Theoretical Foundations in Nursing PDF

Universidad de Sta. Isabel de Naga, Inc. College of Health Sciences Nursing Program THEORETICAL FOUNDATIONS IN NURSING Final Grading Period II. THEORIES...

Universidad de Sta. Isabel de Naga, Inc. College of Health Sciences Nursing Program THEORETICAL FOUNDATIONS IN NURSING Final Grading Period II. THEORIES RELATED TO NURSING HIERARCHY OF NEEDS THEORY Abraham Harold Maslow (April 1, 1908-June 8, 1970) ❑ Born in New York, USA. ❑ An American Psychologist and philosopher best known for his self-actualization theory of psychology, which argued that the primary goal of psychotherapy should be the integration of the self. ❑ Maslow studied psychology at the University of Wisconsin and Gestalt Psychology at the New School for Social Research in New York City before joining the faculty of Brooklyn College in 1937. ❑ In 1951, he became head of the psychology department at Brandeis University (Waltham, Massachusetts), where he remained until 1969. ❑ In his major works, Motivation and Personality (1954) and Toward a Psychology of Being (1962), Maslow argued that each person has a hierarchy of needs that must be satisfied, ranging from basic physiological requirements to love, esteem, and, finally, self- actualization. ❑ As each need is satisfied, the next higher level in the emotional hierarchy dominates conscious functioning. Maslow believed that truly healthy people were self-actualizers because they satisfied the highest psychological needs, fully integrating the components of their personality or self. ❑ Co-founder of the Journal of Humanistic Psychology in 1961 with Anthony Sutich (SAGE Publishing). ❑ Co-founder of the Journal of Transpersonal Psychology in 1969 with Anthony Sutich and Stanislav Grof (Richards, 2017). HUMANISTIC PSYCHOLOGY ❑ Maslow believed that psychoanalysis focused too much on “the sick half of psychology” and not enough on “the healthy half”. ❑ On the other hand, he believed that behaviorism did not focus enough on how humans differ from the animals studied in behaviorism. ❑ He thus contributed to the third force of psychology that arose in response to this frustration: humanistic psychology. ❑ Humanistic psychology gained influence for its “appreciation for the fundamental inviolability of the human experience” (Bugental, 1963). /mcpm2024 THE HIERARCHY OF NEEDS ❑ Hierarchy literally means “Rank or Division of Angels” ❑ The word comes from the Greek hierarchēs, which was formed by combining the words hieros, meaning “supernatural, holy,” and archos, meaning “ruler.” ❑ Hierarchy has continued to spread its meaning beyond matters ecclesiastical and governmental, and today is commonly found used in reference to any one of a number of different forms of graded classification. ❑ The hierarchy of needs comes from Maslow’s belief that: “the fundamental desires of human beings are similar despite the multitude of conscious desires” (Zalenski & Raspa, 2006). ❑ He contended that the “basic human needs” is the motivation behind behavior. ❑ In his seminal paper on human motivation, Maslow describes his hierarchy of needs as being made up of five needs, which are “physiological, safety, love, esteem, and self- actualization” arranged in a pyramidal manner, with physiological needs making up the bottom of the pyramid (Maslow, 1943). Maslow describes these needs as “being arranged in a hierarchy of prepotency”. ❑ The basic human needs as a hierarchy, a progression from simple physical needs to more complex emotional needs. TYPES OF NEEDS ❑ According to Maslow, the basic physiological needs related to survival (food, water, etc.) must be met first of all. ❑ These basic physiological needs have a greater priority over those higher on the pyramid. They must be met before the person can move on to higher level needs. In other words, a person who is starving will not be concentrating on building his self-esteem. A patient in severe pain will not be concerned with improving his interpersonal relationships. /mcpm2024  ❑ Generally speaking, each lower level must be achieved before the next higher level(s) can be focused upon. ❑ The assumption in Maslow’s theory maintains that a person does not feel a higher need until the needs of the current level have been satisfied. “B” NEEDS VS. “D” NEEDS 1. Deficiency or deprivation Needs The first four levels are considered deficiency or deprivation needs (“D-needs”) in that their lack of satisfaction causes a deficiency that motivates people to meet these needs 2. Growth Needs or B-Needs or Being Needs The needs Maslow believed to be higher, healthier, and more likely to emerge in self- actualizing people are Being Needs, or B-needs. ❑ Growth needs are the highest level, which is self-actualization, or the self-fulfillment. ❑ Maslow suggested that only two percent of the people in the world achieve self - actualization. E.g. Abraham Lincoln, Thomas Jefferson, Albert Einstein, Eleanor Roosevelt. ❑ Self-actualized people were reality and problem centered. ❑ They enjoyed being by themselves, and having deeper relationships with a few people instead of more shallow relations with many people. ❑ They tended to be spontaneous and simple. APPLICATION IN NURSING ❑ Maslow's hierarchy of needs is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions. (Smeltzer SC, Bare BG, 2004) ❑ Identify the level of care required for the patient. Confirming what setting the patient will receive care can help you to understand which patient needs must be met first. /mcpm2024  ❑ Evaluate patient communication to determine what needs are not being met. Body language that includes slouching can reflect a need for respect while crossed arms can denote a need for safety. Grumpy tones and harsh words can also reflect a need for care and concern. ❑ Adjust your behavior towards your patients to show acknowledgement of those needs. Express concern to grumpy patients. Be transparent about procedures and processes to insecure patients. Speak intelligently and respectfully to patients whose behavior indicates a desire for respect. Understand that patients may feel like they are at the mercy of their health and at the medical staff to restore them. ❑ Allow yourself to form a bond with patients. Patients in extended care programs, such as residents in nursing homes, will benefit from bonding with their caretakers. Laugh, joke and enjoy their individual personalities. Express real concern over their lamentations and enjoy when they share happy news of their lives. They do so to bond with you, so embrace it. TRANSACTIONAL ANALYSIS Eric Berne (May 10, 1910-July 15, 1970) ▪ Canadian-born psychiatrist who created the theory of transactional analysis as a way of explaining human behavior. ▪ Born in Montreal, Canada, as Leonard Bernstein. He was the son of David Bernstein, MD, a general practitioner, and Sarah Gordon Bernstein, a professional writer and editor. ▪ Eric was close to his father and spoke fondly of how he accompanied his father, a physician, on medical rounds. Eric later recounted stories of travelling on a horse-pulled sleigh on ice in the cold Montreal winters with his father to visit patients. ▪ Unfortunately, Dr. Bernstein died of tuberculosis at age 38. Mrs. Bernstein then supported herself and her two children working as an editor and writer. She encouraged Eric to follow in his father’s footsteps and to study medicine in Montreal. EDUCATION ▪ He received an M.D. and C.M. (Master of Surgery) from McGill University Medical School in 1935, receiving high marks and accolades from the medical faculty. ▪ Eric came to the United States in 1935 when he began his internship at Englewood Hospital in New Jersey. ▪ In 1936, he began his psychiatric residency at the Psychiatric Clinic of Yale University School of Medicine. ▪ 1938-39, Berne became an American citizen and shortened his name from Eric Lennard Bernstein to Eric Berne. His first appointment post-residency was as a Clinical Assistant in Psychiatry at Mt. Zion Hospital in New York City. PROFESSIONAL CAREER ▪ From 1938-40, Berne was an assistant physician at Ring Sanitarium, Arlington Heights, Massachusetts. ▪ From 1940-43 he was employed as a psychiatrist in a sanitarium and concurrently as a clinical assistant in psychiatry at Mt Sinai Hospital in New York. He also maintained a private practice. /mcpm2024  ▪ Due to World War II, there was significant demand for army psychiatrists. Eric Berne served as a psychiatrist from 1943-46 in the Army Medical Corps, starting as a First Lieutenant and rising to Major. His assignments included Spokane, Washington, Ft. Ord, California and Brigham City, Utah. During the later two years he practiced group therapy in the Psychiatric wards of Bushnell General Hospital in Brigham City. ▪ After his discharge in 1946, he settled in Carmel, California, and resumed his psychoanalytic training that he had begun in New York City, prior to the War, at the San Francisco Psychoanalytic Society and Institute. ▪ In 1947-1949 Berne studied under Erik Erikson. ▪ Transactional analysis (TA) is a widely recognized form of modern psychology. The concept and paradigm were developed by Eric Berne in the late 1950’s. ▪ It is a psychoanalytic theory and method of therapy wherein social transactions are analyzed to determine the ego state of the communicator (whether parent-like, childlike, or adult-like) as a basis for understanding behavior. ▪ It is one of the most accessible theories of psychology that is designed to promote personal growth and change. ▪ It is considered a fundamental therapy for well-being and for helping individuals to reach their full potential in all aspects of life. ▪ In transactional analysis, the communicator is taught to alter the ego state as a way to solve emotional problems. The method deviates from Freudian psychoanalysis which focuses on increasing awareness of the contents of unconsciously held ideas. ▪ Transactional Analysis (TA) is part of social psychology and Berne’s goal was to cure people, instead of just making progress in treating them. Transactional Analysis is based on the idea that people’s early life experiences determine the decisions they will make. These can be both positive and negative decisions that influence their quality of life. This is also referred to as the script. PSYCHOANALYSIS A set of theories and therapeutic techniques related to the study of the unconscious mind, which together form a method of treatment for mental disorders. The discipline was established in the early 1890s by Austrian neurologist Sigmund Freud, who retained the term psychoanalysis for his own school of thought, and stemmed partly from the clinical work of Josef Breuer and others. Psychoanalysis was later developed in different directions, mostly by students of Freud. TRANSACTIONS The framework of Transactional analysis, the key in studying TA and the fundamental unit of social intercourse. Dr. Eric Berne developed transactional analysis in the late 1950s, using “transaction” to describe the fundamental unit of social intercourse, with “transactional analysis” being the study of social interactions between individuals. His influences included contemporaries such as René Spitz, Erik Erikson, Paul Federn, Edoardo Weiss, as well as Freud and Wilder Penfield, a Canadian neurosurgeon. Although Berne defined transactions long before he published Games People Play, his description of transactions in Games is the most easily understood: /mcpm2024  The unit of social intercourse is called a transaction. If two or more people encounter each other… sooner or later one of them will speak, or give some other indication of acknowledging the presence of the others. This is called transactional stimulus. Another person will then say or do something which is in some way related to the stimulus, and that is called the transactional response. With this definition, Dr. Berne defined the basic unit of analysis. At its simplest level, Transactional Analysis is the method for studying interactions between individuals. Berne felt that a therapist could learn what the problem was by simply observing what was communicated (words, body language, facial expressions) in a transaction. So instead of directly asking the patient questions, Berne would frequently observe the patient in a group setting, noting all of the transactions that occurred between the patient and other individuals. BERNE’S 3 EGO STATES Berne distinguishes three different ways to experience the world around us in Transactional Analysis. Based on these three perspectives, people behave differently depending on the situation. These are called the egos, in which thinking, feeling and behavior are the main factors. There’s the Parent, the Adult, the Child, which can be compared to the Winner (parent), Loser (child), and the Neutral (adult). These three egos are present in each person as well. The Child and Parent are rooted in the past. The Adult handles based on the present. Each ego can interact with others. Eric Berne calls that transactions. Within Transactional Analysis, such a transaction is two-way communication. On the one hand there is the actual and intended communication, and on the other there’s the implied psychological sublayer. In addition to the analysis of the interactions between individuals, Transactional Analysis also involves the identification of the ego states behind each and every transaction. Ego state is “a consistent pattern of feeling and experience directly related to a corresponding consistent pattern of behavior.” 1. PARENT The parent represents a massive collection of recordings in the brain of external events experienced or perceived in approximately the first five years of life. Since the majority of the external events experienced by a child are actions of the parent, the ego state was appropriately called Parent. Note that events perceived by the child from individuals that are NOT parents (but who are often in parent-like roles) are also recorded in the Parent. When Transactional Analysts refer to the Parent ego state (as opposed to a biological or stepparent), it is capitalized, the same goes for the other two states (Adult and Child). It is worth noting that, while recording these events, the young child has no way to filter the data; the events are recorded without question and without analysis. One can consider that these events are imposed on the child. The Parent ego is the deeply rooted voice of authority that people think, feel and express in the way parents do towards their children. The Parent ego stands for power and authority, and is pedantic and know-it-ally. The Parent ego is judgmental, critical and uses patronizing language. The ‘raised finger’ is typical for this ego. /mcpm2024  Examples of recordings in the Parent include: ✓ “Always chew with your mouth closed” ✓ “Never talk to strangers” ✓ “Look both ways before you cross the street” 2. CHILD In contrast to the Parent, the Child represents the recordings in the brain of internal events associated with external events the child perceives. Stated another way, stored in the Child are the emotions or feelings which accompanied external events. The Child ego thinks, feels and behaves like a small child. This can be positive; for instance, feeling excited about an upcoming holiday. Often though, it’s expressed negatively in the form of difficult behavior, disagreeing with others, wanting to get their way, rude behavior or anger and rage. Emotion takes over the Child ego and removes all inhibitions. The Child ego enjoys bragging, twisting the truth and making things seem worse than they are to impress others. Like the Parent, recordings in the Child occur from childbirth all the way up to the age of approximately 5 years old. Examples of recordings in the Child include: ✓ “When I saw the monster’s face, I felt really scared” ✓ “The clown at the birthday party was really funny! 3. ADULT The Adult is the last ego state. Close to one year of age, a child begins to exhibit gross motor activity. The child learns that he or she can control a cup from which to drink, that he or she can grab a toy. In social settings, the child can play peek-a-boo or hide and seek. This is the beginning of the Adult in the small child. Adult data grows out of the child’s ability to see what is different than what he or she observed (Parent) or felt (Child). The Adult allows the young person to evaluate and validate Child and Parental data. Berne describes the Adult as being “principally concerned with transforming stimuli into pieces of information, and processing and filing that information on the basis of previous experience” Stated another way, Harris describes the Adult as “a data-processing computer, which grinds out decisions after computing the information from three sources: the Parent, the Child, and the data which the adult has gathered and is gathering” The Adult ego lives in the here and now. This ego has the ability to carefully think and take action based on available facts and data. If you want to change the Parent ego or the Child ego, it’s best to do it through the Adult ego. This ego is verbally skilled and asks many open-ended questions and bases its opinion on facts. The Adult ego also makes comparisons to other situations in order to form an objective opinion. The most important characteristics are showing interest in others, emphatic ability and patience. /mcpm2024  Parent – taught concept Child – felt concept Adult – learned concept ANALYZING TRANSACTIONS When two people communicate, one person initiates a transaction with the transactional stimulus. The person at whom the stimulus is directed will respond with the transactional response. Simple Transactional Analysis involves identifying which ego state directed the stimulus and which ego state in the other person executed the response. According to Dr. Berne, the simplest transactions are between Adult’s ego states. Example: ✓ A surgeon will survey the patient, and based upon the data before him/her, his/her Adult decides that the scalpel is the next instrument required. The surgeon’s Adult holds out his/her hand, providing the transactional stimulus to the nurse. The nurse’s Adult looks at the hand, and based upon previous experiences, concludes that the scalpel is needed. The nurse then places the scalpel in the surgeon’s hand. ▪ Quoting Dr. Berne in Games People Play: “The fevered child asks for a glass of water, and the nurturing mother brings it.” In this, the Child of a small child directs an inquiry to the Parent of his/her mother. ▪ The Parent of the mother acknowledges this stimulus, and then gives the water to the child. In this example, the small child’s request is the stimulus, and the parent providing the water is the response. This is nearly as simple as an Adult- Adult transaction. STRUCTURAL DIAGRAM One of the tools used by a Transactional Analysis practitioner. A structural diagram represents the complete personality of any individual. It includes the Parent, Adult, and Child ego states, all separate and distinct from each other. The diagram was developed by Eric Berne before Games People Play when he was developing his theories of Transactional Analysis. /mcpm2024  COMPLEMENTARY TRANSACTION Not all transactions between humans are healthy or normal. In these cases, the transaction is classified as a crossed transaction. In a crossed transaction, an ego state different than the ego state which received the stimuli is the one that responds An example is as follows: Agent’s Adult: “Do you know where my cuff links are?” (Note that this stimulus is directed at the Respondents Adult). Respondent’s Child: “You always blame me for everything!” This is one the classic crossed transactions that occurs in marriage. Instead of the Respondent’s Adult responding with “I think they’re on the desk”, it is the Respondent’s Child that responds back. CROSSED TRANSACTION It is important to note that when analyzing transactions, one must look beyond what is being said. According to Dr. Berne, one must look at how the words are being delivered as the non-verbal signs accompanying those words are essential. (accents on particular words, changes in tone, volume of the voice, body language, facial expressions, etc.). Transactional Analysts will pay attention to all of these cues when analyzing a transaction and identifying which ego states are involved. For Nurses, to effectively assess our patients and practice effective communication skills, we should pay close attention to non-verbal cues. (These could be identifiers of pain, discomfort or any issues affecting the patient’s underlying health condition) /mcpm2024 STROKES Berne defined a stroke as the “fundamental unit of social action.” A stroke is a unit of recognition, when one person recognizes another person either verbally or non- verbally. Berne introduced the idea of strokes into Transactional Analysis based upon the work of Rene Spitz, a researcher who did pioneering work in the area of child development. Spitz observed that infants deprived of handling – in other words, not receiving any strokes – were more prone to emotional and physical difficulties. These infants lacked the cuddling, touching, and handling that most other infants received. Berne postulated that adults need physical contact just like infants, but have learned to substitute other types of recognition instead of physical stimulation. So while an infant needs cuddling, an adult craves a smile, a wink, a hand gesture, or other form of recognition. Berne defined the term recognition-hunger as this requirement of adults to receive strokes. Berne also reasoned that any stroke, be it positive or negative, is better than no strokes at all. Each person has a need to feel noticed, appreciated and liked by others. 1. Complementary transaction-The equal and therefore effective communication between Child-Child, Adult-Adult, Parent-Parent. 2. Ulterior transaction- The equal communication, followed by for instance the Parent ego to the Child ego. 3. Crossed transaction SCRIPT The Script is central to Transactional Analysis and can be viewed as a well-described approach people use because they already learned and experienced it as a child. Transactional Analysis makes it possible to analyze these scripts. Behavioral change can help alter the scripts. Negative scripts inhibit any individual’s growth and development, whereas positive scripts have a motivating effect. Within Transactional Analysis, three different types of scripts are distinguished; the Winner, the Loser and the Non-winner (neutral). All three scripts can be going on in the same person. /mcpm2024  One example of this is that many men refuse to ever cry in public, because they learned during childhood that ‘boys don’t cry’. There are also less innocuous scripts that make people repeat their behavior and lead to conflicts with their environment. BENEFITS OF TRANSACTIONAL ANALYSIS 1. Designed to promote personal growth and change, transactional analysis offers the opportunity to develop all kinds of skills that can be applied to all areas of life. This makes the therapy valuable for helping to solve many types of problems. 2. TA has been successfully applied in a wide variety of settings outside of counselling, including organizational training and consultancy, parenting, education and coaching. 3. One of the exciting things about transactional analysis is the simple models and language it employs, which help you to understand why you have become who you are today and how (and in what ways) you relate to other people. 4. Essentially, transactional analysis can be used in any field where there is a need for understanding of individuals, communication and relationships. As a result, it is particularly useful where there are issues of conflict, confusion or where something is lacking. Relationship issues - between families, friends and couples - tend to benefit greatly, as TA encourages clients to address problems that have built up over time. 5. Many people find TA therapy appealing as it promotes an equal relationship between client and therapist, in which the client is encouraged to focus on their commitment to change. Berne believed everyone has the capacity to decide what they want for their lives, and the therapy helps clients to recognize their worth and value in order to go about achieving these goals. GENERAL SYSTEMS THEORY Karl Ludwig von Bertalanffy (September 19, 1901 – June 12, 1972) An Austrian-born biologist known as one of the founders of General Systems Theory (GST). He was born and grew up in the little village of Atzgersdorf (now EDUCATION Liesing) near Vienna. Bertalanffy met his wife, Maria, in April 1924 in the Austrian Alps, they were hardly ever apart for the next forty-eight years. She wanted to finish studying but never did, instead devoting her life to Bertalanffy's career. Later, in Canada, she would work both for him and with him in his career, and after his death she compiled two of Bertalanffy's last works. They had one child, a son who followed in his father's footsteps by making his profession in the field of cancer research. Bertalanffy grew up in Austria and subsequently worked in Vienna, London, Canada, and the United States. EDUCATION He grew up as an only child educated at home by private tutors until he was ten. When he arrived at his Gymnasium (a form of grammar school) he was already well habituated in learning by reading, and he continued to study on his own. His neighbor, the famous biologist Paul Kammerer, became a mentor and an example to the young Ludwig. In 1918, Bertalanffy started his studies at the University level in philosophy and art history, first at the University of Innsbruck and then at the University of Vienna. /mcpm2024  In 1926, he finished his PhD thesis (Fechner and the Problem of Higher-Order Integration) on the psychologist and philosopher Gustav Theodor Fechner. For the next six years he concentrated on a project of "theoretical biology" which focused on the philosophy of biology. He received his habilitation in 1934 in "theoretical biology". Bertalanffy was appointed Privatdozent at the University of Vienna in 1934. Today, Bertalanffy is considered to be a founder and one of the principal authors of the interdisciplinary school of thought known as General Systems Theory. According to Weckowicz (1989), he "occupies an important position in the intellectual history of the 20th century. His contributions went beyond biology, and extended into cybernetics, education, history, philosophy, psychiatry, psychology and sociology. Some of his admirers even believe that this theory will one day provide a conceptual framework for all these disciplines". GENERAL SYSTEMS THEORY General Systems Theory is a general science of 'wholeness’. Systems theory may be considered as a specialization of systems thinking and a generalization of systems science. GST is an interdisciplinary practice that describes systems with interacting components, applicable to biology, cybernetics, and other fields. Bertalanffy proposed that the classical laws of thermodynamics applied to closed systems, but not necessarily to "open systems", such as living things. His mathematical model of an organism's growth over time, published in 1934, is still in use today. A system is a cohesive conglomeration of interrelated and interdependent parts which can be natural or human-made. Every system is bounded by space and time, influenced by its environment, defined by its structure and purpose, and expressed through its functioning. A system may be more than the sum of its parts if it expresses synergy or emergent behavior. ASSUMPTIONS ✓ Changing one part of a system may affect other parts or the whole system and it may be possible to predict these changes in patterns of behavior. ✓ For systems that learn and adapt, the growth and the degree of adaptation depend upon how well the system is engaged with its environment. ✓ Some systems support other systems, maintaining the other system to prevent failure. ✓ The goals of systems theory are to model a system's dynamics, constraints, conditions, and to elucidate principles (such as purpose, measure, methods, tools) that can be discerned and applied to other systems at every level of nesting, and in a wide range of fields for achieving optimized equifinality. ✓ General systems theory is about developing broadly applicable concepts and principles, as opposed to concepts and principles specific to one domain of knowledge. /mcpm2024  KEY CONCEPTS IN GENERAL SYSTEMS THEORY In Bertalanffy's book titled General System Theory: Foundations, Development, Applications from 1968, he developed the "Allgemeine Systemlehre" (General Systems Theory) first via lectures beginning in 1937 and then via publications beginning in 1946. Von Bertalanffy's objective was to bring together under one heading the organismic science he had observed in his work as a biologist. His desire was to use the word system for those principles that are common to systems in general. In GST, he writes:...there exist models, principles, and laws that apply to generalized systems or their subclasses, irrespective of their particular kind, the nature of their component elements, and the relationships or "forces" between them. It seems legitimate to ask for a theory, not of systems of a more or less special kind, but of universal principles applying to systems in general. — Von Bertalanffy CHARACTERISTICS OF SYSTEMS "Systems" refer specifically to self-regulating systems. Systems are self-correcting through feedback. Systems have a structure that is defined by its parts and processes. Systems are generalizations of reality. The various parts of a system have functional as well as structural relationships between each other. Systems tend to function in the same way. Every living organism is essentially an open system. Ludwig von Bertalanffy outlines systems inquiry into three major domains: Philosophy, Science, and Technology. He generalized the domains into four integratable domains of systemic inquiry: /mcpm2024  These operate in a recursive relationship, he explained. Integrating Philosophy and Theory as Knowledge, and Method and Application as action, Systems Inquiry then is knowledgeable action. CYBERNETICS The study of the communication and control of regulatory feedback both in living and lifeless systems (organisms, organizations, machines), and in combinations of those. Its focus is how anything (digital, mechanical or biological) controls its behavior, processes information, reacts to information, and changes or can be changed to better accomplish those three primary tasks. The terms "systems theory" and "cybernetics" have been widely used as synonyms. Some authors use the term cybernetic systems to denote a proper subset of the class of general systems, namely those systems that include feedback loops. SYSTEMS THEORY AND NURSING Systems theory has been applied in developing nursing theories and conducting nursing research. Many nursing theorists have drawn from the works of von Bertalanffy on systems theory. ✓ Neuman's Systems Theory ✓ Rogers 's Theory of Unitary Human Beings ✓ Roy's Adaptation Model ✓ Imogene King's Theory of Goal Attainment ✓ Orem Self-care Deficit Theory ✓ Johnson's Behavior Systems Model APPLICATION TO NURSING The importance of the systems approach lies in its potential for evaluating information to help individuals and their families progress toward the goal of healthy living. The protagonist in this scheme is not the individual but the nurse who acts as mechanic in the clinical setting. Health is seen narrowly as a state of thermodynamic balance. Illness lurks in the presence of undesirable - that is, unpredictable - sights, sounds and events. The nurse's job is to assess the extent to which all parts of the patient's system are in working order, and to identify and correct actual or potential threats to the patient's stability. The role of the recipient of nursing care is to comply with the professional's expert maneuvers. /mcpm2024  The nurse "must decide whether to support, to contract or to stabilize the forces at work" and is responsible for "safety and instruction and coordination of care.” This model of a mechanistic nurse may be appropriate in life threatening situations where the nurse restores oxygen or fluid balance, but it is clearly inappropriate in daily life. The nurse who applies general systems theory to nursing will be concerned with all aspects of the life of the individual. For instance, he or she may urge a person to eat a varied diet, strive to be punctual, watch programs other than soap operas on television, improve interpersonal relations or acquire further training or education. Imposition of the values of the western middle class raises scientific and ethical questions. We do not yet have sufficient knowledge to prescribe a regimen for healthy living. A systems model, to be relevant, must take into account the current state of knowledge about health. The health care "client" - whether an individual, a family or a community - and the health professional must work together for ideas and practices that will foster good health and well-being. CHANGE THEORY Kurt Lewin (September 9, 1890 - February 12, 1947) He was born in Germany and later, migrated to the United States. He was one of the most influential psychologists in history. He is considered the father of social psychology and the psychology of organizations. He is well known for his writings on group dynamics, group therapy and social psychology. Kurt Lewin introduced his field theory concepts, emphasizing that the group differs from the simple sum of its parts. He coined the term group dynamics in 1939. His approaches and his theory are applied to many areas nowadays, mainly in the organizational world. From an early age his family moved to Berlin (Germany). There, Lewin studied medicine and then biology in Munich. From a very young age he was also interested in philosophy and psychology, areas that he began studying formally in 1911. His field theory states that “one’s behavior is related both to one’s personal characteristics and to the social situation in which one finds oneself.” He was also an ardent political activist of socialism. He received his doctorate as a philosopher, but during the First World War, he was sent to the battlefront as an artilleryman. He was wounded soon and then returned to his normal life. When Kurt Lewin returned home, he began studying at the Psychological Institute of Berlin and there, he came into contact with several representatives of Gestalt psychology. 1914 - Joined the German army. 1916 - Awarded a Ph.D. from the University of Berlin (although he'd completed the requirements two years prior). 1921 - Became a lecturer at the Psychological Institute of the University of Berlin. /mcpm2024  1933 - Emigrated to the United States. 1935 - Became a professor at the University of Iowa; published A Dynamic Theory of Personality. 1944 - Established research center at MIT. Died at age 56 on February 12, 1947 of a heart attack. A NEW VISION OF PSYCHOLOGY When Kurt Lewin arrived in the United States, the prevailing psychological current was behaviorism. This raised that the man was like a black box. It was born like a blank sheet. The influence of others was what shaped the personality and made everyone what they were. For Lewin, on the other hand, each individual is not passive, but rather establishes an interaction with his environment. Kurt Lewin designed some new postulates to understand human behavior. He borrowed the concept of "field" from physics. In this discipline, this term refers to an area of space that has certain properties or factors that give it a specific configuration. In the same way, for Kurt Lewin, human behavior is the result of a field. This comprises a set of coexisting events, in which the change in one part affects the change of the whole as a whole. In turn, the subject perceives these facts and their dynamics, in a particular way. All this makes up what Kurt Lewin called "living space". LIVING SPACE The variables that are operating in this dynamic field, or vital space, are fundamentally three: 1. Tension 2. Force 3. Necessity Lewin points out that when you want to understand human behavior, all the variables that may be affecting your living space must be taken into account. This includes from the degree of illumination of an enclosure, to the socialization patterns that are in your group. Based on all this, Kurt Lewin states that it is perfectly valid to introduce changes in that environment to study the reactions of the subjects that interact in it and with it. KEY CONCEPTS IN CHANGE THEORY 1. Driving Forces Driving forces are forces that push in a direction that causes change to occur. Driving forces facilitate change because they push the person in the desired direction. They cause a shift in the equilibrium towards change. 2. Restraining Forces Restraining forces are forces that counter driving forces. Restraining forces hinder change because they push the person in the opposite direction. Restraining forces cause a shift in the equilibrium which opposes change /mcpm2024  3. Equilibrium Equilibrium is a state of being where driving forces equal restraining forces and no change occurs. Equilibrium can be raised or lowered by changes that occur between the driving and restraining forces. As future nurses, It is pertinent that the driving forces and restraining forces must be analyzed before implementing a planned change. If you have a large cube of ice but realize that what you want is a cone of ice, what do you do? First you must melt the ice to make it amenable to change (unfreeze). Then you must mold the iced water into the shape you want (change). Finally, you must solidify the new shape (refreeze). THREE DISTINCT AND VITAL STAGES IN LEWIN’S CHANGE THEORY: 1. Unfreeze 2. Change 3. Refreeze By looking at change as a process with distinct stages, you can prepare yourself for what is coming and plan to manage the transition – looking before you leap, so to speak. All too often, people go into change blindly, causing much unnecessary turmoil and chaos. To begin any successful change process, you must first start by understanding why the change must take place. As Lewin placed it, "Motivation for change must be generated before change can occur. One must be helped to re-examine many cherished assumptions about oneself and one’s relations to others." This is the unfreezing stage from which change begins. STEP 1: UNFREEZE ✓ Unfreezing is the process which involves finding a method of making it possible for people to let go of an old pattern that was counterproductive in some way. ✓ Unfreezing is necessary to overcome the strains of individual resistance and group conformity. ✓ Unfreezing can be achieved by the use of three methods: 1. First, increase the driving forces that direct behavior away from the existing situation or status quo. 2. Second, decrease the restraining forces that negatively affect the movement from the existing equilibrium. 3. Third, find a combination of the two methods listed above. ✓ This first stage of change involves preparing the organization to accept that change is necessary, which involves breaking down the existing status quo before you can build up a new way of operating. ✓ Key to this is developing a compelling message showing why the existing way of doing things cannot continue. This is easiest to frame when you can point to declining sales figures, poor financial results, worrying customer satisfaction surveys, or suchlike. These show that things have to change in a way that everyone can understand. ✓ To prepare the organization successfully, you need to start at its core – you need to challenge the beliefs, values, attitudes, and behaviors that currently define it. Using the analogy of a building, you must examine and be prepared to change the existing /mcpm2024  foundations as they might not support add-on stories. Unless this is done, the whole building may risk collapse. ✓ This first part of the change process is usually the most difficult and stressful. When you start cutting down the "way things are done," you put everyone and everything off balance. You may evoke strong reactions in people, and that's exactly what needs to be done. ✓ By forcing the organization to re-examine its core, you effectively create a (controlled) crisis, which in turn can build a strong motivation to seek out a new equilibrium. Without this motivation, you won't get the buy-in and participation necessary to effect any meaningful change. Practical Steps for Unfreezing 1. Determine what needs to change. ▪ Survey the organization to understand the current state. ▪ Understand why change has to take place. 2. Ensure there is strong support from senior management. ▪ Use Stakeholder Analysis and Stakeholder Management to identify and win the support of key people within the organization. ▪ Frame the issue as one of organization-wide importance. 3. Create the need for change. ▪ Create a compelling message about why change has to occur. ▪ Use your vision and strategy as supporting evidence. ▪ Communicate the vision in terms of the change required. ▪ Emphasize the "why.“ 4. Manage and understand the doubts and concerns. ▪ Remain open to employee concerns and address them in terms of the need to change. STEP 2: CHANGE “Moving to a new level or Changing” or Movement This stage involves a process of change in thoughts, feeling, behavior, or all three, that is in some way more liberating or more productive. After the uncertainty created in the unfreeze stage, the change stage is where people begin to resolve their uncertainty and look for new ways to do things. People start to believe and act in ways that support the new direction. The transition from unfreeze to change does not happen overnight: people take time to embrace the new direction and participate proactively in the change. A related change model, the Change Curve, focuses on the specific issue of personal transitions in a changing environment and is useful for understanding this aspect in more detail. In order to accept the change and contribute to making it successful, people need to understand how it will benefit them. Not everyone will fall in line just because the change is necessary and will benefit the company. This is a common assumption and a pitfall that should be avoided. Unfortunately, some people will genuinely be harmed by change, particularly those who benefit strongly from the status quo. Others may take a long time to recognize the benefits that change brings. You need to foresee and manage these situations. /mcpm2024  Time and communication are the two keys to the changes occurring successfully. People need time to understand the changes, and they also need to feel highly connected to the organization throughout the transition period. When you are managing change, this can require a great deal of time and effort, and hands-on management is usually the best approach. Practical Steps for Changing 1. Communicate often. ▪ Do so throughout the planning and implementation of the changes. ▪ Describe the benefits. ▪ Explain exactly how the changes will affect everyone. ▪ Prepare everyone for what is coming. 2. Dispel rumors. ▪ Answer questions openly and honestly. ▪ Deal with problems immediately. ▪ Relate the need for change back to operational necessities. 3. Empower action. ▪ Provide lots of opportunity for employee involvement. ▪ Have line managers provide day-to-day direction. 4. Involve people in the process. ▪ Generate short-term wins to reinforce the change. ▪ Negotiate with external stakeholders as necessary (such as employee organizations). STEP 3: REFREEZE Refreezing is establishing the change as a new habit, so that it now becomes the “standard operating procedure.” Without this stage of refreezing, it is easy to go back to the old ways. When the changes are taking shape and people have embraced the new ways of working, the organization is ready to refreeze. The outward signs of the refreeze are a stable organization chart, consistent job descriptions, verbal understanding of a specific health instruction and positive patient outcomes. The refreeze stage also needs to help people and the organization internalize or institutionalize the changes. This means making sure that the changes are used all the time, and that they are incorporated into everyday business. With a new sense of stability, employees feel confident and comfortable with the new ways of working. The rationale for creating a new sense of stability in our ever-changing world is often questioned. Even though change is a constant in many organizations, this refreezing stage is still important. Without it, employees get caught in a transition trap where they aren't sure how things should be done, so nothing ever gets done to full capacity. In the absence of a new frozen state, it is very difficult to tackle the next change initiative effectively. How do you go about convincing people that something needs changing if you haven't allowed the most recent changes to sink in? Change will be perceived as change for change's sake, and the motivation required to implement new changes simply won't be there. As part of the refreezing process, make sure that you celebrate the success of the change – this helps people to find closure, thanks them for enduring a painful time, and helps them believe that future change will be successful. /mcpm2024 Practical Steps for Refreezing 1. Anchor the changes into the culture. Identity what supports the change. Identify barriers to sustaining change. 2. Develop ways to sustain the change. Ensure leadership support. Create a reward system. Establish feedback systems. Adapt the organizational structure as necessary. 3. Provide support and training. Keep everyone informed and supported. 4. Celebrate success! EXAMPLE USING LEWIN’S CHANGE THEORY Sue, a new nurse working in a medical-surgical unit, identifies that bedside handoff reports are not currently being used during shift reports. Step 1: Unfreeze: Sue recognizes a change is needed for improved patient safety and discusses the concern with Jason, the nurse manager. Current evidence-based practice is shared regarding bedside handoff reports between shifts for patient safety Jason initiates activities such as scheduling unit meetings to discuss evidence-based practice and the need to incorporate bedside handoff reports. Step 2: Change: Jason gains support from the Director of Nursing to implement organizational change and plans staff education about bedside report checklists and the manner in which they are performed. Step 3: Refreeze: Jason adopts bedside handoff reports in a new unit policy and monitors staff for effectiveness. Never ending change is a fact of life and, in particular, nursing and health; therefore, we need to use theories such as Lewin’s Change theory to help us learn, change and improve the provision of nursing care for diverse populations in a constantly and dramatically changing health care environment. PSYCHOSOCIAL THEORY Erik Homburger Erikson (15 June 1902 – 12 May 1994) He was born in Germany. As a German-American developmental psychologist and psychoanalyst, he is well known for his theory on psychological development of human beings. He may be most famous for coining the phrase “identity crisis”. His son, Kai T. Erikson, is a noted American sociologist. As a young man, Erikson attended art school and traveled around Europe. In 1927, when he was invited by the psychoanalyst Anna Freud to teach art, history, and geography at a small private school in Vienna, he entered psychoanalysis with her and underwent training to become a psychoanalyst himself. Despite lacking a bachelor's degree, Erikson served as a professor at prominent institutions, including Harvard, University of California, Berkeley, and Yale. His classic work "Childhood and Society" set forth his theory of the life cycle. Young Man Luther, Identity: Youth and Crisis, and Gandhi's Truth are his other influential works. /mcpm2024  He believed that the achievements and failures of earlier stages influence later stages, whereas later stages modify and transform earlier ones. Erikson's conceptualization of psychosocial development based its model the epigenetic principle of organismic growth in utero. Erikson views psychosocial growth occurs in phases. EIGHT STAGES OF THE LIFE CYCLE Erikson explains 8 developmental stages in which physical, cognitive, instinctual, and sexual changes combine to trigger an internal crisis whose resolution results in either psychosocial regression or growth and the development of specific virtues. ▪ Erikson defined virtue as "inherent strength". ▪ Each stage is characterized by two contradictory emotional forces known as contrary dispositions, usually labeled as “syntonic” and “dystonic” dispositions. These dispositions cause a crisis or task that we need to resolve or master. ▪ According to the Erik Erikson theory, when we resolve this crisis successfully, we gain a sense of competence. Failure to do so may lead to feelings of inadequacy and a less healthy personality. /mcpm2024 1st stage: Trust vs. Mistrust ❑ Erikson’s first stage of psychosocial development starts from infant to about 18 months old. At this stage, infants must learn to trust others, particularly those who care for their basic needs. ❑ The infant is taking the world in through the mouth, eyes, ears, and sense of touch. ❑ A baby whose mother is able to anticipate and respond to its needs in a consistent and timely manner despite its oral aggression will learn to tolerate the inevitable moments of frustration and deprivation. ❑ A person who, as a result of severe disturbances in the earliest dyadic relationships, fails to develop a basic sense of trust or the virtue of hope may be predisposed as an adult to the profound withdrawal and regression characteristic of schizophrenia (Newton DS, Newton PM, 1998). ❑ Small babies may view this “new world” as threatening, as they must depend on others for their survival. Depending on how they are treated by their caregivers, this sense of threat can be replaced by trust. ❑ Caregivers who are sensitive and responsive to their baby’s basic needs, such as food and shelter, help their baby develop a sense of security. When these babies learn that they will receive the care they need when they need it, they begin to feel safe and learn to trust the people around them. ❑ On the other hand, caregivers who are unresponsive to their baby’s needs can cause their baby to view this “new world” as unreliable and unpredictable. These babies may develop a sense of anxiety and mistrust, which will affect how they interact with others as they grow up. ❑ The virtue that is developed upon a healthy resolution of the crisis at this Erikson’s stage is “hope”. This is manifested by a deep faith and conception that everything will turn out to be okay. 2nd stage: Autonomy vs. Shame and Doubt ❑ 1 year old to 3 years old toddlers are at the second stage of Erikson’s stages of development. According to the Erik Erikson theory, children struggle with issues of personal control and establishment of self as an entity. ❑ As children grow physically and cognitively, they acquire skills that allow them to become partially independent of their caregivers. For example, they can play with their toys, feed themselves, go potty by themselves and even dress themselves. ❑ "This stage, therefore, becomes decisive for the ratio between loving good will and hateful self-insistence, between cooperation and willfulness, and between self-expression and compulsive self-restraint or meek compliance." – Erikson ❑ Here, the child will develop an appropriate sense of autonomy, otherwise doubt and shame will undermine free will. ❑ Other disturbances of improper transition of this stage results in perfectionism, inflexibility, stinginess and ruminative and ritualistic behavior of obsessive-compulsive personality disorder. ❑ Being equipped with some degree of trust and a budding self-awareness, these toddlers begin to pay more heed to their own judgement. Parents’ patience and encouragement are crucial in shaping their child’s success at this phase of the Erikson stages. Children who can’t take care of their own basic needs and continue to rely on their caregivers may begin to doubt their abilities. They may also feel shameful when they see other children of their age performing these tasks. /mcpm2024  ❑ As stated in the Erik Erikson’s theory of psychosocial development, the virtue that is developed at this Erikson stage is “Will”. Caregivers who perceive their children’s assertions of will and self- control as healthy striving towards independence will help their children become self-reliant, self-disciplined and responsible individuals who can exercise sound judgement and make decisions for themselves. 3rd stage: Initiative vs. Guilt ❑ This Erikson’s stage of psychosocial development occurs at 3-5 years of age. As toddlers become preschoolers, they begin to develop a sense of purpose. They like to explore and do things on their own. ❑ Here, the child’s task is to develop a sense of initiative as opposed to further shame or guilt. ❑ The child's increasing mastery of locomotor and language skills expands its participation in the outside world and stimulates omnipotent fantasies of wider exploration and conquest. ❑ At this stage, children learn about new concepts in school and through social interactions. Games and imagination are recognized by Erik Erikson theory as means through which these children learn about themselves and their social world. They like to try out new things and learn to cooperate with others to achieve common goals. They assert themselves more frequently, and begin to develop a sense of purposefulness. ❑ These children like to act out various family scenes and roles, such as teachers, police officers, doctors, as they see on TV. They make up stories with toys to demonstrate what they believe is the adult world. They also begin to explore their environment and ask a lot of “why” questions. ❑ As children at this Erikson stage begin to perform more tasks, they learn the importance of social approval. They begin to realize that some of the things that they want to do may not be approved by others. It’s essential for caregivers to encourage and guide their children to explore within limit. ❑ Over-controlling and overly strict caregivers who discourage their children from exploring new things may cause their children to develop a sense of guilt. These children may see themselves as a nuisance to others, and as a result, they take the role of “followers”. This may have a negative impact on their social life and may also hinder their creativity. ❑ Success at this phase of the Erikson stages will lead to the virtue of purpose, which is demonstrated by how the children make decisions, come up with new ideas, as well as work and play with others. 4th stage: Industry vs. Inferiority ❑ During elementary school age (6-13 years old), so called stage of latency. ❑ In this stage, Children become more competitive. They want to do things that their peers can do. They learn to read, write, do math, and play sports. ❑ Teachers play a significant role in these children’s life, as they are the ones who teach them these skills. ❑ At this time, children begin to expand their social network. They get to know their abilities as well as others’ abilities. They compare themselves to their peers as they feel the need to validate their competency. They feel proud and confident when they can do things as well as their peers. If they don’t measure up, they feel inferior. ❑ The child tries to master the crisis of industry versus inferiority aiming toward the development of a sense of competence. /mcpm2024  ❑ According to the Erik Erikson theory, by resolving the crisis at this stage, children develop the virtue of “competence” This virtue is demonstrated by making things, getting results, applying skills and feeling capable. 5th stage: Identity vs. Role Confusion ❑ At puberty, the fifth stage, the task of adolescence is to navigate their “identity crisis” as each individual struggle with a degree of “identity confusion.” ❑ This stage of the Erikson stages of development happens during adolescence (13-21 years old). ❑ It marks the shift from childhood to adulthood. It is also the turning point where “what the person has come to be” meets “the person society expects one to become.” ❑ At this point, young people experience a lot of changes in their body. They begin to contemplate on the role they want to play in the adult world. They examine existential questions such as “Who am I?” and “What can I be?”. They also try to develop their occupational and sexual identities by exploring different possibilities. ❑ Young people who succeed at this stage develop a strong sense of identity. When they come across challenges and problems, they can commit to their principles, ideals and beliefs. Those who fail to establish their own identity at this stage tend to be confused about themselves and about their future. They may end up following other people’s ideas. ❑ The lasting outcome of this stage can be a capacity for fidelity. The Erik Erikson theory suggests that young people who succeed at resolving the crisis at this stage develops the virtue of “fidelity”. ❑ This is characterized by the self-esteem and self-confidence that are requisite to associating freely with people and beliefs on the basis of their value, loyalty, and integrity. 6th stage: Intimacy vs. Isolation ❑ Young adulthood, at the stage of genitality or sixth stage, is marked by the crisis of intimacy versus isolation, out of which may come the achievement of a capacity for love. ❑ After having developed a strong sense of identity at stage five, young adults (21-39 years old) become concerned about finding companionship and intimacy at Erikson’s stage six of psychosocial development. ❑ It is at this stage that young adults think about settling down and starting families, and they are mor willing to sacrifice and compromise for the sake of their relationships. ❑ However, as they form relationships with others, they also get to experience rejections, such as being rejected by someone they like and breaking up with their partners. Painful rejections and sometimes fear of being rejected may result in what Erikson called “distantiation”. This happens when young adults isolate themselves to avoid and even destroy the people and negative forces that appear to be harmful to them. ❑ The virtue that is developed upon resolving the crisis at this stage is “love”. The Erikson theory suggests that at this stage, young adults develop the capacity to offer love, both physically and emotionally, and to accept love in return. They also become more adept at forming sincere reciprocal relationships and bond with others for mutual fulfilment. 7th stage: Generativity vs. Stagnation ❑ Generativity is primarily the concern for establishing and guiding the next generation. /mcpm2024  ❑ This failure of generativity can lead to profound personal stagnation, masked by a form of escape, such as alcohol and drug abuse, and sexual and other infidelities. Mid-life crisis may occur. ❑ At the seventh stage of Erikson’s stages of development, the primary concern of middle- aged adults (40-65 years old) is leaving a legacy. They feel the urge to be productive and make contributions to the society. For example, they may volunteer at their church or mentor young kids. They want to leave a legacy and make this world a better place for future generations. ❑ Major milestones may happen at this stage, such as children leaving home, change of career path, etc. Some people may experience mid-life crisis and struggle with finding new purposes in their lives. Failure to resolve the crisis at this stage may lead people to experience stagnation. They become uninterested in their environment and the people around them. ❑ Care is the virtue that corresponds to this stage. ❑ By successfully resolving the crisis at this stage, people develop the virtue of “care,” they are able to offer unconditional support for their children, their community and the society. 8th stage: Integrity vs. Despair ❑ At the last stage of Erikson’s stages of development, people are in late adulthood (65 years old and older). They are typically retirees. It is important for them to feel a sense of fulfillment knowing that they have done something significant and made meaningful contributions to the society during their younger years. ❑ "The acceptance of one's one and only life cycle and of the people who have become significant to it as something that had to be and that, by necessity, permitted of no substitutions." ❑ The individual in possession of the virtue of wisdom and a sense of integrity has room to tolerate the proximity of death and to achieve. ❑ When the attempt to attain integrity has failed, the individual may become deeply disgusted with the external world, and contemptuous of persons as well as institutions. ❑ When they look back at their lives, they experience a sense of integrity when they feel proud of their achievements. They are satisfied with the hand they were dealt with and have few regrets. This is truly possible on if they have successfully resolved the psychosocial crises in the earlier Erikson stages. ❑ People who are unsuccessful at this stage experience despair. they feel that they have wasted their lives and experience many regrets. They may feel bitterness towards what they were not able to accomplish in their lives and wish they could have second chances. ❑ Upon resolving the crisis at this stage successfully, people develop the virtue of “wisdom”. This is characterized by composure, broadmindedness, appropriate emotional forbearance, and peace of mind. These elderly people are likely to reflect on their lives positively even in the face of imminent death. /mcpm2024 NURSING IMPLICATIONS ✓ Application of Erikson's stages of psychosocial development helps in analyzing patient's symptomatic behavior in the context of traumatic past experiences and struggles with current developmental tasks. ✓ When patients' resolutions of previous psychosocial stages have been so faulty as to seriously compromise their adult development, they have the opportunity to rework every development through the relationship with the therapist. (Newton DS, Newton PM, 1998). ✓ "The object of psychotherapy is not to head off future conflict but to assist the patient in emerging from each crisis "with an increased sense of inner unity, with an increase of good judgment, and an increase in the capacity `to do well' according to his own standards and to the standards of those who are significant to him." (Erikson in Identity: Youth and Crisis) MORAL DEVELOPMENT THEORY Lawrence Kohlberg (October 25, 1927 – January 19, 1987) ▪ He was an American psychologist best known for his theory of stages of moral development. ▪ Born in Bronxville, New York. He was the youngest of four children of Alfred Kohlberg, a Jewish German entrepreneur, and of his second wife, Charlotte Albrecht, a Christian German chemist. ▪ He served as a professor in the Psychology Department at the University of Chicago and at the Graduate School of Education at Harvard University. ▪ Even though it was considered unusual in his era, he decided to study the topic of moral judgment, extending Jean Piaget's account of children's moral development from twenty- five years earlier. In fact, it took Kohlberg five years before he was able to publish an article based on his views. Kohlberg's work reflected and extended not only Piaget's findings but also the theories of philosophers George Herbert Mead and James Mark Baldwin. At the same time, he was creating a new field within psychology: "moral development". /mcpm2024  In an empirical study using six criteria, such as citations and recognition, Kohlberg was found to be the 30th most eminent psychologist of the 20th century. Kohlberg graduated from Phillips Academy in Andover, Massachusetts, in 1945. After serving in the U.S. merchant marine, he worked on a ship that had been hired by Haganah, the Zionist military organization, to smuggle Jewish war refugees into Palestine, past the British blockade. The ship was intercepted, however, and Kohlberg was imprisoned in a British internment camp in Cyprus. Returning to the U.S. in 1948, he enrolled at the University of Chicago, where he completed a Bachelors of Arts in psychology in one year and a Ph.D. in psychology in 1958. He subsequently held teaching positions at various institutions before settling at Harvard University in 1968. Lawrence Kohlberg devised a theory in which he explained six stages of moral development divided into three levels. Morality is the system one uses to decide what is right and wrong; how one’s conscience affects choices. Moral development refers to the capacity of the individual to act in accord with conscience and moral imperatives rather than egocentric values. Kohlberg defines moral judgments "as judgments of value, as social judgments, and as judgments that oblige an individual to take action.” MORAL DEVELOPMENT THEORY ❑ By the second year of life, “moral emotions” are emerged. ❑ By 36 months, most children demonstrate the internalization of parental standards. ❑ During the school years, the importance of rules and adhering to them become well defined. ❑ Moral development after adolescent period is complex and influenced by social factors. ❑ Kohlberg's six stages can be more generally grouped into three levels of two stages each: pre-conventional, conventional and post-conventional. ❑ Following Piaget's constructivist requirements for a stage model, as described in his theory of cognitive development, it is extremely rare to regress in stages—to lose the use of higher stage abilities. Stages cannot be skipped; each provides a new and necessary perspective, more comprehensive and differentiated than its predecessors but integrated within them. /mcpm2024  PRE-CONVENTIONAL LEVEL ✓ The pre-conventional level of moral reasoning is especially common in children and is expected to occur in animals, although adults can also exhibit this level of reasoning. ✓ Reasoners at this level judge the morality of an action by its direct consequences. The pre-conventional level consists of the first and second stages of moral development and is solely concerned with the self in an egocentric manner. ✓ A child with pre-conventional morality has not yet adopted or internalized society's conventions regarding what is right or wrong but instead focuses largely on external consequences that certain actions may bring. Stage One: Obedience and punishment driven Morality ❑ Individuals focus on the direct consequences of their actions on themselves. For example, an action is perceived as morally wrong because the perpetrator is punished. "The last time I did that I got spanked, so I will not do it again." The worse the punishment for the act is, the more "bad" the act is perceived to be. ❑ This can give rise to an inference that even innocent victims are guilty in proportion to their suffering. It is "egocentric", lacking recognition that others' points of view are different from one's own. There is "deference to superior power or prestige". ❑ An example of obedience and punishment driven morality would be a child refusing to do something because it is wrong and that the consequences could result in punishment. For example, a child's classmate tries to dare the child to skip school. The child would apply obedience and punishment driven morality by refusing to skip school because he would get punished. Stage Two: Self-interest driven Morality ❑ In this stage, it expresses the "what's in it for me" position, in which right behavior is defined by whatever the individual believes to be in their best interest, or whatever is "convenient," but understood in a narrow way which does not consider one's reputation or relationships to groups of people. ❑ Stage two reasoning shows a limited interest in the needs of others, but only to a point where it might further the individual's own interests. As result, concern for others is not based on loyalty or intrinsic respect, but rather a "You scratch my back, and I'll scratch yours" mentality, which is commonly described as quid pro quo, a Latin term that means doing or giving something in order to get something in return. ❑ The lack of a societal perspective in the pre-conventional level is quite different from the social contract (stage five), as all actions at this stage have the purpose of serving the individual's own needs or interests. For the stage two theorist, the world's perspective is often seen as morally relative. CONVENTIONAL LEVEL ❑ The conventional level of moral reasoning is typical for adolescents and adults. To reason in a conventional way is to judge the morality of actions by comparing them to society's views and expectations. The conventional level consists of the third and fourth stages of moral development. ❑ Conventional morality is characterized by an acceptance of society's conventions concerning right and wrong. At this level an individual obeys rules and follows society's norms even when there are no consequences for obedience or disobedience. Adherence to rules and conventions is somewhat rigid, however, and a rule's appropriateness or fairness is seldom questioned. /mcpm2024  Stage Three: Good intentions as determined by social consensus ❑ In this stage, the self enters society by conforming to social standards. ❑ Individuals are receptive to approval or disapproval from others as it reflects society's views. They try to be a "good boy" or "good girl" to live up to these expectations, having learned that being regarded as good benefits the self. ❑ Stage three reasoning may judge the morality of an action by evaluating its consequences in terms of a person's relationships, which now begin to include things like respect, gratitude, and the "golden rule". "I want to be liked and thought well of; apparently, not being naughty makes people like me." Conforming to the rules for one's social role is not yet fully understood. ❑ The intentions of actors play a more significant role in reasoning at this stage; one may feel more forgiving if one thinks that "they mean very well". Stage Four: Authority and social order obedience driven ❑ In this stage, it is important to obey laws, dictums, and social conventions because of their importance in maintaining a functioning society. ❑ Moral reasoning in stage four is thus beyond the need for individual approval exhibited in stage three. ❑ A central ideal or ideals often prescribe what is right and wrong. If one person violates a law, perhaps everyone would—thus there is an obligation and a duty to uphold laws and rules. ❑ When someone does violate a law, it is morally wrong; culpability is thus a significant factor in this stage as it separates the bad domains from the good ones. ❑ Most active members of society remain at stage four, where morality is still predominantly dictated by an outside force. POST-CONVENTIONAL LEVEL ❑ The post-conventional level, also known as the principled level, is marked by a growing realization that individuals are separate entities from society, and that the individual's own perspective may take precedence over society's view; individuals may disobey rules inconsistent with their own principles. ❑ Post-conventional moralists live by their own ethical principles—principles that typically include such basic human rights as life, liberty, and justice. ❑ People who exhibit post-conventional morality view rules as useful but changeable mechanisms—ideally rules can maintain the general social order and protect human rights. ❑ Rules are not absolute dictates that must be obeyed without question. Because post- conventional individuals elevate their own moral evaluation of a situation over social conventions, their behavior, especially at stage six, can be confused with that of those at the pre-conventional level. ❑ Some theorists have speculated that many people may never reach this level of abstract moral reasoning. Stage Five: Social contract driven Morality ❑ In this stage, the world is viewed as holding different opinions, rights, and values. Such perspectives should be mutually respected as unique to each person or community. /mcpm2024  ❑ Laws are regarded as social contracts rather than rigid edicts. Those that do not promote the general welfare should be changed when necessary to meet "the greatest good for the greatest number of people". ❑ This is achieved through majority decision and inevitable compromise. Democratic government is based on stage five reasoning. Stage Six: Universal ethical principles driven Morality ❑ Laws are valid only insofar as they are grounded in justice, and a commitment to justice carries with it an obligation to disobey unjust laws. ❑ Legal rights are unnecessary, as social contracts are not essential for deontic moral action. Decisions are not reached hypothetically in a conditional way but rather categorically in an absolute way. ❑ In this stage, action is never a means but always an end in itself; the individual acts because it is right, and not because it avoids punishment, it is in their best interest, expected, legal, or previously agreed upon. ❑ Although Kohlberg insisted that stage six exists, he found it difficult to identify individuals who consistently operated at this level. APPLICATION OF THEORY IN NURSING ▪ Nurses should aspire to develop their own moral reasoning as much as possible. This will help them treat their patients with more compassion and effectiveness. It can be difficult to develop moral reasoning once nurses are out in the workforce simply because they are so busy. This is why it is important for student nurses to develop an advanced level of moral reasoning before they even begin treating patients. /mcpm2024