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SUBJECT: OBSTETRICS AND GYNAECOLOGICAL NURSING.

SEMINAR ON
THEORIES, MODELS AND
APPROACHES APPLIED TO
MIDWIFERY PRACTICE.

SUBMITTED TO

SUBMITTED BY

SI.NO PAGE NO
CONTENT

MATERNAL ROLE ATTAINMENT THEORY


1 (RAMONA T. MERCER)

PARENT CHILD INTERACTION MODEL


2
(KATHRYNE E. BARNARD)

SYSTEM MODEL
3 (BETTY NEUMAN)

4
ADAPTATION MODEL
(SR. CALLISTA ROY)

1
CORE, CARE AND CURE MODEL
5
(LYDIA HALL)

6 BIBLIOGRAPHY

MATERNAL ROLE ATTAINMENT THEROY (RAMONA T . MERCER)

CREDENTIALS AND BACKGROUND OF THE THEROIST

 Ramnona T. Mercer began her nursing career in 1950, when she was graduated from St.
Margaret’s school of nursing.
 She worked as a nurse, head nurse, and instructor in the areas of paediatrics, obstetrics, and
contagious diseases.
 She completed a bachelor of science degree in nursing in 1962 from the university of New
Mexico.
 She went to earn an M.S.N. in maternal child health nursing from the University fo Pittsburgh
in 1973.
 She worked as a clinical instructor, assistant professor, associate professor and finally as
professor in the same department and remained in that position until her retirement in 1987.
 As a head nurse in pediatrics and staff nurse in intrapartum, postpartum, and newborn nursery
units, Ramona Mercer had a great deal of experience in nursing care for mothers and infants.
This gave her a strong foundation for creating her Maternal Role Attainment Theory for
nursing.

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MAJOR CONCEPTS AND DEFINITIONS

a) Maternal age

Chronological and developmental

b) Perception of birth experience

A woman’s perception of her performance during labor and birth.

c) Early maternal infant separation

Separation from the mother after birth due to illness and or prematurity

d) Self esteem
An individual’s perception of how others view on and self acceptance of the perception
e) Flexibility
Role are not rigidly fixed; therefore, who fills the roles is not important
f) Child rearing attitudes
Maternal attitudes or beliefs about childrearing.
g) Health status
The mother’s and father’s perception of their prior health, current health, health outlook,
resistance susceptibility to illness, health worry concern, sickness orientation and rejection of
the sick role.
h) Anxiety
A trait in which there is specific proneness to perceive stressful situations as dangerous or
threatening and as situation specific state.
i) Depression
Having a group of depressive symptoms, and in particular the affective component ao fthe
depressed mood.
j) Role strain
The conflict and difficulty felt by the women in fulfilling the maternal role obligation
k) Gratification
The satisfaction, enjoyment reward or pleasure that a woman experiences in interacting with
her infant, and in fulfilling the usual tasks inherent in mothering,
l) Attachment
A component of the parental role and identity. Attachment is viewed as a process in which an
enduring affectional and emotional commitment to an individual is formed.
m) Infant temperament
An easy versus a difficult temperament, it is related to whether the infant sends hard to read
cues, leading to feeling of incompetence and frustration in the mother.
n) Infant health status
Illness causing maternal infant separation, interfering with the attachment process
o) Infant characteristics
Temperament appearance, and health status
p) Family functioning
The individual’s view of the activities and relationship between the family and its subsystems
and broader social units.
q) Stress
Positively and negatively perceived life events and environmental variables

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r) Social support
The amount of help actually received
s) Mother father relationship
Perception of the mate relationship that includes intended and actual values, goals, , and
agreements between two.
t) Culture
The total way of life learned and passed on from generation to generation.

MAJOR ASSUMPTIONS

1) A relatively stable “core self”, acquired through lifelong socialization, determines how a
mother defines and perceives events; her perceptions of her infant’s and others’ reponses to
her mothering, along with her life situation, are the real world to which she responds.
2) In addition to the mother’s socialization, her developmental level and innate personality
characteristics also influence her behavioural responses.
3) The mother’s role partner, her infant, will reflect the mother’s competence in the mothering
role via growth and development.
4) The infant is considered an active partner in the maternal role taking process, affected by the
role enactment.
5) Maternal identity develops along with maternal attachment and depends on the other.

Nursing

Mercer does not define nursing but refers to nursing as a science emerging from a ‘turbulent
adolescence to adulthood.’ Nurses are the health professionals having the most ‘sustained and intense
interaction with women in the maternity cycle.’ Nurses are responsible for ‘promoting the health’ of
families and children; nurses are “pioneers” in developing and sharing assessment strategies for these
clients.

Obstetrical nursing, according to Mercer, is the diagnosis and treatment of women’s and men’s
responses to actual or potential health problems during pregnancy, childbirth, and post partum period.

Person

Mercer does not specifically define but refers to the ‘self ’or ‘core self’. She views the self as separate
from the roles that are played. Through maternal individuation, a woman amy regain her own
‘personhood’ as she extrapolates her ‘self’ from the mother infant dyad. The core self evolves from a
culture context and determines how situations are defined and shaped.

Health

In her theory Mercer defines health status as the mother’s and father’s perception of their prior
health, health outlook, resistance-susceptibility to illness, health worry concern, sickness orientation,
and rejection of the sick role. Health status of the newborn is the extent of pathology present and
infant health status by parental rating of overall health. The health status of a family is negatively
affected by antepartum stress. Health status is an important indirect influence on satisfaction with
relationships in child bearing families.

Environment

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Mercer does not define environment. She does, however, address the individual’s culture, mate,
family and or support network, and size of that network as it relates to maternal role attainment. A
mate’s love, support and nurturance were important factors in enabling woman to mother her child.
The responses of mates, parents, other relatives, and friends are closely evaluated by the role taker.
Supportive responses provided sanction for their mothering role and seemed to communicate
confidence. In their ability to mother. The mate, parent, family and friends were also identified as
sources of coping and help for the new mother.

THEORETICAL ASSERTATION

1. The immediate environment in which the maternal role attainment occurs is the micro system,
which includes the family, and factors such as family functioning, mother father relationship,
social support, and stress. The variables contained within the micro system interact with one
ore more of the other variables in affecting maternal role. The infant as an individual is
embedded within the family system. The family is viewed as a semi closed system
maintaining boundaries and control over interchange between the family system and other
social systems.
2. The exosystem encompasses, influences, and delimits the microsystem. The mother-infant
unit is not contained within the exosystm, but the exosysetem may determine in part what
happens to the developin maternal role and the child.
3. The macrosystm refers to the general prototypes existing in a particular culture or transmitted
cultural consistencies.

Maternal role attainment system is a process that follows four stages of role acquisition

1. Anticipatory – begins social and psychological adjustment to the role by learning the
expectations of the role. The mother fantasizes about the role, relates to the fetus in utero, and
begins role play
2. Formal- begins with assumption of the role at birth; role behaviours are guided by formal,
consensual expectations of others in the mother’s social system.
3. Informal- begins as mother develops unique ways of dealing with the role not conveyed by
the social system
4. Personal- the mother experiences a sense of harmony, confidence, and competence in the way
she performs the role; maternal role is achieved.

PARENT CHILD INTERACTION MODEL (KATHERINE E BARNARD)

MAJOR CONCEPTS AND DEVINITIONS

A major focus of Barnard’s work was the development of assessment tools to evaluate the child
health, growth, and development while viewing the parent and child as an interactive system.
Barnard stated that the parent infant system. Barnard stated that at the parent infant system was
influenced by individual characteristics of each member and that the individual characteristics
were also modified to meet the needs of the system. She defines modification as adaptive
behaviour.

THREE MAJOR CONCEPTS FORM THE CONCEPT FORM THE BASIS OF THIS THEORY

CHILD

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in describing the child, Barnard used the characteristics of “newborn behaviour, feeding and
sleeping patterns, physical appearance, temperament and the child’s ability to hi/her care giver
and environment.”

MOTHER

mother refers to the child’s mother or caregiver and his or her important characteristics. The
mother’s characteristics include her “psycosocial assets, her concerns about her child, her own
health, the amount of life change she experienced, her expectation for her child, and most
important, her parenting style and her adaptional skills.”

ENVIROMENT

The environment represents the environment of both child and mother. Characteristics of the
environment include aspects of the physical environment of the family, the father, the father’s
involvement in the degree of parent mutuality in regard t child rearing.

MAJOR ASSUMPTIONS

NURSING

A process by which the patient is assisted in maintenance and promotion ot his independence.
This process by which the patient is assisted in maintenance and promotion of his independence
this process maybe educational, therapeutic, or restorative: it involves facilitation of change, most
probably a change in the environment.” Five years later, in a 1981 key note address to the first
international nursing research conference, she defined nursing as “the diagnosis and treatment of
human responses to health problems.”

PERSON

When Barnard describes a person or human being, she speaks of the ability ‘to take auditory,
visual, and tactile stimuli but also to make meaningful associations from what he takes in. This
term includes infants, children, and adults.

HEALTH

Although Barnard does not define health, she describes the family “ as the basic unit of health
care.” In the nursing child assessment satellite training study guide, she states “in health care, the
ultimate goal is primary prevention.” Barnard emphasizes the importance of striving to reach
one’s maximum potential. She believes “we must promote new values in society, which up to
now has valued not health, but absence of disease.” She wrote for the definition for the scope of
practice on maternal child health.

ENVIRONMENT

Environment is an essential aspect of Baranard’s theory. In child health assessment “in essence,
the environment includes all experiences encountered by the child; people, objects, places,
sounds, visual and tactile sensations.” She makes a distinction between the animate and inanimate
environments. “the inanimate environment refers to the objects available to the child for
exploration and manipulation. The animate environment includes the activities of the care taker
sed in arousing and directing the young child to external world.”

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THEORETICAL ASSERTATIONS

1. In child health assessment the ultimate goal is to identify the problems at a point before
they develop and when intervention would be most effective.
2. Environmental factors, as typified by the process of parent child interaction, are important
for determining the child health outcome.
3. The caregiver- infant interaction provides information that reflects the nature of the
child’s ongoing environment.
4. The caregiver brings a basic style and level of skill that are enduring characteristics the
caregiver’s adaptive capacity is more readily influenced by responses of the infant and
her environmental support.
5. In adaptive parent child interaction, there is a process: of mutual modification in that the
parent’s behaviour influences the infant or child and I turn the child influences the parent
so that both are changed.
6. The adaptive process is modifiable than the mother’s or infant’s basic characteristics;
therefore. In intervention the nurse should lend support to the mother’s sensitivity and
response to her infant’s cues rather than trying to change her characteristics or styles.
7. An important quality of promoting the child’s learning is in permitting child-initiated
behaviours and in reinforcing the child’s attempt at task.
8. A major issue for the nursing profession is support of the child’s giver during the first
year of life.
9. Interactive assessment is important in any comprehensive child health care model.
10. Assessment of the child’s environment is important in any child health assessment model.

BETTY NEUMAN'S SYSTEM MODEL

Betty Neuman’s system model provides a comprehensive flexible holistic and system based
perspective for nursing.

It focuses on the response of the client system to actual or potential environmental stressors and the
use of primary, secondary and tertiary nursing prevention intervention for retention, attainment, and
maintenance of optimal client system wellness.

HISTORY AND BACKGROUND OF THE THEORIST

Betty Neuman was born in 1924, in Lowel, Ohio.

BS in nursing in 1957

MS in Mental Health Public health consultation, from UCLA in 1966.

Ph.D. in clinical psychology

a pioneer in the community mental health movement in the late 1960s.

developed the model while working as a lecturer in community health nursing at University of
California, Los Angeles.

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The models was initially developed in response to graduate nursing students expression of a need for
course content that would expose them to breadth of nursing problems prior to focusing on specific
nursing problem areas.

The model was published in 1972 as “A Model for Teaching Total Person Approach to Patient
Problems” in Nursing Research.

It was refined and subsequently published in the first edition of Conceptual Models for Nursing
Practice, 1974, and in the second edition in 1980.

BASIC ASSUMPTIONS

 Each client system is unique, a composite of factors and characteristics within a given range
of responses contained within a basic structure.
 Many known, unknown, and universal stressors exist. Each differ in it’s potential for
disturbing a client’s usual stability level or normal LOD
 The particular inter-relationships of client variables at any point in time can affect the degree
to which a client is protected by the flexible LOD against possible reaction to stressors.
 Each client/ client system has evolved a normal range of responses to the environment that is
referred to as a normal LOD. The normal LOD can be used as a standard from which to
measure health deviation.
 When the flexible LOD is no longer capable of protecting the client/ client system against an
environmental stressor, the stressor breaks through the normal LOD
 The client whether in a state of wellness or illness, is a dynamic composite of the inter-
relationships of the variables. Wellness is on a continuum of available energy to support the
system in an optimal state of system stability.
 Implicit within each client system are internal resistance factors known as LOR, which
function to stabilize and realign the client to the usual wellness state.
 Primary prevention relates to G.K. that is applied in client assessment and intervention, in
identification and reduction of possible or actual risk factors.
 Secondary prevention relates to symptomatology following a reaction to stressor, appropriate
ranking of intervention priorities and treatment to reduce their noxious effects.
 Tertiary prevention relates to adjustive processes taking place as reconstitution begins and
maintenance factors move the back in circular manner toward primary prevention.
 The client as a system is in dynamic, constant energy exchange with the environment.

MAJOR CONCEPTS

Content

 The variables of the person in interaction with the internal and external environment comprise
the whole client system

Basic structure/Central core

 common client survival factors in unique individual characteristics representing basic system
energy resources.
 The basis structure, or central core, is made up of the basic survival factors that are common
to the species (Neuman,2002).
 These factors include:- - Normal temp. range, Genetic structure.- Response pattern. Organ
strength or weakness, Ego structure

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 Stability, or homeostasis, occurs when the amount of energy that is available exceeds that
being used by the system.
 A homeostatic body system is constantly in a dynamic process of input, output, feedback, and
compensation, which leads to a state of balance.

Degree to reaction

 the amount of system instability resulting from stressor invasion of the normal LOD.

Entropy

 a process of energy depletion and disorganization moving the system toward illness or
possible death.

Flexible LOD

 a protective, accordion like mechanism that surrounds and protects the normal LOD from
invasion by stressors.

Normal LOD

 It represents what the client has become over time, or the usual state of wellness. It is
considered dynamic because it can expand or contract over time.

Line of Resistance-LOR

 The series of concentric circles that surrounds the basic structure.


 Protection factors activated when stressors have penetrated the normal LOD, causing a
reaction
 symptomatology. E.g. mobilization of WBC and activation of immune system mechanism

Input- output

 The matter, energy, and information exchanged between client and environment that is
entering or leaving the system at any point in time.

Negentropy

 A process of energy conservation that increase organization and complexity, moving the
system toward stability or a higher degree of wellness.

Open system

 A system in which there is continuous flow of input and process, output and feedback. It is a
system of organized complexity where all elements are in interaction.

Prevention as intervention

 Interventions modes for nursing action and determinants for entry of both client and nurse in
to health care system.

Reconstitution

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 The return and maintenance of system stability, following treatment for stressor reaction,
which may result in a higher or lower level of wellness.

Stability

 A state of balance of harmony requiring energy exchanges as the client adequately copes with
stressors to retain, attain, or maintain an optimal level of health thus preserving system
integrity.

Stressors

 environmental factors, intra (emotion, feeling), inter (role expectation), and extra personal
(job or finance pressure) in nature, that have potential for disrupting system stability.
 A stressor is any phenomenon that might penetrate both the F and N LOD, resulting either a
positive or negative outcome.

Wellness/Illness

 Wellness is the condition in which all system parts and subparts are in harmony with the
whole system of the client.
 Illness is a state of insufficiency with disrupting needs unsatisfied (Neuman, 2002).
 Illness is an excessive expenditure of energy… when more energy is used by the system in its
state of disorganization than is built and stored; the outcome may be death (Neuman, 2002).

Prevention

 the primary nursing intervention. Prevention focuses on keeping stressors and the stress
response from having a detrimental effect on the body.

PRIMARY PREVENTION

 Primary prevention occurs before the system reacts to a stressor. On the one hand, it
strengthens the person (primary the flexible LOD) to enable him to better deal with stressors
 On the other hand manipulates the environment to reduce or weaken stressors.
 Primary prevention includes health promotion and maintenance of wellness.

SECONDARY PREVENTION

 Secondary prevention occurs after the system reacts to a stressor and is provided in terms of
existing system.
 Secondary prevention focuses on preventing damage to the central core by strengthening the
internal lines of resistance and/or removing the stressor.

TERTIARY PREVENTION

 Tertiary prevention occurs after the system has been treated through secondary prevention
strategies.
 Tertiary prevention offers support to the client and attempts to add energy to the system or
reduce energy needed in order to facilitate reconstitution.

FOUR NURSING PARADIGMS

PERSON

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 human being is a total person as a client system and the person is a layered multidimensional
being.

Each layer consists of five person variable or subsystems:

 Physiological- Refer of the physicochemical structure and function of the body.


 Psychological- Refers to mental processes and emotions.
 Socio-cultural- Refers to relationships; and social/cultural expectations and activities.
 Spiritual- Refers to the influence of spiritual beliefs.
 Developmental- Refers to those processes related to development over the lifespan.

ENVIRONMENT

 The environment is seen to be the totality of the internal and external forces which surround a
person and with which they interact at any given time.
 These forces include the intrapersonal, interpersonal and extra-personal stressors which can
affect the person’s normal line of defense and so can affect the stability of the system.
 The internal environment exists within the client system.
 The external environment exists outside the client system.
 Neuman also identified a created environment which is an
environment that is created and developed unconsciously by the
client and is symbolic of system wholeness.

HEALTH

 Neuman sees health as being equated with wellness. She defines health/wellness as “the
condition in which all parts and subparts (variables) are in harmony with the whole of the
client (Neuman, 1995)”.
 The client system moves toward illness and death when more energy is needed than is
available. The client system moved toward wellness when more energy is available than is
needed

NURSING

 Neuman sees nursing as a unique profession that is concerned with all of the variables which
influence the response a person might have to a stressor.
 The person is seen as a whole, and it is the task of nursing to address the whole person.
 Neuman defines nursing as “action which assist individuals, families and groups to maintain a
maximum level of wellness, and the primary aim is stability of the patient/client system,
through nursing interventions to reduce stressors.’’
 Neuman states that, because the nurse’s perception will influence the care given, then not
only must the patient/client’s perception be assessed, but so must those of the caregiver
(nurse).
 The role of the nurse is seen in terms of degree of reaction to stressors, and the use of
primary, secondary and tertiary interventions

ACCEPTANCE BY THE NURSING COMMUNITY

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 Neuman’s model has been described as a grand nursing theory by walker and Avant.
 Grand theories can provide a comprehensive perspective for nursing practice, education, and
research and Neuman’s model does.

PRACTICE

 The Neuman systems model has been applied and adapted to various specialties include
family therapy, public health, rehabilitation, and hospital nursing.
 The sub specialties include pulmonary, renal, critical care, and hospital medical units. One of
the model’s strengths is that it can be used in a variety of settings
 Using this conceptual model permits comparison of a nurse’s interpretation of a problem with
that of the patient, so the patient and nurse do not work on two separate problems.
 The role of the nurse in the model is to work with the patient to move him as far as possible
along a continuum toward wellness.
 Because this model requires individual interaction with the total health care system, it is
indicative of the futuristic direction the nursing profession is taking.
 The patient is being relabeled as a consumer with individual needs and wants.

EDUCATION

The model has also been widely accepted in academic circles.

curriculum guide for a conceptual framework at Indiana University, Northwestern State University in
Shreveport, Louisiana.

RESEARCH

A study was published by Riehl and Roy to test the usefulness of the Neuman model in nursing
practice.

Acceptance by the nursing community for research applying this model is in the beginning stages and
positive.

NEUMAN'S SYSTEM MODEL AND THE CHARACTERISTICS OF A THEORY

 Neuman's model connects the interrelated concepts in such a way as to create a different way
of looking at a particular phenomenon.
 Neuman’s model in general presents itself as logically consistent.
 There is a logical sequence in the process of nursing wherein emphasis on the importance of
accurate data assessment is basic to the sequential steps of the nursing process.
 Neuman’s model is fairly simple and straightforward in approach.
 The terms used are easily identifiable and for the most part have definitions that are broadly
accepted.
 Neuman’s model, due to its high level and breadth of abstraction, lends itself to theory
development.
 The model has provided clear, comprehensive guidelines for nursing education and practice in
a variety of settings; this is its primary contribution to nursing knowledge.
 Neuman's model is applicable in the practice as assessment/intervention instrument together
with comprehensive guidelines for its use with the nursing process.

ROY'S ADAPTATION MODEL

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Introduction

Sr.Callista Roy, a prominent nurse theorist, writer, lecturer, researcher and teacher

Professor and Nurse Theorist at the Boston College of Nursing in Chestnut Hill

Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and Mrs. Fabien Roy

she earned a Bachelor of Arts with a major in nursing from Mount St. Mary's College, Los Angeles in
1963.

a master's degree program in pediatric nursing at the University of California ,Los Angeles in 1966.

She also earned a master’s and PhD in Sociology in 1973 and 1977 ,respectively.

Sr. Callista had the significant opportunity of working with Dorothy E. Johnson

Johnson's work with focusing knowledge for the discipline of nursing convinced Sr. Callista of the
importance of describing the nature of nursing as a service to society and prompted her to begin
developing her model with the goal of nursing being to promote adaptation.

She joined the faculty of Mount St. Mary's College in 1966, teaching both pediatric and maternity
nursing.

She organized course content according to a view of person and family as adaptive systems.

She introduced her ideas about ‘Adaptation Nursing’ as the basis for an integrated nursing curriculum.

Goal of nursing to direct nursing education, practice and research

Model as a basis of curriculum impetus for growth--Mount St. Mary’s College

1970-The model was implemented in Mount St. Mary’s school

1971- she was made chair of the nursing department at the college.

THEORY DESCRIPTION

The central questions of Roy’s theory are:

 Who is the focus of nursing care?


 What is the target of nursing care?
 When is nursing care indicated?

Roy’s first ideas appeared in a graduate paper written at UCLA in 1964.

Published these ideas in "Nursing outlook" in 1970

Subsequently different components of her framework crystallized during 1970s, ’80s, and ’90s

Over the years she identified assumptions on which her theory is based.

Explicit assumptions (Roy 1989; Roy and Andrews 1991)

 The person is a bio-psycho-social being.

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 The person is in constant interaction with a changing environment.
 To cope with a changing world, person uses both innate and acquired mechanisms which are
biological, psychological and social in origin.
 Health and illness are inevitable dimensions of the person’s life.
 To respond positively to environmental changes, the person must adapt.
 The person’s adaptation is a function of the stimulus he is exposed to and his adaptation level
 The person’s adaptation level is such that it comprises a zone indicating the range of
stimulation that will lead to a positive response.
 The person has 4 modes of adaptation: physiologic needs, self- concept, role function and
inter-dependence.
 "Nursing accepts the humanistic approach of valuing other persons’ opinions, and view
points" Interpersonal relations are an integral part of nursing
 There is a dynamic objective for existence with ultimate goal of achieving dignity and
integrity.

Implicit assumptions

 A person can be reduced to parts for study and care.


 Nursing is based on causality.
 Patient’s values and opinions are to be considered and respected.
 A state of adaptation frees an individual’s energy to respond to other stimuli.

ROY ADAPTATION MODEL CONCEPTS: EARLY AND REVISED

 Adaptation -- goal of nursing


 Person -- adaptive system
 Environment -- stimuli
 Health -- outcome of adaptation
 Nursing -- promoting adaptation and health

Concepts-Adaptation

 Responding positively to environmental changes.


 The process and outcome of individuals and groups who use conscious awareness, self
reflection and choice to create human and environmental integration

Concepts-Person

 Bio-psycho-social being in constant interaction with a changing environment


 Uses innate and acquired mechanisms to adapt
 An adaptive system described as a whole comprised of parts
 Functions as a unity for some purpose
 Includes people as individuals or in groups-families, organizations, communities, and society
as a whole.

Concepts-Environment

 Focal - internal or external and immediately confronting the person


 Contextual- all stimuli present in the situation that contribute to effect of focal stimulus
 Residual-a factor whose effects in the current situation are unclear

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 All conditions, circumstances, and influences surrounding and affecting the development and
behavior of persons and groups with particular consideration of mutuality of person and earth
resources, including focal, contextual and residual stimuli

Concepts-Health

 Inevitable dimension of person's life


 Represented by a health-illness continuum
 A state and a process of being and becoming integrated and whole

Concepts-Nursing

 To promote adaptation in the four adaptive modes


 To promote adaptation for individuals and groups in the four adaptive modes, thus
contributing to health, quality of life, and dying with dignity by assessing behaviors and
factors that influence adaptive abilities and by intervening to enhance environmental
interactions

Concepts-Subsystems

 Cognator subsystem — A major coping process involving 4 cognitive-emotive channels:


perceptual and information processing, learning, judgment and emotion.
 Regulator subsystem — a basic type of adaptive process that responds automatically through
neural, chemical, and endocrine coping channels

Relationships

 Derived Four Adaptive Modes


 500 Samples of Patient Behavior
 What was the patient doing?
 What did the patient look like when needing nursing care?

Four Adaptive Modes

 Physiologic Needs
 Self Concept
 Role Function
 Interdependence

Usefulness of Adaptation Model

 Scientific knowledge for practice


 Clinical assessment and intervention
 Research variables
 To guide nursing practice
 To organize nursing education
 Curricular frame work for various nursing colleges

Summary

 5 elements -person, goal of nursing, nursing activities, health and environment

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 Persons are viewed as living adaptive systems whose behaviours may be classified as
adaptive responses or ineffective responses.
 These behaviors are derived from regulator and cognator mechanisms.
 These mechanisms work with in 4 adaptive modes.
 The goal of nursing is to promote adaptive responses in relation to 4 adaptive modes, using
information about person’s adaptation level, and various stimuli.
 Nursing activities involve manipulation of these stimuli to promote adaptive responses.
 Health is a process of becoming integrated and able to meet goals of survival, growth,
reproduction, and mastery.
 The environment consists of person’s internal and external stimuli.

DOROTHEA OREM'S SELF-CARE THEORY

DOROTHEA OREM (1914-2007)

Introduction

One of foremost nursing theorists.

Born 1914 in Baltimore.

Earned her diploma at Providence Hospital – Washington, DC

1939 – BSN Ed., Catholic University of America

1945 – MSN Ed., Catholic University of America

Involved in nursing practice, nursing service, and nursing education

During her professional career, she worked as a staff nurse, private duty nurse, nurse educator and
administrator and nurse consultant

Received honorary Doctor of Science degree in 1976

Published first formal articulation of her ideas in Nursing: Concepts of Practice in 197, second in
1980, and in 1995.

Major assumptions

People should be self-reliant and responsible for their own care and others in their family needing care

People are distinct individuals

Nursing is a form of action – interaction between two or more persons

Successfully meeting universal and development self-care requisites is an important component of


primary care prevention and ill health

A person’s knowledge of potential health problems is necessary for promoting self-care behaviors

Self care and dependent care are behaviors learned within a socio-cultural context

Concepts

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Nursing – is art, a helping service, and a technology

 Actions deliberately selected and performed by nurses to help individuals or groups under
their care to maintain or change conditions in themselves or their environments
 Encompasses the patient’s perspective of health condition ,the physician’s perspective , and
the nursing perspective
 Goal of nursing – to render the patient or members of his family capable of meeting the
patient’s self care needs
 To maintain a state of health
 To regain normal or near normal state of health in the event of disease or injury
 To stabilize ,control ,or minimize the effects of chronic poor health or disability

Health – health and healthy are terms used to describe living things …

 It is when they are structurally and functionally whole or sound … wholeness or integrity.
.includes that which makes a person human,…operating in conjunction with physiological
and psychophysiological mechanisms and a material structure and in relation to and
interacting with other human beings

Environment

 environment components are enthronement factors, enthronement elements, conditions, and


developed environment

Human being – has the capacity to reflect, symbolize and use symbols

 Conceptualized as a total being with universal, developmental needs and capable of


continuous self care
 A unity that can function biologically, symbolically and socially

Nursing client

 A human being who has "health related /health derived limitations that render him incapable
of continuous self care or dependent care or limitations that result in ineffective / incomplete
care.
 A human being is the focus of nursing only when a self –care requisites exceeds self care
capabilities

Nursing problem

 deficits in universal, developmental, and health derived or health related conditions

Nursing process

 a system to determine (1)why a person is under care (2)a plan for care ,(3)the implementation
of care

Nursing therapeutics

 deliberate, systematic and purposeful action

Orem’s general theory of nursing in three related parts:-

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1) Theory of self care
2) Theory of self care deficit
3) Theory of nursing system

A. Theory of Self Care

This theory Includes:

 Self care – practice of activities that individual initiates and perform on their own behalf in
maintaining life ,health and well being
 Self care agency – is a human ability which is "the ability for engaging in self care"
-conditioned by age developmental state, life experience sociocultural orientation health and
available resources
 Therapeutic self care demand – "totality of self care actions to be performed for some
duration in order to meet self care requisites by using valid methods and related sets of
operations and actions"
 Self care requisites-action directed towards provision of self care. 3 categories of self care
requisites are-

1. Universal

 Developmental
 Health deviation

2. Universal self care requisites

 Associated with life processes and the maintenance of the integrity of human structure and
functioning
 Common to all , ADL
 Identifies these requisites as:
 Maintenance of sufficient intake of air ,water, food
 Provision of care assoc with elimination process
 Balance between activity and rest, between solitude and social interaction
 Prevention of hazards to human life well being and
 Promotion of human functioning

3. Developmental self care requisites

 Associated with developmental processes/ derived from a condition…. Or associated with an


event
 E.g. adjusting to a new job
 adjusting to body changes
 Health deviation self care
 Required in conditions of illness, injury, or disease .these include:--
 Seeking and securing appropriate medical assistance
 Being aware of and attending to the effects and results of pathologic conditions
 Effectively carrying out medically prescribed measures
 Modifying self concepts in accepting oneself as being in a particular state of health and in
specific forms of health care

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 Learning to live with effects of pathologic conditions

B. Theory of self care deficit

Specifies when nursing is needed

Nursing is required when an adult (or in the case of a dependent, the parent) is incapable or limited in
the provision of continuous effective self care. Orem identifies 5 methods of helping:

 Acting for and doing for others


 Guiding others
 Supporting another
 Providing an environment promoting personal development in relation to meet future
demands
 Teaching another

C. Theory of Nursing Systems

 Describes how the patient’s self care needs will be met by the nurse , the patient, or both
 Identifies 3 classifications of nursing system to meet the self care requisites of the patient:-
 Wholly compensatory system
 Partly compensatory system
 Supportive – educative system
 Design and elements of nursing system define
 Scope of nursing responsibility in health care situations
 General and specific roles of nurses and patients
 Reasons for nurses’ relationship with patients and
 The kinds of actions to be performed and the performance patterns and nurses’ and patients’
actions in regulating patients’ self care agency and in meeting their self care demand
 Orem recognized that specialized technologies are usually developed by members of the
health profession
 A technology is systematized information about a process or a method for affecting some
desired result through deliberate practical endeavor ,with or without use of materials or
instruments

Theory Testing
 Orem’s theory has been used as the basis for the development of research instruments to assist
researchers in using the theory
 A self care questionnaire was developed and tested by Moore(1995) for the special purpose of
measuring the self care practice of children and adolescents
 The theory has been used as a conceptual framework in assoc. degree programs also in many
nursing schools

Strengths

 Provides a comprehensive base to nursing practice


 It has utility for professional nursing in the areas of nursing practice nursing curricula ,nursing
education administration ,and nursing research
 Specifies when nursing is needed

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 Also includes continuing education as part of the professional component of nursing
education
 Her self care approach is contemporary with the concepts of health promotion and health
maintenance
 Expanded her focus of individual self care to include multi person units

Limitations

 In general system theory a system is viewed as a single whole thing while Orem defines a
system as a single whole ,thing
 Health is often viewed as dynamic and ever changing .Orem’s visual presentation of the
boxed nursing systems implies three static conditions of health
 Appears that the theory is illness oriented rather with no indication of its use in wellness
settings

Summary

 Orem’s general theory of nursing is composed of three constructs .Throughout her work ,she
interprets the concepts of human beings, health, nursing and society .and has defined 3 steps
of nursing process. It has a broad scope in clinical practice and to lesser extent in research
,education and administration

HALLS THEORY

MODEL

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CORE

The third area that nursing shares with all of the helping professions is that of using
relationships for therapeutic effect, and it’s designed as the core.

The core model of the framework dominates when nurses and patients are able to discuss
emotional concerns and distress to physical and mental changes due to patients’ disease process. This
area emphasizes the social, emotional, spiritual, and intellectual needs of the patient in relation to
family, institution, community and the world. These emotions and concerns effect compliance to the
medical plan and quality of life.

An essential role of nurses in the healthcare plan is to assist with management of patients by
providing medical, physical, and social care.

Knowledges that are foundational to the core were based on the social sciences and
therapeutic use of self. Knowledge and skills the nurse needs in order to use self therapeutically
include knowing self and learning interpersonal skills.

According to hall the role of professional nursing was created through the provision of care
that facilities the interpersonal process and invited the patient to learn to reach the core of his
difficulties while seeing him through the cure that is possible. Through the professional nursing
process, the patient has the opportunity to making the illness a learning experience from which may
emerge even healthier than before his illness.

CARE

. The care circle is the intimate care nurses provide to patients to assist in bathing, dressing,
feeding, toileting, and assistance with daily activities and it belongs exclusively to nursing. Nursing is
required when people are not able to undertake these activities for themselves. The care model
dominates when Nurses provide hands on care to patients

Patient education and discharge planning begins in the care model. During this phase, nurses have the
primary role of answering questions and address concerns in relation to disease process and its
management.

A hand on care for patients produces an environment of comfort and trust and promotes open
communication between nurses and patients. Open communication encourages expressions of
thoughts and fears and decreases anxiety. Patients develop feelings of security and verbalize concerns
of disease management, emotional, and/or social issues in relation to the lifestyle changes they are
experiencing.

Also Hall cautioned against viewing intimate bodily care as a task or trade. According to she the
laying on of hands to wash around a body is an activity, it is a trade; but if you look behind the
activity for the rationale and intent, look beyond it for the opportunities that the activity opens up for
something more enriching in growth, learning and healing production on the part of the patient, then
it’s a profession.

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CURE

The second aspect of nursing process is shared with medicine and is labeled the “cure”. Cure
is based in the pathological and therapeutic sciences, involves working with the patient and family in
relation to the medical care, and is shared with other members of the health care team

The cure model dominates when nurses perform physical assessments and care management plans for
the patients. During this phase, nurses assess patients’ ability to perform activities of daily living
based on physical changes that occur during walking, talking or bathing.

Hall comments on two ways that this medical aspect of nursing may be viewed. It may be viewed as
the nurse assisting the doctor by assuming medical task or functions. The other view of this aspect of
nursing is to see the nurse helping the patient through his/her medical, surgical, and rehabilitative care
in the role of comforter and nurturer.

Also Hall felt that the nursing profession was assuming more and more of the medical aspects of care
while at the same time giving away the nurturing process of nursing to less well-prepared persons.

HALL’S MODEL & NURSING’S METAPARADIGM

PERSON

 Referred to “the patient”


 A human being acted upon by a professional nurse.
 Patients who have their care, cure, and core needs met have improved self-esteem.

ENVIRONMENT

 Refers to the social environment.


 Includes everything from a person’s food to a nurse’s verbal & nonverbal interactions with
the patient

HEALTH

 Maintained by the intimate bodily care by nurses, the disease management and treatment &
the emotional and social structure of the patient
 Health & disease are the focus of the professional nurses.
 Nurses help patients through their healing process.

NURSING

 Provides intimate bodily care, emotional and social support to the patient
 Supports the nursing process.
 Nursing care should be delivered only by professional nurses.
 Nursing is a discipline distinct from medicine focusing on the patient’s reparative process
rather than on their disease!!

CONCLUSION

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Nurses work with the medical team to assist in evaluating patients’ understanding of
symptoms of their disease, compliance to diet and medication regimens, and the importance of
informed follow up with their physician or nurses. Nurses can promote trust and facilitate open
communication with patients when providing hands on care.

Registered Practical Nurses have an important role in management of patients, assessment


and education. Lydia Hall’s Framework of Care, Cure, and Core provide a model for nurses to follow
when evaluating patients’ physical, medical, and social needs. The individualized care offered by
nurses promotes improved quality of life and decreased hospital readmissions of the patients.

SUMMARY

The Hall’s believes that in spite of success in keeping people alive, there was a failure in
helping the patients live fully with chronic pathology. She reflected that in the early part of twentieth
century, a person came to the hospital for care. In the 1950s &1960s, the focus changed, and a person
came to the hospital for cure. After the patients biological crisis was stabilized, Hall believed that care
should be the primary focus and the nurses were the most qualified to provide the type of care that
would enable patients to achieve the maximum potential.

Hall believed patients should receive care only from professional nurses. Nursing involves interacting
with a patient in a complex process of teaching and learning.
Hall’s nursing model has three interrelated circles that “the care circle is the intimate bodily
care nurses provide to patients to assist with daily activities, the cure circle of the framework is the
disease management and treatment of the patient, and the core circle symbolizes the emotional and
social structure of the patient.

Hall’s Framework of Care, Cure, and Core provide a model for nurses to follow when
evaluating patients’ physical, medical, and social needs.

REFERENCES

 Tomey, A. & Alligood, M. (2002). Significance of theory for nursing as a discipline and
profession. Nursing Theorists and their work. Mosby, St. Louis, Missouri, United States of
America.
 Whelan, E. G. (1984). Analysis and application of Dorothea Orem’s Self-care Practuce
Model. Retrieved October 31, 2006.
 George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed.
Norwalk, Appleton & Lange.
 Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia.
Lippincott Williams& wilkins.
 Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed.
Philadelphia, Lippincott.

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