Florence

TERNOPIL STATE MEDICAL UNIVERSITY

INSTITUTE OF NURSING

Lecture 3

Theories, Models and Concepts applied to Community Health Nursing. Conceptual models: The Neuman System Model

 

 

After studying this chapter, you should be able to:

 

·        Discuss the different nursing theories and models.

·        Explain the Neuman system model

·        Identify and describe Conceptual models

 

Introduction

There are many nursing theories, frameworks, and models in nursing, this chapter addresses only selected ones. The theories discussed have been selected because they represent the development of nursing’s scientific thought.

 

Florence Nightingale

Nightingale did not develop a theory of nursing as theory is defined today, but rather she provided the nursing profession with the philosophical basis from which other theories have emerged and developed. Nightingale’s ideas about nursing have guided both theoretical thought and actual nursing practice throughout the history of modern nursing. Nightingale considered nursing similar to a religious calling to be answered only by women with an all-consuming and passionate response. She considered nursing to be both an art and a science and believed that nurses should be formally educated. Her writings did not focus on the nature of the person but did stress the importance of caring for the ill person rather than caring for the illness. In Nightingale’s view, the person was a passive recipient of care, and nursing’s primary focus was on the manipulation of the person’s environment to maintain or achieve a state of health. Despite the fact that she did not believe in the germ theory, her experiences in the Crimean War magnified her interest in the principles of sanitation and the relationship between environment and health. A person’s health was the direct result of environmental influences, specifically cleanliness, light, pure air, pure water, and efficient drainage. Through manipulating the environment, nursing “aims to discover the laws of nature that would assist in putting the patient in the best possible condition so that nature can effect a cure” (Nightingale, 1859, p. 6). Nursing’s main focus was health, and health was closely related to nursing. Nursing was concerned with the healthy, as well as the sick (Nightingale, 1859).

Nightingale’s principles regarding environment health- nursing were implemented in America at the turn of the 20th century. With the development of hospital- based schools of nursing, Nightingale’s principles of sanitation were used to clean up the rat-infested, dirty hospitals of the day. With the use of Nightingale’s ideas, hospitals became a place for people to recover rather than a place to die. When, for a variety of reasons, hospitals did not hire their owursing graduates, nurses applied Nightingale’s principles in the community in the development of public health nursing. The Henry Street Settlement founded by Lillian Wald is an excellent example of Nightingale’s theory in practice. Private duty nursing and public health nursing remained the primary focus of nursing practice until World War II. At this time, there was a tremendous increase in scientific knowledge and technology affecting health care. As the practice of medicine became more scientifically based, more clients were cared for in hospital settings. Nursing practice likewise became centered in the hospital rather than the home. With this development, it became clear that nursing did not have an adequate theory base to organize new knowledge and guide nursing practice. Nursing began to further develop its knowledge base by incorporating the principles of Nightingale into moderursing theory.

 

Early Nursing Theories

By its very nature, the development of nursing’s theoretical base has progressed in a methodical and systematic, albeit slow, fashion. Knowledge development is an ongoing process that is often influenced by driving forces outside the discipline of nursing. The early nurse theorists were not attempting to address the metaparadigm concepts because initial consensus on these had not yet been achieved. Rather, these theories were attempting to answer the question, “What is nursing?”

 

Hildegard Peplau

Hildegard Peplau, a psychiatric nurse, combined her research and experience in the development of a theory of psychodynamic nursing, published in Interpersonal Relations in Nursing (1952). Drawing from her own knowledge and that from other disciplines, Peplau defined the concepts and stages involved in the development of the nurse-client relationship. From that relationship, she identified the roles of the nurse as stranger, resource person, teacher, leader, surrogate, and counselor. Peplau developed a middle-range theory with a focus on both nursing and the person and did not incorporate all aspects of the metaparadigm into her theory. Although other theories may view the nurseclient relationship differently, the primacy of this relationship iursing has remained.

 

Virginia Henderson

Virginia Henderson’s definition of nursing, considered to be a classic, first appeared in 1955. The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he has the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. (Henderson, 1966, p. 15) Together with Bertha Harmer, Henderson attempted to identify those basic humaeeds viewed as the basis of nursing care. These needs include the need to maintain physiologic balance, to adjust to the environment, to communicate and participate in social interaction, and to worship according to one’s faith. Her 14 basic needs were published in the Textbook of the Principles and Practice of Nursing, one of the first nursing textbooks. Henderson viewed the nursing role as helping the client from dependence to independence. As an early nursing theorist, Henderson did not intend to develop a theory of nursing, but rather she attempted to define the unique focus of nursing. Henderson’s emphasis on basic humaeeds as the central focus of nursing practice has led to further theory development regarding the needs of the person and how nursing can assist in meeting those needs.

 

Faye Abdellah

Faye Abdellah, acknowledging the influence of Henderson, expanded Henderson’s 14 needs into 21 problems that she believed would serve as a knowledge base for nursing. Throughout her career, she strongly supported the idea that nursing research would be the key factor in helping nursing to emerge as a true profession. The research that was done regarding these commoeeds/problems has served as a foundation for the development of what we now know as nursing diagnoses.

 

Joyce Travelbee

Joyce Travelbee, an educator and psychiatric nurse, was influenced by the philosophy of existentialism, a movement that is centered on individual existence in an incomprehensible world and the role that free will plays in it, and searched to find meaning in life’s experiences. She extensively developed the ideas of sympathy, empathy, and rapport in which the nurse could begin to comprehend and relate to the uniqueness of others. Her work focused on the human-to-human relationship and on finding meaning in experiences such as pain, illness, and distress. Travelbee based most of her theory on her own experiences and readings and first published her work in Interpersonal Aspects of Nursing in 1966.

 

Josephine Paterson and Loretta Zderad

The work of Josephine Paterson and Loretta Zderad was similar to that of Travelbee in that it emphasized the humanistic and existential basis of nursing practice. According to Paterson and Zderad, theory developed from the practice of nursing. Although the models proposed by Travelbee and Paterson and Zderad had some impact at the time of their initial introduction, they did not gain wide popularity and application iursing. The work of Travelbee and Paterson and Zderad most appropriately fit the Simultaneity Paradigm. Current theorists—such as Watson, Rogers, Parse, Fitzpatrick, and Newman—who have an existential orientation, are rediscovering the merits of Travelbee and Paterson and Zderad.

 

Contemporary Nursing Theories

Although early nursing theorists attempted to answer the question “What is nursing?,” contemporary theorists addressed the metaparadigm concepts in more depth, focused more specifically oursing actions, and tried to answer the question “When is nursing needed?” The work of contemporary theorists such as Levine, Orem, and Roy form the theoretical basis for many interventions in current nursing practice.

 

Myra Levine

Myra Levine’s Conservation Theory is directly grounded iursing practice. In her attempt to describe, explain, and predict the phenomena of concern to nursing, Levine published the four conservation principles in 1969 in Introduction to Clinical Nursing. Conservation is derived from the Latin word “to keep together.” Levine believed in the wholeness of the human being and the primary focus of conservation is to maintain that wholeness. Levine viewed nursing as assisting clients with the conservation of their uniqueness by helping clients to adapt appropriately. Conservation principles are universal principles designed to link concepts into a cohesive framework within which nursing practice in different environments can be performed (Levine, 1990). According to Levine, the four principles of conservation are:

Conservation of Energy: “The individual requires a balance of energy and a constant renewal of energy to maintain life activities” (Levine, 1990, p. 197).

Conservation of Structural Integrity: “Structural integrity is concerned with the processes of healing . . . to restore wholeness and continuity after injury or illness” (Levine, 1989, p. 333).

Conservation of Personal Integrity: “Everyone seeks to defend his or her identity as a self, in both that hidden, intensely private person that dwells within and in the public faces assumed as individuals move through their relationships with others” (Levine, 1989, p. 334).

Conservation of Social Integrity: “No diagnosis should be made that does not include the other persons whose lives are entwined with that of the individual” (Levine, 1989, p. 336). According to Levine, the person is who the person knows himself or herself to be and the environment is the context in which the person lives his or her life. In Levine’s view, health is socially defined and the goal of nursing is based on the four conservation principles. Levine did not operationally define and relate the metaparadigm concepts in her theory because her original work was initially intended to be a medical-surgical nursing textbook and not a developed nursing theory. In reevaluating her theory 20 years later, Levine stated that she has “grown in [her] conviction that they [the conservation principles] continue to offer an approach to nursing that is scientific, research oriented, and above all suitable in daily practice in many environments” (Levine, 1989, p. 331). A nurse who is involved in acute care situations such as an emergency room or intensive care unit often deals with clients who are exposed to severe threats to physiological integrity. The conservation of structural integrity is often the immediate priority in these acute care situations.

For example, when a nurse in an emergency room is dealing with a client who has been in a severe motor vehicle accident, the client’s structural integrity is at risk. When the client’s structural integrity has been damaged, the client must put all available energy into healing the self. The nurse tries to provide care for that client so that energy can be conserved for the processes of healing. In addition to experiencing a threat to structural integrity, this client has other needs as well. The client has social relationships and these relationships are also disrupted by the accident. The nurse is concerned with the client’s spouse and family who are part of the social unit. Even in this time of crisis in the emergency room, the client’s social integrity is of concern. Finally, the nurse is also concerned about the client’s personal integrity because the traumatic experience and necessary treatment can be frightening and dehumanizing. As the nurse strives to maintain the client’s structural, social, and personal integrity, the nurse recognizes that the client is a person who is a unique individual. Levine’s four conservation principles can also be useful in a home setting in which the family rather than a single individual is the client. The nurse recognizes that energy within the family needs to be maintained to keep the family whole. In caring for the family, the nurse needs to maintain the structural, social, and personal integrity of the family and of each individual while dealing with the illness of a specific family member. Consider, for example, the nurse who makes a home health visit to see a child with cystic fibrosis. In this situation, the nurse’s attentioeeds to be directed toward conservation of energy for the child. To help conserve the child’s energy for breathing, exercises must be taught to and done by others. The nurse directs strategies toward conserving the child’s structural integrity while recognizing that the child is a unique individual and is a member of a social group, the family. Conservation of social integrity would be accomplished through maintaining interest in and monitoring the family dynamics. Levine is pragmatic, and the conservation principles can be applied to most nursing situations. Her theory is appropriate for use in situations in which the nurse has had a long-term relationship with the client, yet is also useful for short-term relationships. Levine’s theory is congruent with the characteristics of the Totality Paradigm.

 

Dorothea Orem

In attempting to plan a nursing curriculum for licensed practical nurses, Dorothea Orem was searching for a pragmatic framework to organize nursing knowledge. She focused on the questions “What is nursing?” and “When do people need nursing care?” and from this she derived that people need nursing when they are unable to care for themselves. In 1971, she presented the Self- Care Deficit Theory of Nursing (S-CDTN) in the book Nursing Concepts of Practice and has continually revised and updated her theory. Orem’s theory incorporates the medical model rather than rejects it, centers on the individual, is problem oriented, and is easily adaptable in varied clinical situations. These attributes create its wide appeal for application iursing practice. Meleis (1991, p. 401) stated that it has “the widest circle of all theories in practice.” As a grand theory, the S-CDTN has three interconnecting theories: Theory of Self- Care, Theory of Self-Care Deficit, and Theory of Nursing Systems. Each one is discussed below.

 

Theory of Self-Care

According to this theory, self-care is a learned behavior and a deliberate action in response to a need. Orem identified three categories of self-care requisites: universal self-care requisites, developmental self-care requisites, and health-deviation self-care requisites. Universal self-care requisites are common to all human beings and include both physiological and social interactioeeds. Developmental self-care requisites are the needs that arise as the individual grows and develops. Health-deviation self-care requisites result from the needs produced by disease or illness states. Self-care is performed by mature and maturing individuals. When someone else must perform a self-care need, it is termed dependent care.

 

Theory of Self-Care Deficit

This theory purports that nursing care is needed when people are affected by limitations that do not allow them to meet their self-care needs. The relationship between the nurse and the client is established when a self-care deficit is present. Self-care deficits, not medical diagnosis, determine the need for nursing care. According to Orem, the only legitimate need for nursing care is when a self-care deficit exists.

 

Theory of Nursing Systems

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?” This was the original question that prompted the development of Orem’s theory. 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. Orem identified three types of nursing systems: wholly compensatory, partly compensatory, and supportive-educative. In the wholly compensatory nursing system, the nurse supports and protects the client, compensates for the client’s inability to care for self, and attempts to provide care for the client. The nurse would use the wholly compensatory nursing system when caring for a newborn or with a client in a postanesthesia care unit who is recovering from surgery. Both of these clients are completely unable to provide self-care. 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. In the supportive-educative nursing system, the nurse’s actions are to help clients develop their own self-care abilities through knowledge, support, and encouragement. Clients must learn and perform their own self-care activities. The supportive-educative nursing system is being used when a nurse guides a new mother to breastfeed her baby. Counseling a psychiatric client on more adaptive coping strategies is Types of Nursing Systems

 

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 explaiursing phenomena from a systems perspective. Specific research projects in the nursing systems domain include: effectiveness and outcomes of nursing care; components of ethical practice; professional practice models; cost-effective practices; resource requirements for quality care; work and role redesign of the registered nurse.

Specifically, the objectives of this focus are to:

·        Critically evaluate the theoretical and empirical knowledge about inter-and intra-organizational phenomena relevant to the understanding of nursing systems.

·        Develop and validate new theoretical constructs and models that explaiursing phenomena from a systems perspective.

·        Contribute to knowledge development in the domain of nursing systems through the generations of new knowledge as well as the synthesis of nursing knowledge with that of related disciplines.

·        Extend and refine the definition of the domain of nursing systems.

·        Demonstrate expertise in research design, data collection and analytic techniques appropriate to the study of the nursing systems domain.

·        Contribute to the research literature iursing related disciplines;

·        Demonstrate competence in the measurement of macro- and micro-level variables central to nursing systems.

·        Demonstrate competence in working with large data sets to address questions central to nursing systems

 

Neuman Systems Model

The Neuman Systems Model was originally developed in 1970 at the University of California, Los Angeles, by Betty Neuman, Ph.D., RN. 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. After a two-year evaluation of the model, it was published in Nursing Research (Neuman & Young, 1972). The Neuman Systems Model is a unique, systems-based perspective that provides a unifying focus for approaching a wide range of nursing concerns. The Neuman Systems Model is a comprehensive guide for nursing practice, research, education, and administration that is open to creative implementation…(and) has the potential for unifying various health-related theories, clarifying the relationships of variables iursing care and role definitions at various levels of nursing practice. The multidimensionality and wholistic systemic perspective of the Neuman Systems Model is increasingly demonstrating its relevance and reliability in a wide variety of clinical and educational settings throughout the world. (Betty Neuman, 2002)

 

Omaha System

The Omaha System is a comprehensive, research-based classification system designed for use in diverse community, case management, long-term care, and educational settings to enhance health care practice, documentation, and information management.

Consisting of three interrelated components:

·        the Problem Classification Scheme

The Scheme is a comprehensive, orderly, nonexhaustive, mutually exclusive taxonomy designed to identify diverse clients’ health-related concerns. It consists of 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.

·        the Intervention Scheme

The Scheme is a comprehensive, orderly, nonexhaustive, mutually exclusive taxonomy designed to address specific problems for diverse clients. 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.

·        the 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.

Components provide a structure to document client needs and strengths, describe practitioner interventions, and measure client outcomes. Work on the Omaha System began in the 1970s when Visiting Nurse Association (VNA) of Omaha (Nebraska) staff began revising their home health and public health client records and adopting a problem-oriented approach. The goal was to provide a useful guide for practice, a method for documentation, and a framework for information management. From the beginning, DeLanne Simmons, VNA of Omaha Chief Executive Officer, envisioned a computerized management information system that incorporated an integrated, valid and reliable clinical information system organized around clients who received services, not the multidisciplinary practitioners who provided services. Between 1975 and 1986, three research projects were funded by the Division of Nursing, US DHHS to develop and refine the Omaha System.

Further research designed to establish reliability, validity, and usability was conducted between 1989 and 1993, and funded by a National Institute of Nursing Research, NIH RO-1 grant. Practitioners employed at the VNA of Omaha and 7 diverse test sites located throughout the USA participated in the four empirical, inductive studies. Practitioners submitted data based on actual client services they were providing, not on retrospective record review. In addition to the rigorous developmental research, more than 50 unique and diverse additional studies have been conducted to generate findings of practical, economic, scholarly, and professional value. During the early years, information was disseminated through workshops and speeches. The first Omaha System article was published in 1981, the first books in 1992, and the current book in 2005.

 

References

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Barton AJ, Gilbert L, Erickson V, Baramee J, Sowers D, Robertson KJ. (2003, May/June). A guide to assist nurse practitioners with standardized nursing language. CIN: Computers, Informatics, Nursing, 21(3), 128-133.

Barton AJ, Baramee J, Sowers D, Robertson KJ. (2003, December). Articulating the value-added dimension of NP care. Nurse Practitioner, 28(12), 34-40.

Barton AJ, Clark L, Baramee J. (2004, April). Tracking outcomes in community-based care. Home Health Care Management and Practice, 16(3), 171-176.