subsystem After earning her nursing degrees, Roy began her education in sociology, − Achievement Subsystem receiving both a master’s degree in sociology in 1973 − Aggressive-Protective Subsystem doctorate degree in sociology in 1977 from the University of California. Equilibrium - Johnson stated that equilibrium is a key concept in nursing’s specific While working toward her master’s degree, Roy was challenged in a seminar goal. It is defined as “a stabilized but more or less transitory, resting state in which with Dorothy E. Johnson to develop a conceptual model for nursing. the individual is in harmony with himself and with his environment” While working as a pediatric staff nurse, Roy noticed the great resiliency of “It implies that biological and psychological forces are in balance with each other and children and their ability to adapt in response to major physical and psychological with impinging social forces” changes Functional Requirements/Sustenal Imperatives - For the subsystems to develop ROY ADAPTATION MODEL and maintain stability, each must have a constant supply of function requirements. The environment supplies sustenal imperatives such as protection, nurturance, and stimulation. Johnson notes that the biologic system and all other living systems have the same requirements Regulation/Control - The interrelated behavioral subsystems must be regulated in some fashion so that its goals can be realized. Regulation implies that deviations will be detected and corrected. Feedback is, therefore, a requirement of effective control. Tension - a state of being stretched or strained and can be viewed as an end-product of a disturbance in equilibrium. − Constructive in adaptive change or − Destructive in inefficient use of energy, hindering adaptation and causing potential structural damage (Johnson, 1961a). − Tension is the cue to disturbance in equilibrium. Stressor - Internal or external stimuli that produce tension and result in a degree of instability are stressors − “Stimuli may be positive in that they are present; or negative in that something desired or required is absent. Behavioral system Metaparadigm Thus, nursing, as perceived by Johnson, is an external force acting to preserve the organization and integration of the patient’s behavior to an optimal level by means of imposing temporary regulatory or control mechanisms or by providing resources while the patient is experiencing stress or behavioral system imbalance. adaptation occurs when people respond positively to environmental changes, Person and it is the process and outcome of individuals and groups who use − Johnson (1980) viewed the person as a behavioral system with patterned, conscious awareness, self-reflection, and choice to create human and repetitive, and purposeful ways of behaving that link the person with the environmental integration environment. Stimuli Behavior is observed in the last TRANSCRIBED BY: EIZEL ABARENTOS | BSN 1 – Y1 – 8  THEORETICAL FOUNDATION (NCMA110) If you adapt you are positively The person as a whole is made up of six subsystems. These subsystems (the regulator, the cognator, and the four adaptive modes) are interrelated to form a Major Concepts & Definitions complex system for the purpose of adaptation Relationships among the four System - A system is “a set of parts connected to function as a whole for some adaptive modes occur when internal and external stimuli affect more than one purpose and that does so by virtue of the interdependence of its parts” mode, when disruptive behavior occurs in more than one mode, or when one Adaptation Level - “A constantly changing point, made up of focal, contextual, mode becomes the focal, contextual, or residual stimulus for another mode and residual stimuli, which represent the person’s own standard of the range of stimuli to which one can respond with ordinary adaptive responses” The physiological/physical adaptive mode : Behavior in this mode is a Adaptation Problems - Adaptation problems are “broad areas of concern manifestation of the physiological activity of all the cells, tissues, organs, & related to adaptation. These describe the difficulties related to the indicators of systems of the body. positive adaptation” − 5 needs serve to promote physiological integrity, (oxygenation, nutrition, Focal stimulus - the focal stimulus is “the internal or external stimulus most elimination, activity and rest, and protection). immediately confronting the human system” − 4 processes which help maintain physiological integrity (senses, fluid and Contextual stimuli - “are all other stimuli present in the situation that electrolytes, neuro, and endocrine function) contribute to the effect of the focal stimulus” The self-concept group identity adaptive Mode : deals with the person’s beliefs Residual Stimuli - “Are environmental factors within or without the human & feelings about himself/herself. Basic underlying need: psychic integrity system with effects in the current situation that are unclear” (physical perceptions, ideals, goals, moral/ethical beliefs) Example: Group of young women contemplating smoking cessation − Physical self: how one sees his own physical being 1. body sensation: ability to express sensations/feel symptoms − Focal Stimuli: Nicotine Addiction 2. body image: how one sees himself as a physical being − Contextual Stimuli: Belief that smoking is enjoyable, makes them feel good, − Personal self: how one views his qualities, values, worth relaxes them, brings them a sense of comfort, and is part of their routine 1. self-consistency: one’s self-description of qualities; also includes self- − Residual Stimuli: Beliefs and attitudes about their body image and that smoking organization behavior cessation causes weight gain 2. self-ideal/self-expectancy: what one would like to do or be 3. moral-ethical-spiritual self: values, beliefs, religion self-esteem: the value Coping Processes - “Are innate or acquired ways of interacting with the one places on himself/herself changing environment” The role function adaptive mode : involves the position one occupies in Innate Coping Mechanisms - Innate coping mechanisms “are genetically society; behaviors associated with one’s position (role) in society. Basic determined or common to the species and are generally viewed as automatic underlying need: social integrity processes − Primary role: role based on age, sex, developmental state Acquired Coping Mechanisms - “Are developed through strategies such as learning. The experiences encountered throughout life contribute to customary − Secondary role: role(s) a person assumes to complete tasks associated responses to particular stimuli” with a primary role or developmental stage Regulator Subsystem − Tertiary role: a role freely chosen; temporary; associated with − Regulator is “a major coping process involving the neural, chemical, and accomplishments of tasks or goals endocrine systems” The interdependence adaptive mode : associated with one’s relationships and Cognator Subsystem interactions with others and the giving and receiving of love, respect, and value. Basic underlying need: nurturance and affection − Cognator is “a major coping process involving four cognitive-emotive channels: perceptual and information processing, learning, judgment, and − Significant others: intimate relationships (spouse, parent, God) emotion” − Support systems: less intimate relationships (coworkers, friends) − Giving behaviors: giving love, nurturance, affection THEORETICAL ASSERTIONS − Receiving behaviors: receiving/taking in love, nurturance, affection Adaptation Metaparadigm Person − Humans are holistic, adaptive systems. “As an adaptive system, the human system is described as a whole with parts that function as unity for some purpose. Human systems include people as individuals or in groups, including families, organizations, communities, and society as a whole”; Health HUMAN ADAPTIVE SYSTEMS − “Health is a state and a process of being and becoming integrated and a whole person. It is a reflection of adaptation, that is, the interaction of the person and the environment. Roy derived this definition from the thought that adaptation is a process of promoting physiological, psychological, and social integrity, and that integrity implies an unimpaired condition leading to completeness or unity. Environment − According to Roy, environment is “all the conditions, circumstances, and influences surrounding and affecting the development and behavior of persons or groups, with particular consideration of the mutuality of person and earth resources that includes focal, contextual, and residual stimuli” ; − “It is the changing environment [that] stimulates the person to make adaptive responses” Nursing − nursing broadly as a “health care profession that focuses on human life processes and patterns and emphasizes promotion of health for individuals, families, groups, and society as a whole” ROY’S 6 STEP NURSING PROCESS 1. Assesses the behaviors manifested from the four adaptive modes 2. Assesses the stimuli for those behaviors and categorizes them as focal, contextual, or residual stimuli 4 Adaptive System: Physiologic / Physical Adaptive System, Self-concept 3. Makes a statement or nursing diagnosis of the person’s adaptive state Group Identity Adaptive System, Role Function Adaptive System, 4. Set goals to promote adaptation Interdependence Adaptive System 5. Implements interventions aimed at managing the stimuli to promote adaptation Purpose: to achieve physiological, psychological, and social integrity. 6. Evaluates whether the adaptive goals have been met By manipulating the stimuli Person: as a whole is made up of six subsystems (the regulator, the cognator, and not the patient, the nurse enhances “the interaction of the person with their and the four adaptive modes) are interrelated to form a complex system for the environment, thereby promoting health” purpose of adaptation Relationships occur when internal and external stimuli affect more than one mode, when disruptive behavior occurs in more than one mode, or when one mode becomes the focal, contextual, or residual stimulus for another mode. The purpose of the four adaptive modes is to achieve physiological, psychological, and social integrity. TRANSCRIBED BY: EIZEL ABARENTOS | BSN 1 – Y1 – 8  THEORETICAL FOUNDATION (NCMA110) than merely its instrument. This work led to conceptualize the focus of nursing as “nurturing persons living caring and growing in caring”. The idea of the nursing situation as a shared lived experience in which the “caring between” enhances personhood. Personhood is illuminated as living grounded in caring. Nursing is concerned with the broad spectrum of human living. Major Concepts & Definitions Focus and intention of nursing − Disciplines of knowledge are communities of scholars who develop a particular perspective on the world and what it means to be in the world. − The focus of nursing: Discipline of knowledge and professional practice is nurturing persons living and growing in caring. − The general intention of nursing is to know persons as caring and to support and sustain them as they live caring. Nurse enters the relationship with the nursed with the intention of knowing the other as a caring person, and affirming and celebrating the person as caring. − Caring is expressed in nursing and is “the intentional and authentic presence of the nurse with another who is recognized as living in caring and growing in caring”. − Sensitivity and skill in creating unique and effective ways of communicating caring are developed through the nurse’s intention to care. Perspective of persons as caring - The fundamental assumption is that all persons are caring. Caring is lived by each person moment to moment and is an essential characteristic of being human. Caring is a process, and throughout life, each person grows in the capacity to express caring. Person is constantly unfolding in caring. Knowing the person as living caring and growing in caring is foundational to the theory. Nursing situation - Caring is service that nursing offers and lives in the context of the nursing situation. The nursing situation is the locus of all that is known and done in nursing and is conceptualized as “the shared, lived experience in which caring between nurse and nursed enhances personhood”. It is what is present in the mind of the nurse whenever the intent of the nurse is “to nurse”. It involves an expression of values, intentions, and actions of two or more persons choosing to live a nursing relationship. In this lived relationship, all knowledge of nursing is created and understood. Anne Boykin and Savina O. Schoenhofer Personhood - Personhood is a process of living that is grounded in caring. It (Theory Of Nursing As Caring) implies being who we are as authentic caring persons and being open to Background (Anne Boykin) unfolding possibilities for caring. The shared lived experience of caring within Born in 1944 and grew up in Kaukauna, Wisconsin enhances personhood, and both the nurse and the nursed grow in caring. In the 1966: career in nursing from Alverno College in Milwaukee, Wisconsin. intimacy of caring, respect for self as person and respect for other are values MSN: Emory University in Atlanta, Georgia that affirm personhood. PhD: Vanderbilt University in Nashville, Tennessee. Direct invitation - It opens the relationship to true caring between the nurse and 2011: Retired, Professor Emeritus of the Christine E. Lynn College of Nursing at the one nursed. The direct invitation of the nurse offers the opportunity to the Florida Atlantic University one nursed to share what truly matters in the moment. With the intention of truly Currently the Director of the college’s new Anne Boykin Institute for the coming to know the one nursed, the nurse risks entering the other’s world and Advancement of Caring in Nursing. comes to know what is meaningful to him or her. The focus is on what is 1990 - 1999: president-elect / president, member of the nominating committee meaningful for the one being nursed. and as immediate past president, she served as coeditor of the journal, Call for nursing - These are calls for nurturance perceived in the mind of the International Association for Human Caring. nurse. The nurse responds uniquely to the one nursed with a deliberately Nursing as Caring: A Model for Transforming Practice(1993, 2001a) Centered developed knowledge of what it means to be human, acknowledging and on caring as the grounding for nursing. (coauthored with Schoenhofer) affirming the person living caring in unique ways in the immediate situation. Living a Caring-Based Program (1994b). Calls for nursing are uniquely situated personal expressions, they cannot be Power, Politics and Public Policy: A Matter of Caring (1995) as an editor predicted, but originate within persons who are living caring in their lives and Caring as Healing: Renewal Through Hope (1994) coeditor (along with Gaut). who hold hopes and aspirations for growing in caring. “Calls for nursing are Background (Savina O. Schoenhofer) individually relevant ways of saying ‘Know me as caring person in the moment Born in 1940 and spent her formative years in Kansas. 1960: and be with me as I try to live fully who I truly am.” o Spent 3 years in the Amazon region of Brazil, as a volunteer in community Caring between - When the nurse enters the world of the other person with development. the intention of knowing the other as a caring person, the encountering of the o BS and graduate degrees in nursing, psychology, and counseling was completed at nurse and the one nursed gives rise to caring between, within which Wichita State University personhood is nurtured. Through presence and intentionality, the nurse comes 1983: PhD in educational foundations and administration at Kansas State University to know the other, living and growing in caring. Without the caring between the 1990: o Co-founded Nightingale Songs, an early venue for communicating the beauty of nurse and the nursed, unidirectional activity or reciprocal exchange can occur, nursing in poetry and prose. but nursing in its fullest sense does not occur. It is in the context of caring o Caring was the service that patients overwhelmingly recognized. between that personhood is nurtured, each expressing self and recognizing the o Co-authorship with Boykin of Nursing as Caring: A Model for Transforming Practice other as caring person (1993, 2001a), Schoenhofer has written numerous articles on nursing values, primary Nursing response - In responding to the nursing call, the nurse enters the care, nursing education, support, touch, and mentoring. nursing situation with the intention of knowing the other person as caring. This Influenced by three colleagues: Lt. Col. Ann Ashjian (Ret.), Marilyn E. Parker, PhD and Anne Boykin, PhD knowing of person clarifies the call for nursing and shapes the nursing Serves on the Ethics Advisory Committee at the University of Mississippi Medical Center response, transforming the knowledge brought by the nurse to the situation Professor of Nursing at University of Mississippi Medical Center School of Nursing in from general, to particular and unique. Nursing responses to calls for caring Jackson evolve as nurses clarify their understanding of calls through presence and Adjunct Professor at the Florida Atlantic University College of Nursing, Boca Raton. dialogue. She is committed to the study of nursing as caring Story as method for knowing nursing - Story is a method for knowing Theoretical sources nursing and a medium for all forms of nursing inquiry. Nursing stories embody The Theory of Nursing as Caring was borne out of the early curriculum the lived experience of nursing situations involving the nurse and the nursed. development work at Florida Atlantic University College of Nursing. The nursing situation is re-created in narrative or story and are best Recognizing the importance and human necessity of continuing to develop ideas communicated through aesthetic media such as storytelling, poetry, graphic toward a comprehensive conceptual framework that expressed the meaning and arts, and dance to preserve the lived meaning of the situation and the purpose of nursing as a discipline and as a profession. openness of the situation through text. Story as method re-creates and re- The point of departure from traditional thought was the acceptance that caring presents the essence of the experience, making the knowledge of nursing is the end rather than the means of nursing, and the intention of nursing rather available for further study TRANSCRIBED BY: EIZEL ABARENTOS | BSN 1 – Y1 – 8  THEORETICAL FOUNDATION (NCMA110) Theory Of Nursing As Caring Metaparadigm o PhD (1968), MA (1966), MS (1964)– University of California, Los Angeles Person o BS – University of Alexandria, Egypt – 1961 − Persons are caring by virtue of their humanness: Being a person means living caring, 2002-2014: Professor of Nursing and Sociology and Dean Emerita at the University through which being and possibilities are known to the fullest. Each person throughout his of Pennsylvania or her life grows in the capacity to express caring. Person as caring “centers on valuing and Award-winning books: celebrating human wholeness, the human person as living and growing in caring, and active o Theoretical Nursing, Development and Progress personal engagement with others”. o Transitions Theory: Middle-Range and Situation-Specific Theories in Research − Persons are whole and complete in the moment: Respect for the person is communicated by the notion of person as whole or complete in the moment. Being complete and Practice in the moment signifies that there is no insufficiency, no brokenness, and no absence of It began with observations of experiences faced as people deal with changes something. Wholeness, or the fullness of being, is forever present. related to health, well-being, and the ability to care for themselves. − Persons live caring, moment to moment: Caring is a lifetime process that is lived moment Types of transitions include developmental, health and illness, situational, and to moment and is constantly unfolding. In the rhythm of life experiences, we continually organizational. develop expressions of ourselves as caring persons. As competency in caring is developed Acknowledges the role of nurses as they help people go through health/illness and through life, we come to understand what it means to be a caring person, to live caring, and life transitions. to nurture each other as caring Focuses on assisting nurses in facilitating patients’, families’, and communities’ Health healthy transitions. − Personhood is living life grounded in caring. It is a process of living caring and growing in caring: It is being authentic, demonstrating congruence between beliefs and behaviors, and living out the meaning of one’s life. Personhood acknowledges the potential for unfolding caring possibilities moment to moment. Personhood is the universal human call. This implies that the fullness of being human is expressed in living caring uniquely day to day and is enhanced through participation in caring relationships. Environment − Personhood is enhanced through participating in nurturing relationships with caring others. It acknowledges the potential of persons to live caring and is enhanced through participation in nurturing relationships with caring. Caring acknowledges the importance of knowing person as person and transforms nature of relationships. “Through knowing self as caring person, I am able to be authentic to self, freeing me to truly be with others”. Nursing − Nursing is both a discipline and a profession. It is an “exquisitely interwoven” unity of aspects. As a discipline, nursing is a way of knowing, being, valuing, and living in the world, and is envisaged as a unity of knowledge within a larger unity. Major Concepts & Definitions The discipline of nursing attends to the discovery, creation, development, and Types and patterns of transitions refinement of knowledge needed for the practice of nursing. The profession of − Types of transitions include developmental, health and illness, situational, nursing attends to the application of that knowledge in response to human and organizational. needs. − Nursing as caring focuses on the knowledge needed for plenary understanding − Developmental transition includes birth, adolescence, menopause, aging (or of what it means to be human and the distinctive methods needed to verify this senescence), and death. knowledge. As a human science, knowing nursing means knowing in the realms − Health and illness transitions include recovery process, hospital discharge, of personal, empirical, ethical, and aesthetic all at once. and diagnosis of chronic illness. Theoretical assertions − Organizational transitions refer to changing environmental conditions that As a general theory, Nursing as Caring is appropriate for various nursing roles, affect the lives of clients, as well as workers within them. such as individual practice, group or institutional practice, and a variety of − Patterns of transitions include multiplicity and complexity. Many people are practice venues such as acute care, long-term care, nursing administration, and experiencing multiple transitions at the same time rather than experiencing nursing education. a single transition, which cannot be easily distinguished from the contexts of The fundamental assumptions of Nursing as Caring underpin the assertions and their daily lives. concepts of the theory. (1) To be human is to be caring, and Properties of Transition Experience (2) the purpose of the discipline and profession is to come to know persons and Awareness is defined as perception, knowledge, and recognition of a transition nurture them as persons living caring and growing in caring. experience, and level of awareness is often reflected in the degree of congruency These assumptions give rise to the concept of respect for persons as caring between what is known about processes and responses and what constitutes an individuals and respect for what matters to them. The notion of respect grounds expected set of responses and perceptions of individuals undergoing similar and characterizes relationships and is the starting place for all nursing caring transitions. activities. Engagement refers to the degree to which a person demonstrates involvement in The Dance of Caring Persons is a visual representation of the theoretical the process inherent in the transition. assertion that lived caring between the nurse and the nursed expresses Changes and differences. Changes in identities, roles, relationships, abilities, and underlying relationships. The egalitarian spirit of caring respect characterizes patterns of behavior are supposed to bring a sense of movement or direction to each participant in the dance of caring persons, where the contributions of each internal processes, as well as external processes asserted that all transitions dancer, including the one nursed, are honored. involve change, whereas not all change is related to transition. Differences could be Dancers enter the nursing situation, visualized as a circle of caring that provides exemplified by unmet or divergent expectations, feeling different, being perceived organizing purpose and integrated functioning. Dancers move freely; some as different, or seeing the world and others in different ways, and suggested that it dancers touch, some dance alone, but all dance in relation to each other and to might be useful for nurses to consider a client’s level of comfort and mastery in the circle. Each dancer brings special gifts as the nursing situation evolves. dealing with changes and differences. Some dancers may hear different notes and a different rhythm, but all harmonize Time span: all transitions may be characterized as flowing and moving over time. in the unity of the dance and the oneness of the circle. Personal knowing of self Critical points and events are the final property of transitions and