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

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Theories, Conceptual Models and Concepts applied
to Community Health Nursing.
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By the end of this lecture you will be able to

• Explain what is meant by a theory and a model of
  nursing
• Discuss the main features of at least two
  theories of nursing
• Orems Theory
• Roper, Logan Tierney
• Callister Roys model
• Characterize the conceptual models
• the Omaha System,
• Neuman System Model

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Theory

• is a general statement that summarizes and
  organizes knowledge by proposing a general
  relationship between events - if it is a good one
  it will cover a large number of events and
  predict events that have not yet occurred or been
  observedRobson C.

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Theories that Define Nursing or Discuss Nursing
in a General Sense (Philosophies)

• Florence Nightingale
• Virginia Henderson
• Ernestine Wiedenbach

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Theories about Broad Nursing Practice Areas
Grand Theories

• Myra Estrin Levine's Conservation Model
• Betty Neuman's Systems Model
• Sister Callista Roy's Adaptation Model
• Dorthea Orem's Self-Care Model

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Theories about Specific Nursing Actions,
Processes, or Concepts Middle-Range Theories

• Katharine Kolcaba's Theory of Comfort
• Sister Callista Roy's Adaptation Model
• Nola Pender's Health-Promotion Model
• Hildegard Peplau's Interpersonal Relations in
  Nursing

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Theories that Defy Classification

• Martha Rogers's Unitary Human Beings
• Margaret Newman's Health as Expanding
  Consciousness

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A conceptual model

• is the synthesis of a set of concepts and the
  statements that integrate those concepts into a
  whole.

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Theory of Nursing Systems Orems Theory

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

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Dorothea Elizabeth Orem

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

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

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Orems Theory

• Orem identified three types of nursing systems
• wholly compensatory,
• partly compensatory, and
• supportive-educative.

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Orems Theory compensatory nursing system

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

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Orems Theory the partly compensatory nursing
system

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

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Orems Theory the supportive-educative nursing
system

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

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Interpretation of Orems theory through Mandala
art

• Amy Devis, student

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Interpretation of Orems theory through Mandala
art

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

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• Dorthea Orem's Self-Care Model

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Nursing systems

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

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Neuman's systems model

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

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Betty Neuman

• Betty Neuman is a community health nurse and
  clinical psychologist who has developed this
  theory.

• Betty M. Neuman, R.N., B.S.N., M.S., Ph.D., PLC.,
  FAAN

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Neuman's systems model

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

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Neuman's systems model

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

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Neuman's systems model

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

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Betty Neumans Theory interpreted through Mandala
Art

• (Created by Amy, undergraduate nursing student
  Fall 2004)

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Betty Neumans Theory interpreted through Mandala
Art (cont)

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

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• Students art

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Neumans health care systems model

• applied to a rural county regarding traffic
  safety issues concerning the elderly.

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The Omaha System

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

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The Omaha System

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

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The Omaha System

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

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The Omaha System

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

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The Omaha SystemProblem Classification Scheme

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

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The Omaha SystemProblem Classification Scheme

• Environmental Domain Material resources and
  physical surroundings both inside and outside the
  living area, neighborhood, and broader community.
• Income
• Sanitation
• Residence
• Neighborhood/workplace safety

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The Omaha SystemProblem Classification Scheme

• Psychosocial Domain Patterns of behavior,
  emotion, communication, relationships, and
  development.
• Communication with community resourcesSocial
  contactRole changeInterpersonal
  relationshipSpiritualityGriefMental
  healthSexualityCaretaking/parentingNeglectAbus
  eGrowth and development

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The Omaha SystemProblem Classification Scheme

• Physiological Domain Functions and processes
  that maintain life.
• HearingVisionSpeech and languageOral
  healthCognitionPainConsciousnessSkinNeuro-mus
  culo-skeletal functionRespirationCirculationDig
  estion-hydrationBowel functionUrinary
  functionReproductive functionPregnancyPostpartu
  mCommunicable/infectious condition

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The Omaha SystemProblem Classification Scheme

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

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The Omaha System Intervention Scheme

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

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The Omaha System Intervention Scheme

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

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The Omaha System Intervention Scheme

• day care/respitedietary management discipline
  dressing change/wound care durable medical
  equipment education employmentend-of-life care
  environment exercises family planning care
  feeding procedures finances gait
  traininggenetics growth/development care home
  homemaking/housekeeping infection precautions
  interaction

• Targets
• anatomy/physiologyanger managementbehavior
  modification bladder care bonding/attachment
  bowel care cardiac care caretaking/parenting
  skills cast care communicationcommunity
  outreach worker servicescontinuity of care
  coping skills

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The Omaha System Problem Rating Scale for
Outcomes

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

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The Omaha System Problem Rating Scale for
Outcomes

• http//www.omahasystem.org/shmrate.htm

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Roy's Model Of Nursing

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

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Roy's Model Of Nursing

• This model comprises the four domain concepts of
• person,
• health,
• environment, and
• nursing and involves a six step nursing process.

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Roy's Model Of Nursing

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

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Roy's Model Of Nursing

• Roy employs a six-step nursing process which
  includes
• assessment of behaviour,
• assessment of stimuli,
• nursing diagnosis,
• goal setting,
• intervention and evaluation.

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Roy's Model Of Nursing

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

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Roy's Model Of Nursing

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

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Sister Callista Roy's Adaptation Model

• Mandala Representing Roys Adaptation Model
• By Noreen Frodella BSN, RN, BC, Graduate student
  
• http//nursing.jbpub.com/sitzman/artGallery.cfm

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Sister Callista Roy's Adaptation Model

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