Nursing Models and Frameworks for Health Care Delivery
Terms commonly utilized when discussing conceptual models (paradigms) and frameworks for nursing
concept
a word or collection of words that bring forth mental pictures of the properties and meanings of some phenomenon
concepts can be classified in two ways
can be classified as observable concepts
result of sensation
immediately, or very close to being immediately, accessible to direct sensory observations
e.g., patient, nurse
can be classified as constructs
result of thought
not immediately accessible to direct sensory observation
e.g., anxiety
must be connected to an observable concept
e.g., anxiety connected to the observable concepts of rapid heart rate, sweaty palms, hyperventilation
definition
a declarative statement of the intention to use a concept in a particular way
hypothesis
special type of declarative statement, written in a specific format, that expresses the relationship between two or more concepts in a such a way that the relationship between the concepts can be empirically tested and either accepted or rejected
metaparadigm
the most global perspective of the phenomena of concern of a particular discipline
provides the boundaries of the discipline
distinguishes the discipline from other disciplines
makes the discipline unique
a discipline usually has one metaparadigm since there is general agreement among members of the discipline about the phenomena of concern of a discipline
the phenomena of concern generally agreed upon among members of the discipline of nursing are the following:
person/patient
environment
health/illness
nursing
proposition
a declarative statement that expresses the relationship between two or more concepts
Seven elements of effective conceptual models (paradigms) and frameworks for nursing
goal of nursing
the end or aim of nursing, what nursing is trying to achieve as described in the conceptual model (paradigm) or framework
e.g., in Roy's conceptual model, the goal of nursing is "adaptation in each of the four adaptive modes in situations of health and illness"
person/patient
the recipient(s) of nursing care as described in the conceptual model (paradigm) or framwork
e.g., in Roy's conceptual model, the person/patient is "a biopsychosocial being who has four modes of adaptation, based on: physiologic needs, self-concept (physical self, moral-ethical self, self-consistency, self-ideal and expectancy, and self-esteem), role function, and interdependence functions"
role of the nurse
the essential activities of the nurse as described in the conceptual model (paradigm) or framework
e.g., in Roy's conceptual model, the role of the nurse is to "promote patient's adaptive behaviors by manipulating focal, contextual, and residual stimuli"
source of patient difficulty
the actual or potential health problem of the person/patient as described in the conceptual model (paradigm) or framework
e.g., in Roy's conceptual model, the source of patient difficulty is "coping activity that is inadequate to maintain integrity in the face of a need deficit or excess"
intervention focus
the target or focus of nursing intervention as described in the conceptual model (paradigm) or framework
e.g., in Roy's conceptual model, the target or focus of nursing intervention is "the focal, contextual, and residual stimuli"
modes of intervention
the means at the nurse's disposal when intervening as described in the conceptual model (paradigm) or framework
e.g., in Roy's conceptual model, the modes of intervention are "manipulation of the stimuli by increasing, decreasing, and/or maintaining them"
consequences of nursing activity
the expected outcomes of nursing activity as described in the conceptual model (paradigm) or framework
e.g., in Roy's conceptual model, the consequences of nursing activity are "adaptive responses to stimuli by the patient"
Purposes of conceptual models (paradigms) or frameworks for nursing
overall purpose
provide direction and guidance for the following:
structuring professional nursing practice, education, and research
differentiating the focus of nursing from other disciplines
purpose in practice
assist nurses to describe, explain, and predict everyday experiences
serve to guide assessment, intervention, and evaluation of nursing care
provide a rationale for collecting reliable and valid data about the health status of patients, which are essential for effective decision making and implementation
purpose in education
provide a general focus for curriculum design
guide curricular decision-making
purpose in research
offer a conceptual model (paradigm) or framework for generating knowledge and new ideas
assist in discovering gaps in the specific field of study
offer a systematic approach to identify questions for study, select variables, interpret findings, and validate interventions
Arguments for the use of one conceptual model (paradigm) or framework versus several conceptual models (paradigms) or frameworks for nursing
arguments for the use of one conceptual model (paradigm) or framework
would further the development of nursing as a profession
would give all nurses a common conceptual model (paradigm) or framework, enriching communication and research
would promote understanding about the nursing role in nontraditional settings, such as independent practitioner practice, self-help clinics, and health maintenance organizations (HMO's), correcting the common misconception that nurses provide care only for sick persons
arguments against the use of one conceptual model (paradigm) or framework
most disciplines have several conceptual models (paradigms) or frameworks which allow members to explore phenomena in different ways and from different view points
several conceptual models (paradigms) or frameworks increase an understanding of the nature of nursing and its scope
several conceptual models (paradigms) or frameworks foster development of the full scope and potential of the discipline
Overview of Levine's model
key terms
holism
wholeness
change
adaptation
the process by which people maintain their wholeness or integrity as they respond to environmental challenges
integrity
internal environment
homeostasis
static state
homeorhesis
integration of bodily functions that resembles a stabilized flow rather than a static state
external environment
operational
that portion of the external environment which interacts with living tissue even though the individual does not possess sensory organs that can record the presence of these factors and includes all forms of radiation, microorganisms, and pollutants
perceptual
that portion of the external environment which individuals respond to with their sense organs and includes light, sound, touch, temperature, chemical change that is smelled or tasted, and position sense and balance
conceptual
that portion of the external environment that consists of language, ideas, symbols, and concepts and inventions and encompasses the exchange of language, the ability to think and experience emotion, value systems, religious beliefs, ethnic and cultural traditions, and individual psychological patterns that come from life experiences
levels or organismic response
fight or flight
inflammatory response
stress
perceptual awareness
perceptual systems
basic orienting system
visual system
auditory system
haptic system
taste-smell system
consevation
health as patterns of adaptive change
goal or nursing
promotion of wholeness
trophicognosis
a nursing care judgment arrived at by the scientific method
conservation principles
conservation of energy
a natural law found to hold everywhere in the universe for all animate and inanimate entities
conservation of structural integrity
focuses attention on healing
conservation of personal integrity
focuses attention on the patient as a person
conservation of social integrity
focuses attention on the individual's place in his or her family, community, and society
theory of therapeutic intervention
theory of redundancy
Overview of Roger's model
key terms
unitary human beings
energy fields
human beings
environment
helicy
principle that asserts that human and environmental field patterns are continuous, innovative and probabilistic, and are characterized by increasing diversity and nonrepeating rhythmicities
integrality
principle that emphasizes the continuous mutual human field and environmental field process
health
an expression of the life process
nursing
a learned profession
a science and an art
openess
pattern
four dimensionality
a nonlinear domain without spatial or temporal attributes
resonancy
principle that asserts that human and environmental fields are identified by wave patterns, that manifest continuous change from lower to higher frequencies
goal of nursing
to promote maximal well-being of the human and environmental energy fields
nursing process
theory of accelerating evolution
theory of paranormal phenomena
theory of rhythmical correlates of change
Overview of Roy's model
key terms
adaptive system
cognator mechanism
innate or acquired coping mechanism used to respond to changing environmental stimuli receives input from the external environment and from changes in the individual's internal state
it then processes the changes through neural-chemical-endocrine channels to produce responses
regulator mechanism
innate or acquired coping mechanisms used to respond to changing environmental stimuli also receives input from external and internal stimuli that involve psychological, social, physical, and physiological factors, including regulator subsystem outputs
these stimuli then are processed through cognitive/emotive pathways, including perceptual/information processing, learning, judgment, and emotion
adaptive modes
phyiological
the biological mode of adaptation that is concerned with basic needs requisite to maintaining the physical and physiological integrity of the human system
self-concept
the psychosocial mode of adaptation that is concerned with individuals' conceptions of their physical and personal selves
the physical self deals with body sensation and body image
the personal self encompasses self-consistency, self-ideal, and the moral-ethical-spiritual self
role function
the psychosocial mode of adaptation that is concerned with individuals' performance of roles on the basis of their positions within society
interdependence
the psychosocial mode of adaptatin that is concerned with the development and maintenance of satisfying affectional relationships with significant others
environment
internal
external
stimuli
focal
are the stimuli most immediately confronting the individual
contextual
are the contributing factors in the situation
residual
are other unknown factors that may influence the situation
when the factors making up residual stimuli become known, they are considered contextual stimuli
adaptation
adatation level
adaptation zone
adpative response
are those that promote the integrity of the person in terms of the goals of the human adaptive system, including survival, growth, reproduction, and mastery
ineffective response
are those that do not contribute to the goals of the human adaptive system
goal of nursing
to promote adaptation
nursing process
assessment of behavior
assessment of influencing factors (stimuli)
nursing diagnoses
goal setting
intervention
evaluation
theory of the person as an adaptive system
theories of the adaptive modes
Overview of Orem's model
key terms
self-care
action directed by individuals to themselves or their environments to: regulate their own functioning and development in the interest of sustaining life, maintaining or restoring integrated functioning under stable or changing environmental conditions, and maintaining or bringing about a condition of well-being
dependent care
self-care requisites
universal self-care requisites
are associated with life processes and maintenance of the integrity of human structure and function
developmental self-care requisites
are associated with human developmental processes and conditions and events that occur during various stages of the life-cycle, as well as with events that may adversely affect development
health deviation self-care requisites
are associated with genetic and constitutional defects and human structural and functional deviations and their effects, as well as with medical diagnostic and treatment measures prescribed or performed by physicians
therapeutic self-care demand
the action demand on individuals to meet some complex of universal, developmental, and health deviation self-care requisites
self-care agency
a complex capability of maturing and mature individuals to: determine the presence and characteristics of specific requirements for regulating their own functioning and development, make judgments and decisions about what to do. perform care measures to meet specific self-care requisites
basic conditioning factors
reflect features of individuals or their living situations, such as age, gender, health state, developmental age, sociocultural, health care system variables, family system elements, and patterns of living
power components
self-care deficit
defined as the expression of a relationship of inadequacy between self-care agency and the therapeutic self-care demand
dependent-care deficit
nursing agency
a complex property or attribute of nurses developed through specialized education and training in the theoretical and practical nursing sciences and through their development of the art of nursing in reality situations
goal of nursing
to help people meet theor own therapeutic self-care demands
nursing process
diagnosis and prescription
designing and planning
producing care to regulate therapeutic self-care demandand self-care agency
nursing systems
a dynamic action system produced by nurses as they engage in the diagnostic, prescriptive, and regulatory operations of nursing practice
wholly compensatory nursing system
nursing system selected when the patient cannot or should not perform any self-care actions
the partly compensatory nursing system
nursing system selected when the patient can perform some, but not all, self-care actions
the supportive-educative nursing system
nursing system selected when the patient can and should perform all self-care actions
methods of assisting
acting for or doing for another
guiding another
supporting another physcially or psychologically
providing a developmental environment
teaching another
theory of self-care
theory of self-care deficits
theory of nursing systems
Overview of Johnson's model
key terms
behavioral system
subsystems
attachment or affiliative subsystem
functions are attainment of the security needed for survival as well as social inclusion, intimacy, and the formation and maintenance of social bonds
dependency subsystem
functions are succoring behavior that call for a response of nurturance as well as approval, attention or recognition, and physical assistance
ingestive subsystem
function is appetite satisfaction, with regard to when, how, why, how much, and under what conditions the individual eats, which is governed by social and psychological considerations as well as biologic requirements for food and fluids
eliminative subsystem
function is elimination, with regard to when, how, and under what conditions the individual eliminates waste
sexual subsystem
functions are procreation and gratification, with regard to behaviors dependent upon the individual's biologic sex, including, but not limited to, courting and mating
aggressive subsystem
function is protection and preservation of self and society
achievement subsystem
function is mastery or control of some aspect of self or environment, with regard to intellectual, physical, creative, mechanical, social, and care-taking (of children, spouse, home) skills
subsystem functional requirements
protection
protection from noxious influences with which the system cannot cope
nurturance
nurturance through the input of appropriate supplies from the environment
stimulation
stimulation to enhance growth and prevent stagnation
subsystem structural elements
drive or goal
refers to motivation for behavior
the specific drive of each subsystem cannot be observed directly but must be inferred from the individual's actual behavior and from the consequences of that behavior
set
refers to the individual's predisposition to act in certain ways, rather than in other ways, to fulfill the function of the subsystem
choice
refers to the individual's total behavior repertoire for fulfilling subsystem functions
the behavioral repertoire encompasses the scope of action alternatives from which the person can choose
action or behavior
refers to the actual behavior in a situation and is the only structural element that can be observed directly
the ability of the subsystems to fulfill their functions depends upon certain requirements
behavioral system balance and stability
goals of nursing
restore, maintain, or attain behavioral system balance and stability
nursing as an external regulatory force
impose external or regulatory or control mechanisms
examples of external regulatory or control measures: setting limits for behavior, inhibition of ineffective behavioral responses. assisting patients to acquire new behavioral responses
change structural units
examples of changing structural elements: altering set by instruction or counseling, adding choices by teaching and skills
fulfill functional requirements
examples of fulfillment of functional requirements: protecting the patient from overwhelming noxious influences, supplying adequate nurturance, providing stimulation
Overview of King's model
key terms
personal systems
are individuals, who are regarded as rational, sentient, social beings
perception
is a process or organizing, interpreting, and transforming information from sense data and memory that gives meaning to one's experience, represents one's image of reality, and influences one's behavior
self
is a composite of thoughts and feelings which constitute a person's awareness of individual existence, of who and what he or she is
growth and development
include cellular, molecular, and behavioral changes in human beings and are a function of genetic endowment, meaningful and satisfying experiences, and an environment conducive to helping individuals move toward maturity
body image
is a person's perceptions of his or her own body
time
is the duration between the occurrence of one event and the occurrence of another event
space
exists in all directions and is the physical area called territory
learning
interpersonal systems
are composed of two, three, or more individuals interacting in a given situation
interaction
are the acts of two or more persons in mutual presence
the process of interactions between two or more individuals represents a sequence of verbal and nonverbal behaviors that are goal directed
communcation
is the vehicle by which human relations are developed and maintained
this concept encompasses intrapersonal and interpersonal communication, as well as verbal and nonverbal communication
transaction
is a process of interaction in which human beings communicate with the environment to achieve goals that are valued
transactions are goal-directed human behaviors
role
is a set of behaviors expected when occupying a position in a social system
stress
is a dynamic state whereby a human being interacts with the environment to maintain balance for growth, development, and performance, which involves an exchange of energy and information between the person and the environment for regulation and control of stressors
coping
social systems
are organized boundary systems of social roles, behaviors, and practices developed to maintain values and the mechanisms to regulate the practices and rules
organization
is composed of human beings with prescribed roles and positions who use resources to accomplish personal and organizational goals
authority
is a transactional process characterized by active, reciprocal relations in which members' values, backgrounds, and perceptions play a role in defining, validating, and accepting the authority of individuals within an organization
power
is the process whereby one or more persons influence other persons in a situation
status
is the position of an individual in a group or a group in relation to other groups in an organization
decision-making
in organizations is a dynamic and systematic process by which goal-directed choice of perceived alternatives is made and acted upon by individuals or groups to answer a question and attain a goal
control
envornment
internal
external
health
dynamic life experiences
ability to function in social roles
goal of nursing
help individuals maintain their health so they can function in their roles
nursing process
perception
judgment
action
reaction
interaction
transaction
theory of goal attainment
proposes that nurse and patient interactions are characterized by verbal and nonverbal communication, in which information is exchanged and interpreted; by transactions, in which values, needs, and wants of each member of the dyad are shared; by perceptions of nurse and patient and the situation; by self in role of client and self in role of nurse; and by stressors influencing each person and the situation in time and space
the process follows a sequence whereby nurse and patient:
meet in some situation
perceive each other
make judgments about the other
take some mental action
react to each one's perceptions of the other
share information about their perceptions
identify special goals, problems, or concerns
explore means to achieve a goal and agree to means to the goal
transact as goals are attained
Overview of Neuman's model
key terms
patient/patient systems
individual
family
community
variables
physiological
refer to bodily structure and function
psychological
refer to mental processes and relationships
sociocultural
refer to social and cultural functionsdevelopmental
development
refer to the developmental processes of life
spiritual
refer to aspects of spirituality on a continuum from complete unawareness or denial to a consciously developed high level of spiritual understanding
central core
a basic structure of survival factors common to the species, such as variables contained within, innate or genetic features, and strength and weakness of the system parts, such as temperature range, genetic response patterns, ego structure, strengths and weaknesses of body organs and cognitive ability
flexible line of defense
the outermost ring is the FLEXIBLE LINE OF DEFENSE
this mechanism is a protective buffer for the patient's normal or stable state
ideally, it prevents invasion of stressors and keeps the patient system free from stressor reactions or symtomatology
the flexible line of defense is thought of as a dynamic, accordion-like mechanism, rapidly expanding away from or drawing closer to the normal line of defense
when the flexible line is expanded away from the normal line of defense, greater protection against stressor invasion is provided
when it draws closer to the normal line, less protection is provided
normal line of defense
the NORMAL LINE OF DEFENSE
lies between the flexible line of defense and the lines of resistance
the normal line of defense is the patient system's normal or usual wellness state
it reflects what the patient has become or evolved to over time and is the result of adjustment between patient system variables and environmental stressors
expansion of the normal line of defense reflects an enhanced wellness state; contraction, a diminished state of wellness
lines of resistance
the innermost rings are the LINES OF RESISTANCE
these lines are involuntarily activated when a stressor invades the normal line of defense
the lines of resistance attempt to stabilize the patient system and foster a return to the normal line of defense
these lines contain internal factors that support the basic structure and the normal line of defense, such as mobilization of white blood cells. If the lines of resistance are effective, the system can reconstitute; if they are ineffective, death may ensue
environment
defined as all internal and external actors or influences surrounding the patient system
internal
consists of all forces or interactions influence internal to or contained solely within the boundaries of the defined patient system
it is the source of intrapersonal stressors
external
consists of all forces or interactions influence external to or exist outside the defined patient system
it is the source of interpersonal extrapersonal stressors
created
is subconsciously developed by the patient as a symbolic expression of system wholeness
it supersedes and encompasses the internal and external environments
stressors
intrapersonal
interpersonal
extrapersonal
patient system stability
variances from wellness
reconstitution
goal of nursing
retain, attain, and matain optimal patient wellness
nursing process
nursing diagnosis
nursing goals
nursing outcomes
prevention as intervention format
primary prevention
the action required to retain patient system stability
Interventions involving primary prevention is selected when the risk of or hazard from a stressor is known but a reaction has not yet occurred
interventions involving primary prevention attempt to reduce the possibility of the patient's encounter with the stressor or strengthen the flexible line of defense to decrease the possibility of a reaction when the stressor is encountered
secondary prevention
the action required to attain system stability. Intervention involving secondary prevention is selected when a reaction to a stressor has already occurred
interventions involving secondary prevention deal with existing symptoms and attempt to strengthen the lines of resistance through use of the patient's internal and external resources
tertiary prevention
the action required to maintain system stability
interventions involving tertiary prevention are selected when some degree of patient system stability has occurred following secondary prevention interventions
