Prelim-Notes (2).pdf

NCM 100 NOTES Week 1 NURSING is a prac ce-oriented discipline. Nursing knowledge is derived from basic and nursing sciences, experience, aesthe cs, nurses’ a tudes, and standards of prac ce. FACT is something that is seen happening or exis ng. It is an empirical observa on. IDEA is a group of interrelated facts. Idea is an image or formula on of something imagined and visualized, of something vaguely assumed, guessed or sensed out of related facts or observa ons. It is a person’s concep on of what is the best example of something PHENOMENON is an aspect of reality that can be consciously sensed or experienced. Examples of phenomena of nursing include caring, self-care, and pa ent responses to stress. CONCEPTS are ideas and mental images that help to describe phenomena. Concept is a word or cluster of words describing an object, idea or event. It is an abstrac on based on observa on of certain behaviors or characteris cs. It describes the essence of a thing.  Example: tower o It can be concrete or abstract. Thus, each concept must be speciﬁcally deﬁned by the theorist. o The METAPARADIGM concepts of person, environment, health, and nursing serve as an umbrella for other concepts that may be present in a nursing theory.  Types of Concept 1. Concrete/empirical concept speciﬁc to me and place observable 2. Abstract concepts independent of me or place indirectly observable/not observable CONCEPTUAL FRAMEWORK  set of interrelated concepts that serve as building blocks of theories  interrelated concepts or abstrac ons that are assembled together in some  rela onal scheme by virtue of their relevance to a common theme HYPOTHESIS  a statement of predicted rela onships between two or more variables, subjected to tes ng in empirical studies  a temporary stand or predic on or guess while the inves ga on goes on  educated guess ASSUMPTION  basic principles that are accepted as being true on the basis of logic or reason without proof or veriﬁca on  statements that describe concepts deﬁni ons, purpose, rela onships, and structure of a theory THEORY  A set of concepts, deﬁni ons, rela onships, and assump ons that project a systema c view of a phenomena  a formal statement that is constructed in order to organize ideas & explain event  a group of related concepts that propose ac ons that guide prac ce  a systema c way of looking at the world in order to describe, explain, predict and control it THEORETICAL FRAMEWORK  a set of interrelated theories that organizes the direc on of a research endeavor/scien ﬁc inquiry COMPONENTS OF A THEORY 1. PURPOSE  explains why the theory was formulated and speciﬁes the context and situa ons in which it should be applied 2. CONCEPTS AND DEFINITIONS  Concepts are logis c labels that are assigned to objects or events.  Deﬁni on deﬁnes the concept in rela on to other concepts and permits the descrip on and classiﬁca on of phenomena. It convey the general meaning of the concepts. 3. THEORETICAL STATEMENTS  statements about the rela onship between two or more concepts and are used to connect concepts to devise the theory 4. STRUCTURE AND LINKAGES  The structure of a theory provides overall form to the theory  Theore cal linkages oﬀer a reasoned explana on of why the variables in the theory may be connected in some manner 5. ASSUMPTIONS  The assump ons of a theory are based on what the theorist considers to be adequate empirical evidence to support proposi ons, on accepted knowledge, or on personal beliefs or values. 6. MODELS  schema c representa on of some aspect of reality  Theore cal models represent the real world through language or symbols and direc onal arrows. CHARACTERISTICS OF A THEORY 1. Theories can interrelate concepts in such a way to create a diﬀerent way of looking at a par cular phenomenon. 2. Theories must be logical in nature. 3. Theories should be rela vely simple yet generalizable. 4. Theories can be the bases for hypothesis that can be tested. 5. Theories contribute to and assist in increasing general body of knowledge within the discipline through the research implemented to validate them. 6. Theories can be u lized by the prac oner to guide & improve their prac ce. 7. Theories must be consistent with other validated theories, laws & principles but will leave open unanswered ques ons that need to be inves gated. PARADIGM  Model that explains the linkages of science, philosophy, and theory accepted and applied by the discipline. The paradigm of nursing includes four links: the person, health, environment/situa on, and nursing.  NURSING PARADIGM paterns or models used to show a clear rela onship among the exis ng theore cal works in nursing  The elements of the nursing paradigm direct the ac vity of the nursing profession, including knowledge development, philosophy, theory, educa onal experience, research, and prac ce METAPARADIGM  It served as an organizing structure for exis ng nursing frameworks and introduced a way of organizing individual theore cal works in a meaningful structure.  A global perspec ve of a discipline that iden ﬁes the primary phenomena of interest to that discipline and explains how the discipline deals with those phenomena in a unique manner  Nursing metaparadigm: embodies the knowledge base, theory, philosophy, research, prac ce, and educa onal experience and literature iden ﬁed with the profession. DOMAIN  The view or perspec ve of the discipline or a profession.  It contains the: 1. Central concepts 2. Values & Beliefs 3. Subject 4. Central problems of the discipline 5. Phenomena of interest  The domain of nursing provides both a prac cal and theore cal aspect of the discipline.  It is the knowledge of nursing prac ce as well as the knowledge of nursing history, nursing theory, educa on, and research.  The domain of nursing gives nurses a comprehensive perspec ve that allows you to iden fy and treat pa ents’ health care needs at all levels and in all health care se ngs. NURSING THEORY is an organized framework of concepts and purposes designed to guide the prac ce of nursing. PURPOSES OF NURSING THEORY  In Educa on o Theory clariﬁes the central meanings and improves the status of the profession.  In Research o Theory sets limits on what ques ons to ask and what methods to use to pursue answers to the ques ons.  In Clinical Prac ce o guides research o provides the nurse with goals for assessment, diagnosis, and interven on. o a tool that renders prac ce more eﬃcient, more eﬀec ve, and goal directed o Language of theory provides us with common grounds for communica on o and with labels and deﬁni ons for phenomena o Professional autonomy and accountability are enhanced by theory use in prac ce. DOMAIN AND NURSING THEORY RELATIONSHIP  Nursing has iden ﬁed its domain in a paradigm that includes four linkages: 1. Person/client - is the recipient of nursing care, including individual pa ents, groups, families, and communi es. The person is central to the nursing care you provide. 2. Health – deﬁned as what can be assessed, whereas well-being is the human experience of health or wholeness. 3. Environment/situa on – it includes factors that aﬀect individuals internally and externally. It means not only in the everyday surroundings but all se ng where nursing care is provided. 4. Nursing – described as a caring rela onship, an enabling condi on of connec on and concern. Caring is primary because caring sets up the possibility of giving and receiving help. It is central to all nursing theories. Deﬁni ons of nursing describe what nursing is, what nurses do, and how nurses interact with clients. NURSING AS A SCIENCE - owes much of its research-orientedness to the systematic works of Florence Nightingale TYPES OF NURSING THEORIES 1. Grand theories – broad and complex. It does not provide guidance for speciﬁc nursing interven ons; but it provides the structural framework for broad, abstract ideas about nursing 2. Middle-range theories – address speciﬁc phenomena and reﬂect prac ce. It tends to focus on a speciﬁc ﬁeld of nursing, such as uncertainty, incon nence, social support, quality of life, and caring, rather than reﬂect on a wide variety of nursing care situa ons 3. Descrip ve theories – ﬁrst level of theory development. It describes a phenomenon, speculate on why they occur, and describe their consequences such as grief or caring. 4. Predic ve theories – iden fy condi ons or factors that predict a phenomenon. 5. Prescrip ve theories – address nursing interven ons and predict their consequences REASONS TO STUDY NURSING THEORY  Everyday prac ce enriches theory  Both prac ce and theory are guided by values and beliefs  Theory helps to reframe our thinking about nursing  Theory guides use of ideas and techniques  Theory can close the gap between theory and research  To envision poten ali es  The overall goal of nursing knowledge is to explain the prac ce of nursing as diﬀerent and dis nct from the prac ce of medicine, psychology, and other health care disciplines. Theory generates nursing knowledge for use in prac ce, thus suppor ng evidencebased prac ce. So how do nurses use theory in everyday prac ce?  Organize pa ent data  Understand pa ent data  Analyze pa ent data  Make decisions about nursing interven ons  Plan pa ent care  Predict outcomes of care  Evaluate pa ent outcomes Week 2 Empiricism and Rationalism Modern science was established over 400 years ago as an intellectual ac vity to formalize given phenomena of interest in an atempt to describe, explain, predict, or control states of aﬀairs in nature. Scien ﬁc ac vity has persisted because it has improved quality of life and has sa sﬁed human needs for crea ve work, a sense of order, and the desire to understand the unknown (Bronowski, 1979; Gale, 1979; Piaget, 1970). The development of nursing science has evolved since the 1960s as a pursuit to be understood as a scien ﬁc discipline. Being a scien ﬁc discipline means iden fying nursing’s unique contribu on to the care of pa ents, families, and communi es. It means that nurses can conduct clinical and basic nursing research to establish the scien ﬁc base for the care of individuals across the life span. For example, research revealed gaps between the pain management needs of pa ents and the informa on communicated by pa ents and clinicians during oﬃce visits. Although many older adults have painful but not readily visible condi ons (e.g., symptoma c osteoarthri s), litle research has examined how the style or format of a health care prac oner’s ques ons inﬂuence the quality and amount of diagnos c informa on obtained from older adults. A recent study tested the theory that a certain type of ques on would elicit the most response. The theory was conﬁrmed when ﬁndings supported that the open-ended ques ons prompted pa ents to provide a larger amount of diagnos cally useful pain informa on than did the closed-ended ques ons (McDonald, Shea, Rose, & Fedo, 2009). While this study is one example of nursing science, advance prac ce nurses should be familiar with the long history of the science of nursing. Historical views To formalize the science of nursing, basic ques ons must be considered, such as: What is science, knowledge, and truth? What methods produce scien ﬁc knowledge? These are philosophical ques ons. The term epistemology is concerned with the theory of knowledge in philosophical inquiry. The par cular philosophical perspec ve selected to answer these ques ons will inﬂuence how scien sts perform scien ﬁc ac vi es, how they interpret outcomes, and even what they regard as science and knowledge (Brown, 1977). Although philosophy has been documented as an ac vity for 3000 years, formal science is a rela vely new human pursuit (Brown, 1977; Foucault, 1973). Scien ﬁc ac vity has only recently become the object of inves ga on. Two compe ng philosophical founda ons of science, ra onalism and empiricism, have evolved in the era of modern science with several varia ons. Gale (1979) labeled these alterna ve epistemologies as centrally concerned with the power of reason and the power of sensory experience. Gale noted similarity in the divergent views of science in the me of the classical Greeks. For example, Aristotle believed that advances in biological science would develop through systema c observa on of objects and events in the natural world, whereas Pythagoras believed that knowledge of the natural world would develop from mathema cal reasoning (Brown, 1977; Gale, 1979). Nursing science has been characterized by two branching philosophies of knowledge as the discipline developed. Various terms are u lized to describe these two stances: empiricist and interpre ve, mechanis c and holis c, quan ta ve and qualita ve, and deduc ve and induc ve forms of science. Understanding the nature of these philosophical stances facilitates apprecia on for what each form contributes to nursing knowledge. Ra onalism Ra onalist epistemology (scope of knowledge) emphasizes the importance of a priori reasoning as the appropriate method for advancing knowledge. A priori reasoning u lizes deduc ve logic by reasoning from the cause to an eﬀect or from a generaliza on to a par cular instance. An example in nursing is to reason that a lack of social support (cause) will result in hospital readmission (eﬀect). This causal reasoning is a theory un l disproven. The tradi onal approach proceeds by explaining hospitaliza on with a systema c explana on (theory) of a given phenomenon (Gale, 1979). This conceptual system is analyzed by addressing the logical structure of the theory and the logical reasoning involved in its development. Theore cal asser ons derived by deduc ve reasoning are then subjected to experimental tes ng to corroborate the theory. Reynolds (1971) labeled this approach the theory-then-research strategy. If the research ﬁndings fail to correspond with the theore cal asser ons, addi onal research is conducted or modiﬁca ons are made in the theory and further tests are devised; otherwise, the theory is discarded in favor of an alterna ve explana on (Gale, 1979; Zeterberg, 1966). Popper (1962) argued that science would evolve more rapidly through the process of conjectures and refuta ons by devising research in an atempt to refute new ideas. For example, his point is simple; you can never prove that all individuals without social support have frequent rehospitaliza ons since there might be one individual that presents with no rehospitaliza on. A single person with no social support that does not have a readmission disproves the theory that all individuals with a lack of social support have hospital readmissions. From Popper’s perspec ve, “research consists of genera ng general hypotheses and then atemp ng to refute them” (Lipton, 2005, p. 1263). So the hypothesis that a lack of social support results in hospital readmission is the phenomena of interest to be refuted. Empiricism The empiricist view is based on the central idea that scien ﬁc knowledge can be derived only from sensory experience (i.e., seeing, feeling, hearing facts). Francis Bacon (Gale, 1979) received credit for popularizing the basis for the empiricist approach to inquiry. Bacon believed that scien ﬁc truth was discovered through generalizing observed facts in the natural world. This approach, called the induc ve method, is based on the idea that the collec on of facts precedes atempts to formulate generaliza ons, or as Reynolds (1971) called it, the research-then-theory strategy. One of the best examples to demonstrate this form of logic in nursing has to do with formula ng diﬀeren al diagnoses. Formula ng a diﬀeren al diagnosis requires collec ng the facts and then devising a list of possible theories to explain the facts. Week 3 Development of Nursing Theories Introduc on Theories are a set of interrelated concepts that give a systema c view of a phenomenon (an observable fact or event) that is explanatory & predic ve in nature. Theories are composed of concepts, deﬁni ons, models, proposi ons & are based on assump ons. Theory gives planners tools for moving beyond intui on to design and evaluate health behavior and health promo on interven ons based on understanding of behavior.[Robert T. Croyle (2005)]. They are derived through two principal methods; deduc ve reasoning and induc ve reasoning. Nursing theorists use both of these methods. Theory is “a crea ve and rigorous structuring of ideas that projects a tenta ve, purposeful, and systema c view of phenomena”. A theory makes it possible to “organize the rela onship among the concepts to describe, explain, predict, and control prac ce” Deﬁni on Concepts - Concepts are basically vehicles of thought that involve images. Concepts are words that describe objects, proper es, or events & are basic components of theory. Types: Empirical concepts Inferen al concepts Abstract concepts Models are representa ons of the interac on among and between the concepts showing paterns. The terms ‘model’ and ‘theory’ are o en wrongly used interchangeably, which further confounds maters. In nursing, models are o en designed by theory authors to depict the beliefs in their theory (Lancaster and Lancaster 1981). They provide an overview of the thinking behind the theory and may demonstrate how theory can be introduced into prac ce, for example, through speciﬁc methods of assessment. Models are useful as they allow the concepts in nursing theory to be successfully applied to nursing prac ce (Lancaster and Lancaster 1981). Their main limita on is that they are only as accurate or useful as the underlying theory. Proposi ons - are statements that explain the rela onship between the concepts. Process - it is a series of ac ons, changes or func ons intended to bring about a desired result. During a process one takes systemic & con nuous steps to meet a goal & uses both assessments & feedback to direct ac ons to the goal. A conceptual framework - directs how these ac ons are carried out. The delivery of nursing care within the nursing process is directed by the way speciﬁc conceptual frameworks & theories deﬁne the person (pa ent), the environment, health & nursing. Importance of nursing theories Nursing theory aims to describe, predict and explain the phenomenon of nursing (Chinn and Jacobs1978). It should provide the founda ons of nursing prac ce, help to generate further knowledge and indicate in which direc on nursing should develop in the future (Brown 1964). Theory is important because it helps us to decide what we know and what we need to know (Parsons1949). It helps to dis nguish what should form the basis of prac ce by explicitly describing nursing. The beneﬁts of having a deﬁned body of theory in nursing include beter pa ent care, enhanced professional status for nurses, improved communica on between nurses, and guidance for research and educa on (Nolan 1996). The main exponent of nursing – caring – cannot be measured, it is vital to have the theory to analyze and explain what nurses do. As medicine tries to make a move towards adop ng a more mul disciplinary approach to health care, nursing con nues to strive to establish a unique body of knowledge. This can be seen as an atempt by the nursing profession to maintain its professional boundaries. The characteris cs of theories Theories are: interrela ng concepts in such a way as to create a diﬀerent way of looking at a par cular phenomenon. logical in nature. generalizable. bases for hypotheses that can be tested. increasing the general body of knowledge within the discipline through the research implemented to validate them. used by the prac oners to guide and improve their prac ce. consistent with other validated theories, laws, and principles but will leave open unanswered ques ons that need to be inves gated. Basic processes in the development of nursing theories Nursing theories are o en based on & inﬂuenced by broadly applicable processes & theories. Following theories are basic to many nursing concepts. (Non-Nursing Theories) 1. General System Theory It describes how to break whole things into parts & then to learn how the parts work together in “systems”. These concepts may be applied to diﬀerent kinds of systems, e.g. Molecules in chemistry, cultures in sociology, and organs in Anatomy & Health in Nursing. 2. Adapta on Theory It deﬁnes adapta on as the adjustment of living mater to other living things & to environmental condi ons. Adapta on is a con nuously occurring process that eﬀects change & involves interac on & response. Human adapta on occurs on three levels : 1. The internal (self) 2. The social (others) & 3. the physical (biochemical reac ons) 3. Developmental Theory It outlines the process of growth & development of humans as orderly & predictable, beginning with concep on & ending with death. The progress & behaviors of an individual within each stage are unique. The growth & development of an individual are inﬂuenced by heredity, temperament, emo onal, & physical environment, life experiences & health status. Common concepts in nursing theories Four concepts common in nursing theory that inﬂuence & determine nursing prac ce are: The person (pa ent). The environment Health Nursing (goals, roles, func ons) Each of these concepts is usually deﬁned & described by a nursing theorist, o en uniquely; although these concepts are common to all nursing theories. Of the four concepts, the most important is that of the person. The focus of nursing, regardless of deﬁni on or theory, is the person. Classiﬁca on of nursing theories A. Depending On Func on (Polit et al 2001) Descrip ve-to iden fy the proper es and workings of a discipline Explanatory-to examine how proper es relate and thus aﬀect the discipline Predic ve-to calculate rela onships between proper es and how they occur Prescrip ve -to iden fy under which condi ons rela onships occur B. Depending on the Generalisability of their principles Metatheory: the theory of theory. Iden ﬁes speciﬁc phenomena through abstract concepts. Grand theory: provides a conceptual framework under which the key concepts and principles of the discipline can be iden ﬁed. Middle range theory: is more precise and only analyses a par cular situa on with a limited number of variables. Prac ce theory: explores one par cular situa on found in nursing. It iden ﬁes explicit goals and details how these goals will be achieved. Development of Nursing Theories Nursing Theories can be based on the philosophical underpinnings of the theories 1. “Needs” theories These theories are based around helping individuals to fulﬁll their physical and mental needs. Needs theories have been cri cized for relying too much on the medical model of health and placing the pa ent in an overtly dependent posi on. 2.“Interac on” theories As described by Peplau (1988), these theories revolve around the rela onships nurses form with pa ents. Such theories have been cri cized for largely ignoring the medical model of health and not atending to basic physical needs. 3. “Outcome” theories" Outcome theories portray the nurse as the changing force, who enables individuals to adapt to or cope with ill health. Outcome theories have been cri cized as too abstract and diﬃcult to implement in prac ce. 4. “Humanis c” Theories Humanis c theories developed in response to the psychoanaly c thought that a person’s des ny was determined early in life. Humanis c theories emphasize a person’s capacity for self-actualiza on. Humanists believe that the person contains within himself the poten al for healthy & crea ve growth. Carl Rogers developed a person –centered model of psychotherapy that emphasizes the uniqueness of the individual. The major contribu on that Rogers added to nursing prac ce is the understandings that each client is a unique individual, so, person-centered approach now prac ce in nursing. Conclusion Theory and prac ce are related. A theory presents a systema c way of understanding events or situa ons. It is a set of concepts, deﬁni ons, and proposi ons that explain or predict these events or situa ons by illustra ng the rela onships between variables. Theories must be applicable to a broad variety of situa ons. They are, by nature, abstract, and don’t have a speciﬁed content or topic area. Like empty coﬀee cups, theories have shapes and boundaries, but nothing inside. They become useful when ﬁlled with prac cal topics, goals, and problems. [Robert T. Croyle (2005)] Week 4 1. Florence Nigh ngale: Environmental Theory Biography of Florence Nigh ngale Florence Nigh ngale (12 May 1820 – 13 August 1910) was a nurse who contributed to developing and shaping the modern nursing prac ce and has set examples for nurses who are standards for today’s profession. Nigh ngale is the ﬁrst nurse theorist well-known for developing the Environmental Theory that revolu onized nursing prac ces to create sanitary condi ons for pa ents to get care. She is recognized as the founder of modern nursing. During the Crimean War, she tended to wounded soldiers at night and was known as “The Lady with the Lamp.” Nigh ngale’s Environmental Theory The Environmental Theory by Florence Nigh ngale deﬁned Nursing as “the act of u lizing the environment of the pa ent to assist him in his recovery.” It involves the nurse’s ini a ve to conﬁgure environmental se ngs appropriate for the gradual restora on of the pa ent’s health and that external factors associated with the pa ent’s surroundings aﬀect the life or biologic and physiologic processes and his development. Nigh ngale discussed the Environmental Theory in her book Notes on Nursing: What it is, What it is Not. She is considered the ﬁrst theorist in nursing and paved the way in the founda on of the nursing profession we know today. Major Concepts of Florence Nigh ngales Theory The major concepts of Florence Nigh ngale’s Theory are: Nursing “What nursing has to do… is to put the pa ent in the best condi on for nature to act upon him” (Nigh ngale, 1859/1992) Nigh ngale stated that nursing “ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selec on and administra on of diet – all at the least expense of vital power to the pa ent.” She reﬂected the art of nursing in her statement that “the art of nursing, as now prac ced, seems to be expressly cons tuted to unmake what God had made disease to be, viz., a repara ve process.” Human Beings Human beings are not deﬁned by Nigh ngale speciﬁcally. They are deﬁned in rela on to their environment and the impact of the environment upon them. Environment Nigh ngale stresses the physical environment in her wri ng. In her theory, Nigh ngale’s wri ngs reﬂect a community health model in which all that surrounds human beings is considered concerning their health state. Health Nigh ngale (1859/1992) did not deﬁne health speciﬁcally. She stated, “We know nothing of health, the posi ve of which pathology is nega ve, except for the observa on and experience. Given her deﬁni on that the art of nursing is to “unmake what God had made disease,” then the goal of all nursing ac vi es should be client health. She believed that nursing should provide care to the healthy and the ill and discussed health promo on as an ac vity in which nurses should engage. Subconcepts of the Environmental Theory The following are the subconcepts of Florence Nigh ngale’s theory: Health of Houses “Badly constructed houses do for the healthy what badly constructed hospitals do for the sick. Once ensure that the air is stagnant and sickness is certain to follow.” Ven la on and Warming “Keep the air he breathes as pure as the external air, without chilling him.” Nigh ngale believed that the person who repeatedly breathed his or her own air would become sick or remain sick. She was very concerned about “noxious air” or “eﬄuvia” and foul odors from excrement. She also cri cized “fumiga ons,” for she believed that the oﬀensive source, not the smell, must be removed. Nigh ngale also stressed the importance of room temperature. The pa ent should not be too warm or too cold. The temperature could be controlled by an appropriate balance between burning ﬁres and ven la on from windows. Light Nigh ngale believed that second to fresh air, the sick needed light. She noted that direct sunlight was what pa ents wanted. Noise She stated that pa ents should never be “waked inten onally” or accidentally during the ﬁrst part of sleep. She asserted that whispered or long conversa ons about pa ents are thoughtless and cruel. She viewed unnecessary noise, including noise from the female dress, as cruel and irrita ng to the pa ent. Variety She discussed the need for color and form changes, including bringing the pa ent brightly colored ﬂowers or plants. She also advocated rota ng 10 or 12 pain ngs and engravings each day, week, or month to provide variety for the pa ent. Nigh ngale also advocated reading, needlework, wri ng, and cleaning to relieve the sick of boredom. Bed and Bedding Nigh ngale noted that an adult in health exhales about three pints of moisture through the lungs and skin in a 24-hour period. This organic mater enters the sheets and stays there unless the bedding is changed and aired frequently. She believed that the bed should be placed in the lightest part of the room and placed so the pa ent could see out of a window. She also reminded the caregiver never to lean against, sit upon, or unnecessarily shake the pa ent’s bed. Personal Cleanliness “Just as it is necessary to renew the air around a sick person frequently to carry oﬀ morbid eﬄuvia from the lungs and skin, by maintaining free ven la on, so it is necessary to keep pores of the skin free from all obstruc ng excre ons.” “Every nurse ought to wash her hands very frequently during the day.” Nutri on and Taking Food Nigh ngale noted in her Environmental Theory that individuals desire diﬀerent foods at diﬀerent mes of the day and that frequent small servings may be more beneﬁcial to the pa ent than a large breakfast or dinner. She urged that no business be done with pa ents while they are ea ng because this was a distrac on. Chatering Hopes and Advice Florence Nigh ngale wrote in her Environmental Theory that to falsely cheer the sick by making light of their illness and its danger is not helpful. She encouraged the nurse to heed what is being said by visitors, believing that sick persons should hear the good news that would help them become healthier. Social Considera ons Nigh ngale supported the importance of looking beyond the individual to the social environment in which they lived. Environmental Factors In Florence Nigh ngale’s Environmental Theory, she iden ﬁed ﬁve (5) environmental factors: fresh air, pure water, eﬃcient drainage, cleanliness or sanita on, and light or direct sunlight. Pure fresh air – “to keep the air he breathes as pure as the external air without chilling him.” Pure water – “well water of a very impure kind is used for domes c purposes. And when the epidemic disease shows itself, persons using such water are almost sure to suﬀer.” Eﬀec ve drainage – “all the while the sewer may be nothing but a laboratory from which epidemic disease and ill health are being installed into the house.” Cleanliness – “the greater part of nursing consists in preserving cleanliness.” Light (especially direct sunlight) – “the usefulness of light in trea ng disease is very important.” The factors posed great signiﬁcance during Nigh ngale’s me when health ins tu ons had poor sanita on, and health workers had litle educa on and training and were frequently incompetent and unreliable in atending to the pa ents’ needs. Also emphasized in her environmental theory is providing a quiet or noise-free and warm environment, atending to pa ent’s dietary needs by assessment, documenta on of me of food intake, and evalua ng its eﬀects on the pa ent. Deﬁciencies in these ﬁve factors produce illness or lack of health, but the body could repair itself with a nurturing environment. Analysis of the Environmental Theory In the era that we are in today, we are faced with environmental condi ons beyond what ought to be natural and nurturing. Some of the global environmental issues we have now are global warming, nuclear radia on threats, human-made environmental calami es, and pollu on. From these occurrences, Nigh ngale’s model seemed to be ideal. Her concept of providing fresh air to pa ents is in ques on with today’s industrializa on eﬀects. In addi on to the analysis of the concept of ven la on, it is not always beneﬁcial for all clients to have fresh air. Natural air has its impuri es which in turn may infect open wounds and drainages such as in burns. With the idea of providing light, the light emited by the sun today is proven to be harmful already because of the destruc on of the Earth’s ozone layer. Exposing the pa ent constantly to direct sunlight may be more destruc ve to the pa ent’s beterment than beneﬁcial. A healthy environment indeed heals, as Nigh ngale stated. S ll, the ques on now is how our environment would remain healthy amidst the nega ve eﬀects of the progress of technology and industrializa on. Since the applicability of some of the concepts to speciﬁc situa ons today is non-feasible, this theory’s development is uterly needed to accommodate the changes in the environment that we currently have. S ll, above all this, it is very clear that Nigh ngale’s Environmental Theory is superb as a star ng point of our profession’s progression and catalyzed nursing improvement. Assump ons of Florence Nigh ngale’s Theory The assump ons of Florence Nigh ngale in her Environmental Theory are as follows: Florence Nigh ngale believed that ﬁve points were essen al in achieving a healthful house: “pure air, pure water, eﬃcient drainage, cleanliness, and light.” A healthy environment is essen al for healing. She stated that “nature alone cures.” Nurses must make accurate observa ons of their pa ents and report the state of the pa ent to the physician in an orderly manner. Nursing is an art, whereas medicine is a science. Nurses are to be loyal to the medical plan but not servile. Strengths Florence Nigh ngale’s language to write her books was cultured and ﬂowing, logical in format, and elegant in style. Nigh ngale’s Environmental Theory has broad applicability to the prac oner. Her model can be applied in most complex hospital intensive care environments, the home, a worksite, or the community. Reading Nigh ngale’s Environmental Theory raises consciousness in the nurse about how the environment inﬂuences client outcomes. Weaknesses In Nigh ngale’s Environmental Theory, there is scant informa on on the psychosocial environment compared to the physical environment. The applica on of her concepts in the twen eth century is in ques on. Conclusion The Environmental Theory of Nursing is a pa ent-care theory. It focuses on altering the pa ent’s environment to aﬀect change in his or her health. Caring for the pa ent is of more importance than the nursing process, the rela onship between pa ent and nurse, or the individual nurse. In this way, the model must be adapted to ﬁt the needs of individual pa ents. The environmental factors aﬀect diﬀerent pa ents unique to their situa ons and illnesses. The nurse must address these factors on a case-by-case basis to make sure the factors are altered to best care for an individual pa ent and his or her needs. 2. Virginia Henderson: Nursing Need Theory Virginia Avenel Henderson (November 30, 1897 – March 19, 1996) was a nurse, theorist, and author known for her Need Theory and deﬁning nursing as: “The unique func on of the nurse is to assist the individual, sick or well, in the performance of those ac vi es contribu ng to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge.” Henderson is also known as “The First Lady of Nursing,” “The Nigh ngale of Modern Nursing,” “Modern-Day Mother of Nursing,” and “The 20th Century Florence Nigh ngale.” Virginia Henderson’s Need Theory Virginia Henderson developed the Nursing Need Theory to deﬁne the unique focus of nursing prac ce. The theory focuses on the importance of increasing the pa ent’s independence to hasten their progress in the hospital. Henderson’s theory emphasizes the basic human needs and how nurses can meet those needs. “I believe that the func on the nurse performs is primarily an independent one – that of ac ng for the pa ent when he lacks knowledge, physical strength, or the will to act for himself as he would ordinarily act in health or in carrying out prescribed therapy. This func on is seen as complex and crea ve, as oﬀering unlimited opportunity to apply the physical, biological, and social sciences and the development of skills based on them.” (Henderson, 1960) Assump ons of the Need Theory Virginia Henderson’s Need Theory assump ons are: (1) Nurses care for pa ents un l they can care for themselves once again. Although not precisely explained, (2) pa ents desire to return to health. (3) Nurses are willing to serve, and “nurses will devote themselves to the pa ent day and night.” (4) Henderson also believes that the “mind and body are inseparable and are interrelated.” Major Concepts of the Nursing Need Theory The following are the major concepts (nursing metaparadigm) and deﬁni ons of the Need Theory of Virginia Henderson. Individual Henderson states that individuals have basic health needs and require assistance to achieve health and independence or a peaceful death. According to her, an individual achieves wholeness by maintaining physiological and emo onal balance. She deﬁned the pa ent as someone who needs nursing care but did not limit nursing to illness care. Her theory presented the pa ent as a sum of parts with biopsychosocial needs, and the mind and body are inseparable and interrelated. Environment Although the Need Theory did not explicitly deﬁne the environment, Henderson stated that maintaining a suppor ve environment conducive to health is one of her 14 ac vi es for client assistance. Henderson’s theory supports the private and public health sector’s tasks or agencies to keep people healthy. She believes that society wants and expects the nurse’s act for individuals who cannot func on independently. Health Although not explicitly deﬁned in Henderson’s theory, health was taken to mean balance in all realms of human life. It is equated with the independence or ability to perform ac vi es without aid in the 14 components or basic human needs. On the other hand, nurses are key persons in promo ng health, preven ng illness, and curing. According to Henderson, good health is a challenge because it is aﬀected by numerous factors such as age, cultural background, emo onal balance, and others. Nursing Virginia Henderson wrote her deﬁni on of nursing before the development of theore cal nursing. She deﬁned nursing as “the unique func on of the nurse is to assist the individual, sick or well, in the performance of those ac vi es contribu ng to health or its recovery that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.” The nurse’s goal is to make the pa ent complete, whole, or independent. In turn, the nurse collaborates with the physician’s therapeu c plan. Nurses temporarily assist an individual who lacks the necessary strength, will, and knowledge to sa sfy one or more of the 14 basic needs. She states: “The nurse is temporarily the consciousness of the unconscious, the love life for the suicidal, the leg of the amputee, the eyes of the newly blind, a means of locomo on for the infant, knowledge, and conﬁdence of the young mother, the mouthpiece for those too weak or withdrawn to speak.” Addi onally, she stated that “…the nurse does for others what they would do for themselves if they had the strength, the will, and the knowledge. But I go on to say that the nurse makes the pa ent independent of them as soon as possible.” Her deﬁni on of nursing dis nguished a nurse’s role in health care: The nurse is expected to carry out a physician’s therapeu c plan, but individualized care results from the nurse’s crea vity in planning for care. The nurse should be an independent prac oner able to make an independent judgment. In her work Nature of Nursing, she states the nurse’s role is “to get inside the pa ent’s skin and supplement his strength, will or knowledge according to his needs.” The nurse is responsible for assessing the pa ent’s needs, helping them meet health needs, and providing an environment in which the pa ent can perform ac vity unaided. 14 Components of the Need Theory The 14 components of Virginia Henderson’s Need Theory show a holis c nursing approach covering physiological, psychological, spiritual, and social needs. Physiological Components 1. Breathe normally 2. Eat and drink adequately 3. Eliminate body wastes 4. Move and maintain desirable postures 5. Sleep and rest 6. Select suitable clothes – dress and undress 7. Maintain body temperature within normal range by adjus ng clothing and modifying environment 8. Keep the body clean and well-groomed and protect the integument 9. Avoid dangers in the environment and avoid injuring others Psychological Aspects of Communica ng and Learning 10. Communicate with others in expressing emo ons, needs, fears, or opinions. 14. Learn, discover, or sa sfy the curiosity that leads to normal development and health and use the available health facili es. Spiritual and Moral 11. Worship according to one’s faith Sociologically Oriented to Occupa on and Recrea on 12. Work in such a way that there is a sense of accomplishment 13. Play or par cipate in various forms of recrea on Analysis of the Need Theory One cannot say that every individual with similar needs indicated in the 14 ac vi es by Virginia Henderson is the only thing that human beings need in ataining health and survival. With today’s me, there may be added needs that humans are en tled to be provided with by nurses. The priori za on of the 14 Ac vi es was not clearly explained whether the ﬁrst one is a prerequisite to the other. But s ll, it is remarkable that Henderson was able to specify and characterize some of the needs of individuals based on Abraham Maslow’s hierarchy of needs. Some of the ac vi es listed in Henderson’s concepts can only be applied to fully func onal individuals indica ng that there would always be pa ents who always require aided care which is contrary to the goal of nursing indicated in the deﬁni on of nursing by Henderson. Because of the absence of a conceptual diagram, interconnec ons between Henderson’s principles’ concepts and subconcepts are not delineated. Strengths Virginia Henderson’s concept of nursing is widely accepted in nursing prac ce today. Her theory and 14 components are rela vely simple, logical, and applied to individuals of all ages. Weaknesses There is an absence of a conceptual diagram that interconnects Henderson’s theory’s 14 concepts and subconcepts. On assis ng the individual in the dying process, there is litle explana on of what the nurse does to provide “peaceful death.” Applica on of the Need Theory Henderson’s Needs Theory can be applied to nursing prac ce as a way for nurses to set goals based on Henderson’s 14 components. Mee ng the goal of achieving the 14 needs of the client can be a great basis to further improve one’s performance towards nursing care. In nursing research, each of her 14 fundamental concepts can serve as a basis for research, although the statements were not writen in testable terms. 3. Faye Abdellah: 21 Nursing Problems Theory Faye Abdellah is a celebrated nurse theorist, military nurse, and leader in nursing research. Get to know the major concepts of her “21 Nursing Problems” nursing theory, its applica on, and its impact on nursing. Abdellah’s 21 Nursing Problems Theory According to Faye Glenn Abdellah’s theory, “Nursing is based on an art and science that molds the a tudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people, sick or well, cope with their health needs.” The pa ent-centered approach to nursing was developed from Abdellah’s prac ce, and the theory is considered a human needs theory. It was formulated to be an instrument for nursing educa on, so it most suitable and useful in that ﬁeld. The nursing model is intended to guide care in hospital ins tu ons but can also be applied to community health nursing, as well. Assump ons The assump ons Abdellah’s “21 Nursing Problems Theory” relate to change and an cipated changes that aﬀect nursing; the need to appreciate the interconnectedness of social enterprises and social problems; the impact of problems such as poverty, racism, pollu on, educa on, and so forth on health and health care delivery; changing nursing educa on; con nuing educa on for professional nurses; and development of nursing leaders from underserved groups. Learn to know the pa ent. Sort out relevant and signiﬁcant data. Make generaliza ons about available data concerning similar nursing problems presented by other pa ents. Iden fy the therapeu c plan. Test generaliza ons with the pa ent and make addi onal generaliza ons. Validate the pa ent’s conclusions about his nursing problems. Con nue to observe and evaluate the pa ent over a period of me to iden fy any a tudes and clues aﬀec ng this behavior. Explore the pa ent’s and family’s reac on to the therapeu c plan and involve them in the plan. Iden fy how the nurse feels about the pa ent’s nursing problems. Discuss and develop a comprehensive nursing care plan. Major Concepts of 21 Nursing Problems Theory The model has interrelated concepts of health and nursing problems and problem-solving, which is inherently logical in nature. Individual She describes nursing recipients as individuals (and families), although she does not delineate her beliefs or assump ons about the nature of human beings. Health, or the achieving of it, is the purpose of nursing services. Although Abdellah does not deﬁne health, she speaks to “total health needs” and “a healthy state of mind and body.”Buy vitamins and supplements Health may be deﬁned as the dynamic patern of func oning whereby there is a con nued interac on with internal and external forces that results in the op mal use of necessary resources to minimize vulnerabili es. Society Society is included in “planning for op mum health on local, state, and interna onal levels.” However, as Abdellah further delineates her ideas, the focus of nursing service is clearly the individual. Nursing Problems The client’s health needs can be viewed as problems, overt as an apparent condi on, or covert as a hidden or concealed one. Because covert problems can be emo onal, sociological, and interpersonal in nature, they are o en missed or misunderstood. Yet, in many instances, solving the covert problems may solve the overt problems as well. Problem Solving Quality professional nursing care requires that nurses be able to iden fy and solve overt and covert nursing problems. The problem-solving process can meet these requirements by iden fying the problem, selec ng per nent data, formula ng hypotheses, tes ng hypotheses through collec ng data, and revising hypotheses when necessary based on conclusions obtained from the data. Subconcepts The following are the subconcepts of Faye Abdellah’s “21 Nursing Problems” theory and their deﬁni ons. The 21 nursing problems fall into three categories: physical, sociological, and emo onal needs of pa ents; types of interpersonal rela onships between the pa ent and nurse; and common elements of pa ent care. She used Henderson’s 14 basic human needs and nursing research to establish the classiﬁca on of nursing problems. Abdellah’s 21 Nursing Problems are the following: To maintain good hygiene and physical comfort. To promote op mal ac vity: exercise, rest, sleep To promote safety by preven ng accidents, injuries, or other trauma and preven ng the spread of infec on. To maintain good body mechanics and prevent and correct the deformity. To facilitate the maintenance of a supply of oxygen to all body cells. To facilitate the maintenance of nutri on for all body cells. To facilitate the maintenance of elimina on. To facilitate the maintenance of ﬂuid and electrolyte balance. To recognize the physiologic responses of the body to disease condi ons—pathologic, physiologic, and compensatory. To facilitate the maintenance of regulatory mechanisms and func ons. To facilitate the maintenance of sensory func on. To iden fy and accept posi ve and nega ve expressions, feelings, and reac ons. To iden fy and accept interrelatedness of emo ons and organic illness. To facilitate the maintenance of eﬀec ve verbal and nonverbal communica on. To promote the development of produc ve interpersonal rela onships. To facilitate progress toward achievement and personal spiritual goals. To create or maintain a therapeu c environment. To facilitate awareness of self as an individual with varying physical, emo onal, and developmental needs. To accept the op mum possible goals in the light of limita ons, physical and emo onal. To use community resources as an aid in resolving problems that arise from an illness. To understand the role of social problems as inﬂuencing factors in the cause of illness. Moreover, pa ents’ needs are further divided into four categories: basic to all pa ents, sustenance care needs, remedial care needs, and restora ve care needs. Basic Needs The basic needs of an individual pa ent are to maintain good hygiene and physical comfort; promote op mal health through healthy ac vi es, such as exercise, rest, and sleep; promote safety through the preven on of health hazards like accidents, injury, or other trauma and the preven on of the spread of infec on; and maintain good body mechanics and prevent or correct deformity. Sustenal Care Needs Sustenal care needs to facilitate the maintenance of a supply of oxygen to all body cells; facilitate the maintenance of nutri on of all body cells; facilitate the maintenance of elimina on; facilitate the maintenance of ﬂuid and electrolyte balance; recognize the physiological responses of the body to disease condi ons; facilitate the maintenance of regulatory mechanisms and func ons, and facilitate the maintenance of sensory func on. Remedial Care Needs Remedial care needs to iden fy and accept posi ve and nega ve expressions, feelings, and reac ons; iden fy and accept the interrelatedness of emo ons and organic illness; facilitate the maintenance of eﬀec ve verbal and non-verbal communica on; promote the development of produc ve interpersonal rela onships; facilitate progress toward achievement of personal spiritual goals; create and maintain a therapeu c environment; and facilitate awareness of the self as an individual with varying physical, emo onal, and developmental needs. Restora ve Care Needs Restora ve care needs include the acceptance of the op mum possible goals in light of limita ons, both physical and emo onal; the use of community resources as an aid to resolving problems that arise from an illness; and the understanding of the role of social problems as inﬂuen al factors in the case of illness. Abdellah’s work, based on the problem-solving method, serves as a vehicle for delinea ng nursing (pa ent) problems as the pa ent moves toward a healthy outcome. The theory iden ﬁes ten steps to iden fy the pa ent’s problem and 11 nursing skills to develop a treatment typology. Faye Abdellah's 10 Steps to Iden fy the Pa ent's Problem. Click to enlarge. Faye Abdellah’s 10 Steps to Iden fy the Pa ent’s Problem. Click to enlarge. The ten steps are: Learn to know the pa ent. Sort out relevant and signiﬁcant data. Make generaliza ons about available data concerning similar nursing problems presented by other pa ents. Iden fy the therapeu c plan. Test generaliza ons with the pa ent and make addi onal generaliza ons. Validate the pa ent’s conclusions about his nursing problems. Con nue to observe and evaluate the pa ent over a period of me to iden fy any a tudes and clues aﬀec ng his or her behavior. Explore the pa ent and their family’s reac ons to the therapeu c plan and involve them in the plan. Iden fy how the nurses feel about the pa ent’s nursing problems. Discuss and develop a comprehensive nursing care plan. The 11 nursing skills are: observa on of health status skills of communica on applica on of knowledge the teaching of pa ents and families planning and organiza on of work use of resource materials use of personnel resources problem-solving the direc on of work of others therapeu c uses of the self nursing procedure Abdellah also explained nursing as a comprehensive service, which includes: Recognizing the nursing problems of the pa ent Deciding the appropriate course of ac on to take in terms of relevant nursing principles Providing con nuous care of the individual’s total needs Providing con nuous care to relieve pain and discomfort and provide immediate security for the individual Adjus ng the total nursing care plan to meet the pa ent’s individual needs Helping the individual to become more self-direc ng in ataining or maintaining a healthy state of body and mind Instruc ng nursing personnel and family to help the individual do for himself that which he can within his limita ons Helping the individual to adjust to his limita ons and emo onal problems Working with allied health professions in planning for op mum health on local, state, na onal, and interna onal levels Carrying out con nuous evalua on and research to improve nursing techniques and to develop new techniques to meet people’s health needs Pa ent-Centered Approaches to Nursing Faye Abdellah’s work is a set of problems formulated in terms of nursing-centered services used to determine the pa ent’s needs. The nursing-centered orienta on to client care appears to be contradic ng the client-centered approach that Abdellah professes to support. This can be observed by her desire to move away from a disease-centered orienta on. 21 Nursing Problems and The Nursing Process The nursing process in Abdellah’s theory includes assessment, nursing diagnosis, planning, implementa on, and evalua on. In the assessment phase, the nursing problems implement a standard procedure for data collec on. A principle underlying the problem-solving approach is that for each iden ﬁed problem, per nent data is collected. The overt or covert nature of problems necessitates a direct or indirect approach, respec vely. The outcome of the collec on of data in the ﬁrst phase concludes the pa ent’s possible problems, which can be grouped under one or more of the broader nursing problems. This will further lead to the nursing diagnosis. A er formula ng the diagnosis, a nursing care plan is developed, and appropriate nursing interven ons are determined. The nurse now sets those interven ons in ac on, which complete the implementa on phase of the nursing process. The evalua on takes place a er the interven ons have been carried out. The most convenient evalua on would be the nurse’s progress or lack of progress toward achieving the goals established in the planning phase. Analysis With Faye Abdellah’s aim in formula ng a clear categoriza on of pa ent’s problems as health needs, she rather conceptualized nurses’ ac ons in nursing care, which is contrary to her aim. Nurses’ roles were deﬁned to alleviate the problems assessed through the proposed problem-solving approach. The problem-solving approach introduced by Abdellah has the advantage of increasing the nurse’s cri cal and analy cal thinking skills since the care to be provided would be based on sound assessment and valida on of ﬁndings. One can iden fy that the framework is strongly applied to individuals as the focus of nursing care. The inclusion of an aggregate of people such as the community or society would make the theory of Abdellah more generalizable since nurses do not only provide one-person service, especially now that the community healthcare level is sought to have higher importance than cura ve eﬀorts in the hospital. Strengths The following are the strengths of Faye Abdellah’s “21 Nursing Problems” theory. The problem-solving approach is readily generalizable to the client with speciﬁc health needs and speciﬁc nursing problems. With the model’s nature, healthcare providers and prac oners can use Abdellah’s problem-solving approach to guide various ac vi es within the clinical se ng. This is true when considering a nursing prac ce that deals with clients with speciﬁc needs and speciﬁc nursing problems. The language of Faye Abdellah’s framework is simple and easy to comprehend. The theore cal statement greatly focuses on problem-solving, an ac vity that is inherently logical in nature. Weaknesses The following are the limita ons of Faye Abdellah’s “21 Nursing Problems” theory. The major limita on to Abdellah’s theory and the 21 nursing problems is their robust nurse-centered orienta on. She rather conceptualized nurses’ ac ons in nursing care which is contrary to her aim. Another point is the lack of emphasis on what the client is to achieve was given in client care. The framework seems to focus quite heavily on nursing prac ce and individuals. This somewhat limits the generalizing ability, although the problem-solving approach is readily generalizable to clients with speciﬁc health needs and speciﬁc nursing. Also, Abdellah’s framework is inconsistent with the concept of holism. The nature of the 21 nursing problems atests to this. As a result, the client may be diagnosed with numerous problems leading to frac onalized care eﬀorts. Poten al problems might be overlooked because the client is not deemed to be in a par cular illness stage. Conclusion Abdellah’s typology of 21 nursing problems is a conceptual model mainly concerned with pa ent’s needs and nurses’ role in problem iden ﬁca on using a problem analysis approach. According to the model, pa ents are described as having physical, emo onal, and sociological needs. People are also the only jus ﬁca on for the existence of nursing. Without people, nursing would not be a profession since they are the recipients of nursing. Pa ent-centered approaches to nursing health are described as a state mutually exclusive of illness. Abdellah does not deﬁne health but speaks to “total health needs” and “a healthy state of mind and body” in her nursing descrip on. However, Abdellah rather conceptualized nurses’ ac ons in nursing care, contrary to her aim of formula ng a clear categoriza on of pa ents’ problems as health needs. Nurses’ roles were deﬁned to alleviate the problems assessed through the proposed problem-solving approach. As a whole, the theory is intended to guide care not just in the hospital se ng but can also be applied to community nursing, as well. The model has interrelated concepts of health and nursing problems and problem-solving, which is inherently logical in nature. Furthermore, the 21 nursing problems progressed to a second-genera on development referred to as pa ent problems and pa ent outcomes. Abdellah educated the public on AIDS, drug addic on, violence, smoking, and alcoholism. Her work is a problem-centered approach or philosophy of nursing. Week 5 1. Madeleine Leininger: Transcultural Nursing Madeleine Leininger is a nursing theorist who developed the Transcultural Nursing Theory or Culture Care Nursing Theory. Get to know Madeleine Leininger’s biography, theory applica on, and major concepts in this nursing theory study guide. Leininger’s Transcultural Nursing Theory The Transcultural Nursing Theory or Culture Care Theory by Madeleine Leininger involves knowing and understanding diﬀerent cultures concerning nursing and health-illness caring prac ces, beliefs, and values to provide meaningful and eﬃcacious nursing care services to people’s cultural values health-illness context. It focuses on the fact that diﬀerent cultures have diﬀerent caring behaviors and diﬀerent health and illness values, beliefs, and paterns of behaviors. The cultural care worldview ﬂows into knowledge about individuals, families, groups, communi es, and ins tu ons in diverse health care systems. This knowledge provides culturally speciﬁc meanings and expressions about care and health. The next focus is on the generic or folk system, professional care system(s), and nursing care. Informa on about these systems includes the characteris cs and the speciﬁc care features of each. This informa on allows for the iden ﬁca on of similari es and diﬀerences or cultural care universality and cultural care diversity. Next are nursing care decisions and ac ons which involve cultural care preserva on/maintenance, cultural care accommoda on/nego a on, and cultural care re-paterning or restructuring. It is here that nursing care is delivered. Descrip on In 1995, Madeleine Leininger deﬁned transcultural nursing as “a substan ve area of study and prac ced focused on compara ve cultural care (caring) values, beliefs, and prac ces of individuals or groups of similar or diﬀerent cultures to provide culture- speciﬁc and universal nursing care prac ces in promo ng health or well-being or to help people to face unfavorable human condi ons, illness, or death in culturally meaningful ways.” The Transcultural Nursing Theory ﬁrst appeared in Leininger’s Culture Care Diversity and Universality, published in 1991, but it was developed in the 1950s. The theory was further developed in her book Transcultural Nursing, which was published in 1995. In the third edi on of Transcultural Nursing, published in 2002, the theory-based research and the Transcultural theory applica on are explained. Major Concepts of the Transcultural Nursing Theory The following are the major concepts and their deﬁni ons in Madeleine Leininger’s Transcultural Nursing Theory. Transcultural Nursing Transcultural nursing is deﬁned as a learned subﬁeld or branch of nursing that focuses upon the compara ve study and analysis of cultures concerning nursing and health-illness caring prac ces, beliefs, and values to provide meaningful and eﬃcacious nursing care services to their cultural values and health-illness context. Ethnonursing This is the study of nursing care beliefs, values, and prac ces as cogni vely perceived and known by a designated culture through their direct experience, beliefs, and value system (Leininger, 1979). Nursing Nursing is deﬁned as a learned humanis c and scien ﬁc profession and discipline which is focused on human care phenomena and ac vi es to assist, support, facilitate, or enable individuals or groups to maintain or regain their well-being (or health) in culturally meaningful and beneﬁcial ways, or to help people face handicaps or death. Professional Nursing Care (Caring) Professional nursing care (caring) is deﬁned as formal and cogni vely learned professional care knowledge and prac ce skills obtained through educa onal ins tu ons that are used to provide assis ve, suppor ve, enabling, or facilita ve acts to or for another individual or group to improve a human health condi on (or well-being), disability, lifeway, or to work with dying clients. Cultural Congruent (Nursing) Care Cultural congruent (nursing) care is deﬁned as those cogni vely based assis ve, suppor ve, facilita ve, or enabling acts or decisions that are tailor-made to ﬁt with the individual, group, or ins tu onal, cultural values, beliefs, and lifeways to provide or support meaningful, beneﬁcial, and sa sfying health care, or well-being services. Health It is a state of well-being that is culturally deﬁned, valued, and prac ced. It reﬂects individuals’ (or groups) ‘ ability to perform their daily role ac vi es in culturally expressed, beneﬁcial, and paterned lifeways. Human Beings Such are believed to be caring and capable of being concerned about others’ needs, well-being, and survival. Leininger also indicates that nursing as a caring science should focus beyond tradi onal nurse-pa ent interac ons and dyads to include families, groups, communi es, total cultures, and ins tu ons. Society and Environment Leininger did not deﬁne these terms; she speaks instead of worldview, social structure, and environmental context. Worldview Worldview is how people look at the world, or the universe, and form a “picture or value stance” about the world and their lives. Cultural and Social Structure Dimensions Cultural and social structure dimensions are deﬁned as involving the dynamic paterns and features of interrelated structural and organiza onal factors of a par cular culture (subculture or society) which includes religious, kinship (social), poli cal (and legal), economic, educa onal, technological, and cultural values, ethnohistorical factors, and how these factors may be interrelated and func on to inﬂuence human behavior in diﬀerent environmental contexts. Environmental Context Environmental context is the totality of an event, situa on, or par cular experience that gives meaning to human expressions, interpreta ons, and social interac ons in par cular physical, ecological, sociopoli cal, and/or cultural se ngs. Culture Culture is learned, shared, and transmited values, beliefs, norms, and lifeways of a par cular group that guides their thinking, decisions, and ac ons in paterned ways. Culture Care Culture care is deﬁned as the subjec vely and objec vely learned and transmited values, beliefs, and paterned lifeways that assist, support, facilitate, or enable another individual or group to maintain their well-being, health, improve their human condi on lifeway, or deal with illness, handicaps or death. Culture Care Diversity Culture care diversity indicates the variabili es and/or diﬀerences in meanings, paterns, values, lifeways, or symbols of care within or between collec ves related to assis ve, suppor ve, or enabling human care expressions. Culture Care Universality Culture care universality indicates the common, similar, or dominant uniform care meanings, paterns, values, lifeways, or symbols manifest among many cultures and reﬂect assis ve, suppor ve, facilita ve, or enabling ways to help people. (Leininger, 1991) Subconcepts The following are the subconcepts of the Transcultural Nursing Theory of Madeleine Leininger and their deﬁni ons: Generic (Folk or Lay) Care Systems Generic (folk or lay) care systems are culturally learned and transmited, indigenous (or tradi onal), folk (home-based) knowledge and skills used to provide assis ve, suppor ve, enabling, or facilita ve acts toward or for another individual, group, or ins tu on with evident or an cipated needs to ameliorate or improve a human life way, health condi on (or well-being), or to deal with handicaps and death situa ons. Emic Knowledge gained from direct experience or directly from those who have experienced it. It is generic or folk knowledge. Professional Care Systems Professional care systems are deﬁned as formally taught, learned, and transmited professional care, health, illness, wellness, and related knowledge and prac ce skills that prevail in professional ins tu ons, usually with mul disciplinary personnel to serve consumers. E c The knowledge that describes the professional perspec ve. It is professional care knowledge. Ethnohistory Ethnohistory includes those past facts, events, instances, experiences of individuals, groups, cultures, and instruc ons that are primarily people-centered (ethno) and describe, explain, and interpret human lifeways within par cular cultural contexts over short or long periods of me. Care Care as a noun is deﬁned as those abstract and concrete phenomena related to assis ng, suppor ng, or enabling experiences or behaviors toward or for others with evident or an cipated needs to ameliorate or improve a human condi on or lifeway. Care Care as a verb is deﬁned as ac ons and ac vi es directed toward assis ng, suppor ng, or enabling another individual or group with evident or an cipated needs to ameliorate or improve a human condi on or lifeway or face death. Culture Shock Culture shock may result when an outsider atempts to comprehend or adapt eﬀec vely to a diﬀerent cultural group. The outsider is likely to experience feelings of discomfort and helplessness and some degree of disorienta on because of the diﬀerences in cultural values, beliefs, and prac ces. Culture shock may lead to anger and can be reduced by seeking knowledge of the culture before encountering that culture. Cultural Imposi on Cultural imposi on refers to the outsider’s eﬀorts, both subtle and not so subtle, to impose their own cultural values, beliefs, behaviors upon an individual, family, or group from another culture. (Leininger, 1978) Sunrise Model of Madeleine Leininger’s Theory The Sunrise Model is relevant because it enables nurses to develop cri cal and complex thoughts about nursing prac ce. These thoughts should consider and integrate cultural and social structure dimensions in each speciﬁc context, besides nursing care’s biological and psychological aspects. The cultural care worldview ﬂows into knowledge about individuals, families, groups, communi es, and ins tu ons in diverse health care systems. This knowledge provides culturally speciﬁc meanings and expressions concerning care and health. The next focus is on the generic or folk system, professional care systems, and nursing care. Informa on about these systems includes the characteris cs and the speciﬁc care features of each. This informa on allows for the iden ﬁca on of similari es and diﬀerences or cultural care universality and cultural care diversity. Next are nursing care decisions and ac ons which involve cultural care preserva on or maintenance, cultural care accommoda on or nego a on, and cultural care repaterning or restructuring. It is here that nursing care is delivered. Three modes of nursing care decisions and ac ons Cultural care preserva on or Maintenance Cultural care preserva on is also known as maintenance. It includes those assis ve, suppor ng, facilita ve, or enabling professional ac ons and decisions that help people of a par cular culture to retain and/or preserve relevant care values so that they can maintain their well-being, recover from illness, or face handicaps and/or death. Cultural care accommoda on or Nego a on Cultural care accommoda on, also known as nego a on, includes those assis ve, suppor ve, facilita ve, or enabling crea ve professional ac ons and decisions that help people of a designated culture to adapt to or nego ate with others for a beneﬁcial or sa sfying health outcome with professional care providers. Culture care repaterning or Restructuring Culture care repaterning or restructuring includes those assis ve, suppor ng, facilita ve, or enabling professional ac ons and decisions that help clients reorder, change, or greatly modify their lifeways for new, diﬀerent, and beneﬁcial health care patern while respec ng the clients’ cultural values and beliefs and s ll providing a beneﬁcial or healthier lifeway than before the changes were established with the clients. (Leininger, 1991) Assump ons The following are the assump ons of Madeleine Leininger’s theory: Diﬀerent cultures perceive, know, and prac ce care diﬀerently, yet there are some commonali es about care among all world cultures. Values, beliefs, and prac ces for culturally related care are shaped by, and o en embedded in, “the worldview, language, religious (or spiritual), kinship (social), poli cal (or legal), educa onal, economic, technological, ethnohistorical, and environmental context of the culture. While human care is universal across cultures, caring may be demonstrated through diverse expressions, ac ons, paterns, lifestyles, and meanings. Cultural care is the broadest holis c means to know, explain, interpret, and predict nursing care phenomena to guide nursing care prac ces. All cultures have generic or folk health care prac ces, that professional prac ces vary across cultures, and that there will be cultural similari es and diﬀerences between the care-receivers (generic) and the professional caregivers in any culture. Care is the dis nct, dominant, unifying, and central focus of nursing, and while curing and healing cannot occur eﬀec vely without care, care may occur without a cure. Care and caring are essen al for humans’ survival and their growth, health, well-being, healing, and ability to deal with handicaps and death. Nursing, as a transcultural care discipline and profession, has a central purpose of serving human beings in all areas of the world; that when culturally based nursing care is beneﬁcial and healthy, it contributes to the well-being of the client(s) – whether individuals, groups, families, communi es, or ins tu ons – as they func on within the context of their environments. Nursing care will be culturally congruent or beneﬁcial only when the nurse knows the clients. The clients’ paterns, expressions, and cultural values are used in appropriate and meaningful ways by the nurse with the clients. If clients receive nursing care that is not at least reasonably culturally congruent (that is, compa ble with and respec ul of the clients’ lifeways, beliefs, and values), the client will demonstrate signs of stress, noncompliance, cultural conﬂicts, and/or ethical or moral concerns. Analysis In Leininger’s nursing theory, it was stated that the nurse would help the client move towards ameliora on or improvement of their health prac ce or condi on. This statement would be of great diﬃculty for the nurse because ins lling new ideas in a diﬀerent culture might present an intrusive intent for the “insiders.” Culture is a strong set of prac ces developed over genera ons that would make it diﬃcult to penetrate. The whole ac vity of immersing yourself within a diﬀerent culture is me-consuming to understand their beliefs and prac ces fully. Another is that it would be costly on the part of the nurse. Because of its ﬁnancial constraints and unclear ways of being ﬁnancially compensated, it can be the reason why nurses do not engage much with this kind of nursing approach. Because of the intrusive nature, resistance from the “insiders” might impose a risk to the nurse’s safety, especially for cultures with highly taboo prac ces. It is highly commendable that Leininger formulated a theory that is speciﬁed to a mul cultural aspect of care. On the other side, too much was given to the culture concept per se that Leininger failed to discuss the func ons or roles of nurses comprehensively. It was not stated how to assist, support or enable the client to atuning them to an improved lifeway. Strengths Leininger has developed the Sunrise Model in a logical order to demonstrate the interrela onships of the concepts in her theory of Culture Care Diversity and Universality. Leininger’s theory is essen ally parsimonious in that the necessary concepts are incorporated in such a manner that the theory and its model can be applied in many diﬀerent se ngs. It is highly generalizable. The concepts and rela onships presented are at a level of abstrac on, which allows them to be applied in many diﬀerent situa ons. Though not simple in terms, it can be easily understood upon the ﬁrst contact. Weakness The theory and model are not simple in terms. Conclusion According to transcultural nursing, nursing care aims to provide care congruent with cultural values, beliefs, and prac ces. 2. Dorothea Orem: Self-Care Deﬁcit Theory Dorothea Orem is a nurse theorist who pioneered the Self-Care Deﬁcit Nursing Theory. Get to know Orem’s biography and works, including a discussion about the major concepts, subconcepts, nursing metaparadigm, and applica on of Self- Care Deﬁcit Theory. Dorothea Orem’s Self-Care Deﬁcit Theory There are instances wherein pa ents are encouraged to bring out the best in them despite being ill for a period of me. This is very par cular in rehabilita on se ngs, in which pa ents are en tled to be more independent a er being cared for by physicians and nurses. Between 1959 and 2001, Dorothea Orem developed the Self-Care Nursing Theory or the Orem Model of Nursing. It is considered a grand nursing theory, which means the theory covers a broad scope with general concepts applicable to all instances of nursing. Descrip on Dorothea Orem’s Self-Care Deﬁcit Theory deﬁned Nursing as “The act of assis ng others in the provision and management of self-care to maintain or improve human func oning at the home level of eﬀec veness.” It focuses on each individual’s ability to perform self-care, deﬁned as “the prac ce of ac vi es that individuals ini ate and perform on their own behalf in maintaining life, health, and well-being.” “The condi on that validates the existence of a requirement for nursing in an adult is the absence of the ability to maintain con nuously that amount and quality of self-care which is therapeu c in sustaining life and health, in recovering from disease or injury, or in coping with their eﬀects. With children, the condi on is the parent’s inability (or guardian) to maintain con nuity for the child the amount and quality of care that is therapeu c.” (Orem, 1991) Assump ons of the Self-Care Deﬁcit Theory Dorothea Orem’s Self-Care Theory assump ons are: (1) To stay alive and remain func onal, humans engage in constant communica on and connect among themselves and their environment. (2) The power to act deliberately is exercised to iden fy needs and to make needed judgments. (3) Mature human beings experience priva ons in the form of ac on in care of self and others involving making life-sustaining and func on-regula ng ac ons. (4) Human agency is exercised in discovering, developing, and transmi ng to others ways and means to iden fy needs for, and make inputs into, self and others. (5) Groups of human beings with structured rela onships cluster tasks and allocate responsibili es for providing care to group members. Major Concepts of the Self-Care Deﬁcit Theory In this sec on are the deﬁni ons of the major concepts of Dorothea Orem’s Self-Care Deﬁcit Theory: Nursing Nursing is an art through which the prac oner of nursing gives specialized assistance to persons with disabili es, making more than ordinary assistance necessary to meet self-care needs. The nurse also intelligently par cipates in the medical care the individual receives from the physician. Humans Humans are deﬁned as “men, women, and children cared for either singly or as social units” and are the “material object” of nurses and others who provide direct care. Environment The environment has physical, chemical, and biological features. It includes the family, culture, and community. Health Health is “being structurally and func onally whole or sound.” Also, health is a state that encompasses both the health of individuals and groups, and human health is the ability to reﬂect on oneself, symbolize experience, and communicate with others. Self-Care Self-care is the performance or prac ce of ac vi es that individuals ini ate and perform on their own behalf to maintain life, health, and well-being. Self-Care Agency Self-care agency is the human’s ability or power to engage in self-care and is aﬀected by basic condi oning factors. Basic Condi oning Factors Basic condi oning factors are age, gender, developmental state, health state, socio-cultural orienta on, health care system factors, family system factors, paterns of living, environmental factors, and resource adequacy and availability. Therapeu c Self-Care Demand Therapeu c Self-care Demand is the totality of “self-care ac ons to be performed for some dura on to meet known self-care requisites by using valid methods and related sets of ac ons and opera ons.” Self-Care Deﬁcit Self-care Deﬁcit delineates when nursing is needed. Nursing is required when an adult (or in the case of a dependent, the parent or guardian) is incapable of or limited in providing con nuous eﬀec ve self-care. Nursing Agency Nursing Agency is a complex property or atribute of people educated and trained as nurses that enables them to act, know, and help others meet their therapeu c self-care demands by exercising or developing their own self-care agency. Nursing System Nursing System is the product of a series of rela ons between the persons: legi mate nurse and legi mate client. This system is ac vated when the client’s therapeu c self-care demand exceeds the available self-care agency, leading to nursing. Theories The Self-Care or Self-Care Deﬁcit Theory of Nursing is composed of three interrelated theories: (1) the theory of self-care, (2) the self-care deﬁcit theory, and (3) the theory of nursing systems, which is further classiﬁed into wholly compensatory, par ally compensatory and suppor ve-educa ve. Theory of Self-Care This theory focuses on the performance or prac ce of ac vi es that individuals ini ate and perform on their own behalf to maintain life, health, and well-being. Self-Care Requisites Self-care Requisites or requirements can be deﬁned as ac ons directed toward the provision of self-care. It is presented in three categories: Universal Self-Care Requisites Universal self-care requisites are associated with life processes and the maintenance of the human structure and func oning integrity. The maintenance of a suﬃcient intake of air The maintenance of a suﬃcient intake of water The maintenance of a suﬃcient intake of food The provision of care associated with the elimina on process and excrements The maintenance of a balance between ac vity and rest The maintenance of a balance between solitude and social interac on The preven on of hazards to human life, human func oning, and human well-being The promo on of human func oning and development within social groups in accord with human poten al, known human limita ons, and the human desire to be normal Normalcy is used in the sense of that which is essen ally human and that which is in accord with the gene c and cons tu onal characteris cs and individuals’ talents. Developmental self-care requisites Developmental self-care requisites are “either specialized expressions of universal self-care requisites that have been par cularized for developmental processes or they are new requisites derived from a condi on or associated with an event.” Health devia on self-care requisites Health devia on self-care requisites are required in condi ons of illness, injury, or disease or may result from medical measures required to diagnose and correct the condi on. Seeking and securing appropriate medical assistance. Being aware of and atending to the eﬀects and results of pathologic condi ons and states Eﬀec vely carrying out medically prescribed diagnos c, therapeu c, and rehabilita ve measures. Being aware of and atending to or regula ng the discomfor ng or deleterious eﬀects of prescribed medical measures Modifying the self-concept (and self-image) in accep ng oneself as being in a par cular state of health and in need of speciﬁc forms of health care Learning to live with the eﬀects of pathologic condi ons and states and the eﬀects of medical diagnos c and treatment measures in a lifestyle that promotes con nued personal development Theory of Self-Care Deﬁcit This theory delineates when nursing is needed. Nursing is required when an adult (or in the case of a dependent, the parent or guardian) is incapable of or limited in providing con nuous eﬀec ve self-care. Orem iden ﬁed 5 methods of helping: Ac ng for and doing for others Guiding others Suppor ng another Providing an environment promo ng personal development about meet future demands Teaching another Theory of Nursing System This theory is the product of a series of rela ons between the persons: legi mate nurse and legi mate client. This system is ac vated when the client’s therapeu c self-care demand exceeds the available self-care agency, leading to nursing. Wholly Compensatory Nursing System This is represented by a situa on in which the individual is unable “to engage in those self-care ac ons requiring self-directed and controlled ambula on and manipula ve movement or the medical prescrip on to refrain from such ac vity… Persons with these limita ons are socially dependent on others for their con nued existence and well-being.” Example: care of a newborn, care of client recovering from surgery in a post-anesthesia care unit Par al Compensatory Nursing System This is represented by a situa on in which “both nurse and perform care measures or other ac ons involving manipula ve tasks or ambula on… [Either] the pa ent or the nurse may have a major role in the performance of care measures.” Example: Nurse can assist the postopera ve client in ambula ng, Nurse can bring a meal tray for a client who can feed himself Suppor ve-Educa ve System This is also known as a suppor ve-developmental system. The person “can perform or can and should learn to perform required measures of externally or internally oriented therapeu c self-care but cannot do so without assistance.” Example: Nurse guides a mother on how to breas eed her baby, Counseling a psychiatric client on more adap ve coping strategies. Dorothea Orem’s Theory and The Nursing Process The Nursing Process presents a method in determining self-care deﬁcits and deﬁning the roles of persons or nurses to meet the self-care demands. Assessment Diagnosis and prescrip on; determine why nursing is needed. Analyze and interpret by making a judgment regarding care. Design of a nursing system and plan for delivery of care. Produc on and management of nursing systems. Step 1 – Collect Data in Six Areas The person’s health status The physician’s perspec ve of the person’s health status The person’s perspec ve of his or health health The health goals within the context of life history, lifestyle, and health status. The person’s requirements for self-care The person’s capacity to perform self-care Nursing Diagnosis & Care Plans Step 2 The nurse designs a system that is wholly or partly compensatory or suppor ve-educa ve. The two ac ons are: (1) Bringing out a good organiza on of the components of pa ents’ therapeu c self-care demands. (2) Selec on of a combina on of helping methods will be eﬀec ve and eﬃcient in compensa ng for/overcoming the pa ent’s self- care deﬁcits. Implementa on & Evalua on Step 3 A nurse assists the pa ent or family in self-care maters to iden fy and describe health and health-related results. Collec ng evidence in evalua ng results achieved against results speciﬁed in the nursing system design. The e ology component of nursing diagnosis directs ac ons. Analysis of the Self-Care Deﬁcit Theory There is a superb focus of Orem’s work which is self-care. Even though there is a wide range of scope seen in the encompassing theory of nursing systems, Orem’s goal of le ng the readers view nursing care to assist people was apparent in every concept presented. From the deﬁni on of health which is sought to be rigid, it can now be reﬁned by making it suitable to the general view of health as a dynamic and ever-changing state. The role of the environment in the nurse-pa ent rela onship, although deﬁned by Orem, was not discussed. Orem set nurses’ role in maintaining health for the pa ent with great coherence following every individual’s life-sustaining needs. Although Orem viewed the parent’s or guardians’ importance in providing for their dependents, the deﬁni on of self-care cannot be directly applied to those who need complete care or assistance with self-care ac vi es such as the infants and the aged. Strengths A major strength of Dorothea Orem’s theory is that it is applicable for nursing by the beginning prac oner and the advanced clinicians. Orem’s theory provides a comprehensive basis for nursing prac ce. It has u lity for professional nursing in the areas of nursing prac ce, nursing educa on, and administra on. The terms self-care, nursing systems, and self-care deﬁcit are easily understood by the beginning student nurse and can be explored in greater depth as they gain more knowledge and experience. She speciﬁcally deﬁnes when nursing is needed: Nursing is needed when the individual cannot maintain con nuously that amount and quality of self-care necessary to sustain life and health, recover from disease or injury, or cope with their eﬀects. Her self-care approach is contemporary with the concepts of health promo on and health maintenance. Three iden ﬁable nursing systems were clearly delineated and are easily understood. Limita ons Orem’s theory, in general, is viewed as a single whole thing, while Orem deﬁnes a system as a single whole thing. Orem’s theory is simple yet complex. The use of self-care in mul tudes of terms, such as self-care agency, self-care demand, self-care deﬁcit, self-care requisites, and universal self-care, can be very confusing to the reader. Orem’s deﬁni on of health was conﬁned to three sta c condi ons, which she refers to as a “concrete nursing system,” which connotes rigidity. Throughout her work, there is a limited acknowledgment of the individual’s emo onal needs. Health is o en viewed as dynamic and ever-changing. Conclusion Orem’s theory is rela vely simple but generalizable to apply to a wide variety of pa ents. It explains the terms self-care, nursing systems, and self-care deﬁcit essen al to students who plan to start their nursing careers. Moreover, this theory signiﬁes that all pa ents want to care for themselves. They can recover more quickly and holis cally by performing their own self-care as much as they’re able. This theory is par cularly used in rehabilita on and primary care or other se ngs where pa ents are encouraged to be independent. Though this theory greatly inﬂuences every pa ent’s independence, the deﬁni on of self-care cannot be directly applied to those who need complete care or assistance with self-care ac vi es such as infants and the aged.

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