FLORENCE NIGHTINGALE“ A Lady with a Lamp “ “What a comfort it was to see her pass. She would speak to one, and nod and smile to as many more; but she could not do it to all you know. We lay there by the hundreds; but we could kiss her shadow as it fell and lay our heads on the pillow again content” ANONYMOUS FLORENCE NIGHTINGALE British nurse, hospital reformer, and humanitarian. Born in Florence, Italy, on May 12, 1820, Nightingale was raised mostly in Derbyshire, England, and received a thorough classical education from her father. In 1849 she went abroad to study the European hospital system, and in 1850 she began training in nursing at the Institute of Saint Vincent de Paul in Alexandria, Egypt. She subsequently studied at the Institute for Protestant Deaconesses at Kaiserswerth, Germany. In 1853, she became superintendent of the Hospital for Invalid Gentlewomen in London. Florence Nightingale (1820 - 1910) “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.” FLORENCE NIGHTINGALE Florence Nightingale undertook nurse’s training at the age of 31. The outbreak of Crimean war and a request by the British to organize nursing care for a military hospital in Turkey gave Nightingale an opportunity for achievement. As she successfully overcame enormous difficulties, Nightingale challenged prejudices against women and elevated the status of all nurses. After the war, she returned to England, where she established a training school for nurses and wrote books about healthcare and nursing education. “No man, not even a doctor, ever gives any other definition of what a nurse should be than this—"devoted and obedient." Florence Nightingale (1820 - 1910) This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman. FLORENCE NIGHTINGALE’S CONTRIBUTIONS Identifying the personal needs of the patient and the role of the nurse in meeting those needs Establishing standards for hospital management Establishing a respected occupation for women Establishing nursing education Recognizing the two components of nursing: health and illness Believing that nursing is separate and distinct from medicine Recognizing that nutrition is important to health Instituting occupational and recreational therapy for sick people Stressing the need for continuing education for nurses Maintaining accurate records, recognized as the beginnings of nursing research Historical Influences on Nursing Theory of FLORENCE NIGHTINGALE Florence Nightingale developed and published a philosophy and a theory of health and nursing that has served as a solid foundation for the nursing profession. Her contributions to nursing theory include identifying the role of the nurse in meeting the patient’s personal needs, recognizing the importance of environmental influences on the care of sick people, and elevating the standards and acceptance of nursing by developing sound principles of nursing education. Nightingale develop her theories of nursing in the late 1800’s. Her foundational work is what nursing theorists expanded upon, starting in the 1950’s until the present time. Central theme: PATIENT MEETING THE PERSONAL NEEDS OF THE WITHIN THE ENVIRONMENT Application to clinical practice: Concern for the environment of the patient, including cleanliness, ventilation, temperature, light, diet, and noise. NIGHTINGALE’S THEORY OF NURSING PHYSICAL ENVIRONMENT CLEANLINESS VENTILATION AIR LIGHT NOISE WATER BEDDING DRAINAGE WARMTH DIET PATIENT CONDITION AND NATURE COMMUNICATION ADVICE VARIETY MORTALITY DATA PREVENTION OF DISEASES SOCIAL ENVIRONMENT PSYCHOLOGICAL ENVIRONMENT NIGHTINGALES THEORY OF NURSING AS RELATED TO SCIENTIFIC THEORIES ADAPTATION NEED THEORY STRESS THEORY Nightingale’s Environmental Concepts VENTILATION WARMTH SMELLS NOISE LIGHT The Evolution of Nursing Research While caring for victims of the Crimean War, Florence Nightingale kept careful and objective records. These records provided baseline data that she later used to determine which nursing interventions were most effective in treating her patients. Since that time, nursing research has taken many different pathways, and all nurses are involved with research either as consumers (nurses who use and evaluate research findings) or as actual investigators who design and implement research studies. Dorothea Orem Born in Baltimore, Maryland. One of America’s foremost nursing theorists. Father was a construction worker Mother was a homemaker. Youngest of two daughters. Education Studied at Providence Hospital school of Nursing in Washington D.C. in 1930’s Got her B.S.N.E. in 1939 and her M.S.N.E in 1946 both from the Catholic University of America Got her M.S.N.E. at Catholic University of America in 1946 1958-1960 upgraded practical nursing training at Department of Health, Education and Welfare Was editor to several texts including Concepts Formalization in Nursing: Process and Production, revised in 1980, 1985, 1991, 1995, 2001 Orem’s Theory of Self Care Each person has a need for self care in order to maintain optimal health and wellness. Each person possesses the ability and responsibility to care for themselves and dependants. Theory is separated into three conceptual theories which include: self care, self care deficit and nursing system. Theory of Self Care Self care is the ability to perform activities and meet personal needs with the goal of maintaining health and wellness of mind, body and spirit. Self care is a learned behaviour influenced by the metaparadigm of person, environment, health and nursing. Three components: universal self care needs, developmental self care needs, and health deviation. Universal Self Care This includes activities which are essential to health and vitality. Eight elements identified these include: air, water, food, elimination, activity and rest, solitude and social interactions, prevention of harm, and promotion of normality. Developmental Self Care Need These include the interventions and teachings designed to return a person to or sustain a level of optimal health and well being. Examples can include such things as toilet training a child or learning healthy eating. Health Deviation Self Care This encompasses the variations in self care which may occur as a result of disability, illness, or injury. In other words the person with a variation is meeting self care and maintaining health and wellness in a more individualize meaning. Theory of Self Care Deficit Every mature person has the ability to meet self care needs, but when a person experiences the inability to do so due to limitations, thus exists a self care deficit. A person benefits from nursing intervention when a health situation inhibits their ability to perform self care or creates a situation where their abilities are not sufficient to maintain own health and wellness. Nursing action focuses on identification of limitation/deficit and implementing appropriate interventions to meet the needs of person. Theory of Nursing Systems The ability of the nurse to aid the person in meeting current and potential self care demands. Focused on person Three support modalities identified in theory including: total compensatory, partial compensatory, and educative/supportive compensatory. The client’s ability for self care involvement will determine under which support modality they would be considered. Wholly or Total Compensatory Encompasses total nurse care-client unable to do for themselves. Charlene receives constant care from her nurse & family, who do everything from feeding her to taking her to doctors Partially Compensatory Involves both the nurse and client sharing in the self care requirements. Educative/Support Compensatory Support elicit the help of the nurse solely as a consultant, teacher or resource person. Client is responsible for their own self care. Nurse’s Role The nurse’s role in helping the client to achieve or maintain a level of optimal health and wellness is to act as an advocate, redirector, support person and teacher, and to provide an environment conducive to therapeutic development. Application of Theory To Nursing Process Orem’s theory of self-care is applied to many undergraduate nursing curricula. The nursing care plan is one example of how her theory of self-care can be applied to nursing process Nursing Care Plan The nursing care plan includes; assessment data pertaining to Gordon’s Functional Assessment, a NANDA nursing diagnosis, the identification of client expected outcomes, the nursing interventions and evaluation. Lydia E. Hall Lydia E. Hall received her basic nursing education at York Hospital of Nursing in York, Pennsylvania. Both her B.S. and M.A. are from Teacher’s College, Columbia University, New York. Lydia E. Hall Lydia Hall was the first director of the Loeb Center for Nursing and Rehabilitation. Her experience in nursing spans the clinical, educational, and supervisory components. Her publications include several articles on the definition of nursing and quality of care. Lydia Hall has put forth what she considers a basic philosophy of nursing, upon which the nurse may base patient care. This philosophy is used as a working reality at the Loeb Center for Nursing. Loeb Center for Nursing and Rehabilitation Lydia Hall originated the philosophy of care of Loeb Center at Montefiore Hospital, Bronx, New York. Loeb Center opened in January 1963 to provide professional nursing care to persons who are past the acute stage of illness. The center’s functioning concept is that the need for professional nursing care increases as the need for medical care decreases. Loeb Center has a capacity of eighty beds and is attached to Montefiore Hospital. The rooms are arranged with patient comfort and maneuverability as first priority. The patient also have assess to a large communal dining room. The primary care givers are professional nurses with non patient care activities being supplied by messengerattendants and secretaries. To create a nondirective selling, there are very few rules, no routine, no schedules, and no dictated mealtimes or specified visiting hours. The nurse at Loeb strive to help the patient determine and clarify goals and, with patient work out ways to achieve the goal at the individual pace, consistent with the medical treatment plan and congruent with the patient’s sense of self. Lydia Hall’s Theory of Nursing Lydia Hall presents her theory of nursing visually by drawing three interlocking circles, each circle presenting a particular aspect of nursing. The circles represent care, core, and cure. The Care Circle The care circle represents the nurturing component of nursing and is exclusive to nursing. Involved in nurturing is the utilization of the factors that make up the concept of mothering (care and comfort of the person). When functioning in the care circle, the nurse applies knowledge of the natural and biological sciences to provide a strong theoretical base for nursing implementations. In interactions with the patient the nurse’s role must be clearly defined. A strong theory base allows the nurse to incorporate closeness and nurturance while maintaining a professional status rather than a mothering status. The patient views the nurse as a potential comforter, one who provides care and comfort through the laying on of hands. The care circle of patient care The Body Natural and biological sciences Intimate bodily care aspect of nursing “The Care” The Core Circle The core circle of patient care involves the therapeutic use of self and is shared with other members of the health team. The nurse uses a freely offered closeness to help the patient bring into awareness the verbal and nonverbal messages being sent to others. Motivations are discovered through the process of bringing the awareness the feelings being experienced. The patient is now able to make conscious decisions based on understood and accepted feelings and motivations. The motivation and energy necessary for healing exist within the patient rather than in the health care team. The core circle of patient care The Person Social sciences Therapeutic use of self aspect of nursing “The Core” The Cure Circle The cure circle of patient care is shared with other members of the health team. The nurse’s role during the entire aspect is different from the care circle since many of the nurse’s actions take on a negative quality of avoidance of pain rather than the patient views the nurse as a potential cause of pain, involved in such actions such as administering injections, versus the potential comforter who provided care and comfort. The core circle of patient care The Disease Pathological and therapeutic sciences Seeing the patient and family through the medical care aspect of nursing “The Cure” Interaction of the Three Aspects of Nursing The three aspects of nursing as Hall identifies them do not function independently, but are interrelated, and they interact and change size depending on the patient’s total course of progress. In philosophy of Loeb Center the professional nurse functions most therapeutically when patients have entered the second stage of their hospital stay (i.e., where they are recuperating and are past the first acute stage). Hall’s three aspects of nursing The Person Therapeutic use of self “The Core” The Body Intimate bodily care The Disease Seeing the patient and family through medical care “The Cure” “The Care” Hall’s Theory and the Nursing Process Influences the nurse’s total approach to the five phases of nursing process. Five Phases of Nursing Process Assessment phase Collection of data about the health status of the individual. According to Hall, the process of data collection is directed for the benefit of the nurse. Pertains to guiding the patient through the cure aspect of nursing. Five Phases of Nursing Process Nursing Diagnosis Statement of the patient’s need or problem area. Five Phases of Nursing Process Planning Involves setting priorities and mutually establishing patientcentered goals. “Patient is the best person to set goals and arrange priorities.” Five Phases of Nursing Process Implementation Involves the actual institution of the plan of care. Actual giving of nursing care Five Phases of Nursing Process Evaluation Process of assessing the patient’s progress toward the health goals. Process is directed toward deciding whether or not the patient is successful in reaching the established goals. Application and Limitations of the Theory Stage of Illness Age The description of how to help a person toward selfawareness The family is mentioned only in the cure circle The theory relates only to those who are ill. Margaret Jean Harman Watson Margaret Jean Harman Watson was born in Southern West Virginia and grew up during 1940s and 1950s in the small town of Welch , Western Virginia in the Appalachian Mountains. As the youngest of eight children, she was surrounded by an extended family-community environment. Watson attended high school in West Virginia and then attended the Lewis Gale School of Nursing in Roanoke, Virginia. After graduation in 1961, she married her husband, Douglas, and move to west to his native state in Colorado. But Douglas died in 1998. After moving to Colorado, Watson continued her nursing education and graduate studies at the University of Colorado. She earned a B.S. in nursing in 1964 at the Boulder campus; an M.S. in psychiatric mental health in 1966 at the health science campus; an Ph.D. In educational psychology ad counseling in 1973 at the Graduate School, Boulder Campus. After Watson completed her Ph.D. degree she joined the School of Nursing faculty of the University of Colorado Health Science Center in Denver, where she had served in both faculty and administrative position. The Center for Human Caring at the University of Colorado was the first interdisciplinary center with an overall commitment to develop in use knowledge of human caring and healing as the moral and scientific basis of clinical practice in nursing scholarship as the foundation for efforts to transform the current health care system. During its existence, the center developed and sponsored numerous clinical , educational and community scholarship activities and project for human caring. During her career, Watson has been active in community programs, having served as a founder and member of the Board of Boulder County Hospice and she has initiated numerous collaborations with area health care facilities. As the recipient of several research and advance education federal grants and awards. Watson featured in several national videos on nursing theory. These include “Circles of Knowledge” and “Conversation on Caring with Jean Watson and Janet Quinn”. Watson's publications reflect the evolution of her theory of caring. Her writings have been geared toward educating nursing students and providing them with ontological and epistemological basis for their praxis and research direction. Much of her current wok begun with the 1979 publication, Nursing: The Philosophy of Science and Caring which she says begun as class notes for a course she was developing. She says the book “emerged from her quest to bring new meaning and dignity to the world of nursing and patient care- care that seemed too limited in its scope at that time, largely defined by medicines paradigm and traditional biomedical science models”. Nursing: Human Science and Human Care- A Theory of Nursing, published in 1985 and re-released in 1998, was her second major work. The purpose of this book was to address some of the conceptual and philosophical problems that still existed in nursing. She hoped that others would join as she sought to “elucidate the human care process in nursing, preserved the concept of person in our science, and better our contribution to society. This book has been translated to Chinese, German, Japanese, Korean and Swedish. In Watson's original philosophy and science of caring, she referred to caring as the essence of nursing practice. Caring is more ideal rather than a task oriented behavior and include such characteristics as the actual caring occasion and the transpersonal caring moment, phenomena that occur when an authentic caring relationship exist between the nurse and the patient. Watson bases her theory for nursing practice on the following 10 Carative factor. Each has a dynamic phenomenological component that is relative to the individuals involved in the relationship as encompassed by nursing. The first three interdependent factors serve as the “philosophical foundation for the science of caring.” I. FORMATION OF A HUMANISTIC – ALTRUISTIC SYSTEM OF VALUES Humanistic and altruistic values are learned early in life, but can be greatly influenced by nurse – educators. 2. INSTALLATION OF FAITH – HOPE This factors, incorporating humanistic and altruistic values, facilitates the promotion of holistic nursing care and positive health within the patient population. 3. CULTIVATIONOF SENSITIVE TO SELF AND TO OHERS The recognition of feelings leads to self- actualization though self – acceptance for both the nurse and the patient. 4. DEVELOPMENT OF A HELPING – TRUST RELATIONSHIP The development of a helping - trust relationship between the nurse and patient is crucial for transpersonal caring. 5. PROMOTION AND ACCEPTANCE THE EXPRESSION OF POSITION AND NEGATIVE FEELINGS. The sharing of feelings is a risk – taking experience for both nurse and patient. 6. SYSTEMATIC USE OF THE SCIENTIFIC PROBLEM SOLVING METHOD FOR DECISION MAKING Use of the nursing process brings a scientific problem – solving to nursing care, 7. PROMOTION OF INTERPERSONAL TEACHING LEARNING This factor is an important concept for nursing in that it separates caring from curing. 8. PROVISION FOR SUPPORTIVE, PROTECTIVE, AND CORRECTIVE MENTSL, PHYSICAL, SOCIOCULTURAL, AND SPIRITUAL ENVIRONMENT Nurses must recognize the influence that internal amd external environment have on the health and illness of individuals. 9. ASSISTANCE WITH GRATIFICATION OF HUMAN NEEDS The nurse recognizes the biophysical, psychophysical, psychosocial, and intrapersonal needs of self and patient. 10. ALLOWANCE FOR EXISTENTIAL PHENOMENOLOGICAL FORCES Phenomology describes data of immediate situation that help people understand the phenomena in question. Nursing the Philosophy and Science of Caring, Watson 28:8-9 States the major assumptions of caring in nursing: Nursing Human Science and Human Care, Watson 26-33 States that both Nursing education and Health care delivery system must be based on human values and concern for the welfare of others. of Myra Estrine Levine Conservation Theory "Levine’s model focuses on individuals as holistic beings, and the major area of concern for nurses in maintenance of a person’s wholeness." Conservation Principles •Energy Integrity •Structural Integrity •Personal integrity; and •Social Integrity Concepts a.Wholeness It emphasizes a sound, organic, progressive, mutuality between diversified functions and parts within an entirety, the boundaries of which are open and fluent Concepts b. Adaptation It is the process of change whereby the individual retains his integrity within realities of his internal and external environment (Levine, 1973) Concepts c. Conservation The way complex systems are able to continue to function even when severely challenged (Levine, 1990) Conservation Historicity Specificity Redundancy Concepts Conservation: Symbolized by a light bulb in the center. Light bulbs give light and are productive. Light bulbs also symbolize ideas… theories are ideas. Historicity: genetics The hearts show dominant (dark pink) and recessive (light pink) traits. Concepts Specificity: Different pathways are coming from the center of the light bulb representing the multiple stimulus response pathways. Redundancy: If one pathway can't get the job done, another pathway will compensate Betty Neuman 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). Neuman has since published three editions of the Neuman Systems Model. The Neuman Systems Model Trustees Group was established in 1988. This group was established for the perpetuation, presevation, and protection of the integrity of the model and any future changes in model must have the consent of the trustees (George, 1996). Biographical Information 1924 Born near Lowell, Ohio. 1947 Received RN Diploma from Peoples Hospital School of Nursing, Akron, Ohio Moved to California and gained experience as a hospital, staff, and head nurse; school nurse and industrial nurse; and as a clinical instructor in medicalsurgical, critical care and communicable disease nursing. 1957 Attended University of California at Los Angeles (UCLA) with double major in psychology and public health. Received BS in nursing from UCLA. 1966 Received Masters degree in Mental Health, Public Health Consultation from UCLA. Recognized as pioneer in the field of nursing involvement in community mental health. Began developing her model while lecturing in community mental health at UCLA. 1972 Her model was first published as a 'Model for teaching total person approach to patient problems' in Nursing Research. 1985 Received doctorate in Clinical Psychology from Pacific Western University. 1998 Received second honorary doctorate - this one from Grand Valley State University, Allendale, Michigan. Neuman’s Model was influenced by a variety of sources: Pierre Telhard deChardin was a catholic priest and scientist who is credited with first proposing the idea of spiritual evolution. He believed that spiritually humans are evolving toward an ultimate perfection that he called the omega point. Gestalt Theory is a theory of german origin that centers around the concept of the gestalt or the whole. It emphasizes the primacy of the phenomenal (the perceived), asserting that the human world of experience is the only immediately given reality. General Adaptation Syndrome is quite pervasive and even taught to high schoolers in their health class. It postulates that there is a nonspecific response to stress involving three stages: 1) alarm, 2) resistance, 3) exhaustion. General Systems Theory grew out of the field of Thermodynamics, a branch of physics, chemistry and engineering. Thermodynamics is the study of the flow of energy from one system to another. General systems theory posits that the world is made up of systems that are interconnected and are influenced by each other; systems can also be concentric with smaller systems forming a larger system. In Short… Neuman's model is just that-a model, not a full theory. It is a conceptual framework, a visual representation, for thinking about humans and nurses and their interactions. The goal is to achieve optimal system stability and balance. Prevention is the main nursing intervention to achieve this balance. Person Variables Physiological - refers of the physicochemical structure and function of the body. Psychological - refers to mental processes and emotions. Sociocultural - 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. Central Core The basic structure, or central core, is made up of the basic survival factors that are common to the species (Neuman, 1995, in George, 1996). These factors include: system variables, genetic features, and the strengths and weaknesses of the system parts. The person's system is an open system and therefore is dynamic and constantly changing and evolving. 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. Flexible Lines of Defense The flexible line of defense is the outer barrier or cushion to the normal line of defense, the line of resistance, and the core structure. The flexible line of defense is dynamic and can be changed/altered in a relatively short period of time. Normal Line of Defense The normal line of defense represents system stability over time. It is considered to be the usual level of stability in the system. The normal line of defense can change over time in response to coping or responding to the environment. Lines of Resistance The lines of resistance protect the basic structure and become activated when environmental stressors invade the normal line of defense. Reconstitution Reconstitution is the increase in energy that occurs in relation to the degree of reaction to the stressor. Reconstitution begins at any point following initiation of treatment for invasion of stressors. Stressors Stressors are capable of having either a positive or negative effect on the client system. A stressor is any environmental force which can potentially affect the stability of the system: they may be: Intrapersonal - occur within person. Interpersonal - occur between individuals. Extrapersonal - occur outside the individual. Prevention Prevention focuses on keeping stressors and the stress response from having a detrimental effect on the body. Primary Primary prevention occurs before the system reacts to a stressor. On the one hand, it strengthens the person (primarily the flexible line of defense) to enable him to better deal with stressors, and on the other hand manipulates the environment to reduce or weaken stressors. Primary prevention includes health promotion and maintenance of wellness. Secondary Secondary prevention occurs after the system reacts to a stressor and is provided in terms of existing systems. Secondary prevention focuses on preventing damage to the central core by strengthening the internal lines of resistance and/or removing the stressor. Tertiary 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. Implications for Practice and Research The main use of the Neuman Model in practice and in research is that its concentric layers allow for a simple classification of how severe a problem is. If a stress response is perceived by the patient or assessed by the nurse, then there has been an invasion of the normal line of defense and a major contraction of the flexible line of defense. Thus, the level of insult can be quantified allowing for graduated interventions. The drawback of this is that there is no way to know whether our operationalization of the person variables is a good representation of the underlying theoretical structures. Person The person is a layered multidimensional being. The person may in fact be an individual, a family, a group, or a community in Neuman's model. The person, with a core of basic structures, is seen as being in constant, dynamic interaction with the environment. The person is seen as being in a state of constant change and-as an open system-in reciprocal interaction with the environment. 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 extrapersonal 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 unconsicously 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)". As the person is in a constant interaction with the environment, the state of wellness (and by implication any other state) is in dynamic equilibrium, rather than in any kind of steady state. Neuman proposes a wellness-illness continuum, with the person's position on that continuum being influenced by their interaction with the variables and the stressors they encounter. The client system moves toward illness and death when more energy is needed than is available. The client system moves 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 actions 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 envisions a 3-stage nursing process: Nursing Diagnosis - based of necessity in a thorough assessment, and with consideration given to five variables in three stressor areas. Nursing Goals - these must be negotiated with the patient, and take account of patient's and nurse's perceptions of variance from wellness Nursing Outcomes - considered in relation to five variables, and achieved through primary, secondary and tertiary interventions. Imogene King A nursing theorist who has made significant contributions to the development of nursing knowledge. King’s Conceptual Framework and Theory of Goal Attainment The concept of self body image growth and development time communication interaction Introduction Imogene King developed a conceptual model for nursing in the mid 1960’s with the idea that human beings are open systems interacting with the environment. King’s worked is considered a conceptual model because it comprises both a conceptual framework and a theory. King’s Conceptual Framework and Theory of Goal Attainment. Finally, King’s work is compared to rural nursing theory in an effort to identify common themes. King’s Theory (Emergency Nursing) The central focus of King’s framework is man as a dynamic human being whose perceptions of objects, persons, and events influence his behavior, social interaction, and health. King’s conceptual framework includes three interacting systems with each system having as own distinct group of concepts and characteristics. Three Interacting Systems Personal system Interpersonal system Social system The Personal System It refers to the individual. An individual’s perceptions of self, of body image, of time and space influence the way he or she responds to persons, objects, and events in his or her life. As individuals grow and develop through the life span, experiences with changes in structure and function of their bodies over time influence their perceptions of self. Interpersonal System Involve individuals interacting with one another. Communication between the nurse and the client can be classified as verbal or nonverbal. Social System Are group of people within a community or society that share common goals, interests, and values. Examples of social systems include the family, the school, and the church. The concepts that king identified as relating to social system are organization, authority, power, status and decision-making. The relationship between the three systems led to King’s Theory of Goal Attainment. The conceptual framework of the interpersonal system had the greatest influence on the development of theory. Ten Major Concepts from the Personal and Interpersonal Systems Human interactions Perception Communication Role Stress Time Space Growth Development Transactions After careful analysis of King’s Conceptual Framework and Theory of Goal Attainment, it is evident that this model can be implemented in an emergency room setting. A busy emergency department often creates an intimidating environment for patients and they may feel threatened, or feel that they have no control over decisions that affect their care. The primary complaint of emergency room patients is the length of waiting time. One intervention that has proven successful in this situation has been the installation of televisions and telephones in patients rooms in the emergency department. These devices seem to help the patients pass the time and reduce some of the frustrations associated with long waiting times. Nursing Theory (Rural Setting) Rural residents are a unique group of individuals Rural residents are more likely to comply with health care regimens that do not interfere with their daily routines, or create inconveniences for them. For these reasons, nurses dealing with rural populations must be aware of the differences that exist between rural and urban populations. After careful consideration of the concepts associated with King’s three interacting systems, the concept of perception, growth and development, time, communication and interaction are helpful to the nurse when attempting to explain and predict the health practices of rural clients. Rural dwellers have a different perception of health than that of urban dwellers. It is important for the nurse to be non-judgmental in these situations because this is simply a way of life for rural residents, a way of life that they have come to accept as the norm. Growth and development is another concept that is applicable to rural nursing. King’s Concept of time can also be attributed to rural communities. The last two concepts from King’s framework that are useful when working with rural clients are communication and interaction. Using King’s Theory of Goal Attainment in the rural community presents some challenges in the nurse. Mutual goal setting would only be successful if the clients trusted that the goals would benefit them. Because rural residents are time-oriented individuals, the goals must be attainable without interfering with their daily lives, or the goals will likely go unmet. There are elements of King’s theory that are applicable to both the emergency and to nursing practice in rural settings. Concepts from King’s work are useful regardless of the context in which they are used. Human beings are dynamic individuals and they are continuously interacting with their respective environments. King conceptualizations in the early 1960’s continue to guide the practice of nursing. Martha Rogers Science of Unitary Human Beings BIOGRAPHY Martha E. Rogers was born May 12, 1914, in Dallas, Texas, the eldest of four children. She began her collegiate education at the University of Tennessee in Knoxville, where she studied science from 1931 to 1933. She received her nursing diploma from Knoxville General Hospital School of Nursing in 1936. In 1937 she received a B.S. from George Peabody College in Nashville, Tennessee. Her other degrees include an M.A. in public health nursing supervision from Teacher's College, Columbia University, New York in 1945 and an M.P.H. in 1952 and a Sc.D. in 1954, both from Johns Hopkins University in Baltimore. For 21 years, from 1954 to 1975, she was Professor and Head of the Division of Nursing at New York University. In 1979 she became Professor Emeritus and was an active member of the nursing profession until her death on March 13, 1994. Rogers' early nursing practice was in rural public health nursing in Michigan and in visiting nurse supervision, stimulating, idealistic, visionary, prophetic, philosophic, academic, outspoken, humorous, blunt, and ethical. She has been widely recognized and honored for her contributions and leadership in nursing. Her nursing past colleagues consider her one of the most original thinkers in363. education, and practice in Connecticut. She then established the Visiting Nurse Service of Phoenix, Arizona. Her publications include three books and over 200 articles; she continued to write and publish extensively. She lectured in 46 states, the District of Columbia, Brazil, Puerto Rico, Mexico, Holland, China, Newfoundland, Columbia, and other countries. Rogers received honorary doctorates in Science, Letters, and Humane Letters from such renowned institutions as Duquesne University, University of San Diego, Iona College, Fairfield University, Mercy College, and Washburn University of Topeka. In addition, she received numerous awards and citations for her contributions and leadership in nursing. She received citations for "Inspiring Leadership in the Field of Intergroup Relations" by Chi Eta Phi Sorority, "In Recognition of Your Outstanding Contribution to Nursing" by New York University. "For Distinguished Service to Nursing" by Teachers College, and many others. She was honored by the many awards, funds, and scholarships that have been established in her name. A verbal portrait of Rogers might include such descriptive terms as The Science of Unitary Human Beings Washburn University utilizes Dr. Martha Rogers' Science of Unitary Human Beings as a conceptual framework in its course of study. Conceptual models give students a "hook" to which they can hang theories and evolve abstraction (a lens through which they view the profession of nursing). In order to understand the Rogerian Dr. Rogers presented her evolutionary model in 1970 with the publication of An Introduction to the Theoretical Basis of Nursing. This view presented a drastic but attractive way of viewing human interaction and the nursing process. Her concepts are derived from the view of the universe as a collection of open systems of which we interact independently and continuously without causality. framework a set of definitions must be defined as a building block for the larger abstract system. Energy Energy is irreducible, indivisible and has a definable pattern. Energy is the continuous interaction between a person with the environment. Each individual has their own degree, identity and intensity of interaction with the environment. The combined energy between individual and environment is inseparable and integrated completely. Openness Both human and environmental systems are open. This also implies that the systems exchange energy continuously and remain open--always. Change affects both systems mutually. People today are different then they had been the day before and can never return to the person they were. Humans do not adapt to their environment but are integral with the environment Pandimensionality Human beings have unique properties that enable them to be irreducible and indivisible. Though we live in a three-dimensional world we are aware of other dimensions that affect our lives. A three-dimensional world fails to take into account the concept of time. Rogers coined the term pandimensionality to describe a reality without any spatial or time restraints. This better describes a reality without linear, spatial or temporal restraints Pattern Human energy can be differentiated from environmental energy by its pattern. Patterns cannot be seen but manifestations of the pattern can be observable. Human patterns can be described as a single weave that is dynamic, unpredictable, creative and continuous. An analogy would be a kaleidoscope. As the kaleidoscope is rotated (simulating time) each piece of colored glass falls in an unpredictable manner, with the collection of pieces creating a unique form with equally unique color distribution. There is some order in the turning of the kaleidoscope but the changes of pattern are never predictable or the same. Human patterns are also unpredictable within a degree of order. Each human perceives and interacts with their environment with a different degree of energy. Principles of Homeodynamics The principles of homeodynamics postulate a way of perceiving unitary man. Change in the life process in man are predicted to be inseparable from environmental changes and to reflect the mutual and simultaneous interaction between the two at any point space-time. Changes are irreversible, nonrepeatable. They are rhythmical in nature and evidence growing complexity of pattern and organization. Change proceeds by the continuous repatterning of both man and environment by resonating waves. Evidence of conditions under which these principles hold arises out of examination of the real world. Investigations of a range of phenomena are necessary to provide the substantive data which can further the translation of these principles into practical application. . Scientific research in nursing is beginning to underwrite the moving boundaries of nursing advances. Maintenance and promotion of health, disease prevention, diagnosis, intervention, and rehabilitation-nursing's goals-take on added dimensions as theoretical knowledge provides new direction to practice. Principles of Homeodynamics derive from the abstract system and postulate the nature of change. The principles are listed as follows: Principle of Resonancy The continuous change from lower to higher frequency wave patterns in human and environmental fields. Principle of Helicy The continuous innovative, unpredictable, increasing diversity of human and environmental field patterns. Principle of Integrality The continuous mutual human field and environmental field process. FAYE G. ABDELLAH ABDELLAH’S THEORY Although Abdellah’s writings are not specific as to a theoretical statement can be derived by using her three major concepts of health, nursing problems, and problem solving. Using the definition that a theory states the relationship between concepts, Abdellah’s theory would state that nursing is the use of the problem solving approach with key nursing problems related to the health needs of people. Such a theoretical statement maintains problem solving as the vehicle for the nursing problems as the client is moved toward health-the outcome. BASIC CONCEPT HEALTH The 21 Nursing Problems To maintain good hygiene and physical comport To promote optimal activity exercise, rest, and sleep. To promote safely through the prevention of accidents, injury, or other trauma and through the prevention of the spread of infection. To maintain good body mechanics and prevent and correct deformities. To facilitate the maintenance of a supply of oxygen to all body cells. To facilitate the maintenance of nutrition of all body cells. To facilitate the maintenance of elimination. To facilitate the maintenance of fluid and electrolyte balance. To recognize the physiological responses of the body to disease conditions-pathological, physiological, and compensatory. To facilitate the maintenance of regulatory mechanism and function. To facilitate the maintenance of sensory function. To identify and accept positive and negative expressions, feelings, and reactions. To identify and accept the interrelatedness of emotions and organic illness. To facilitate the maintenance of effective verbal and non-verbal communication. To promote the development of productive interpersonal relationships. To facilitate progress towards achievement of personal spiritual goals. To create and/or maintain therapeutic environment. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs. To accept the optimum possible goals in the light of limitations, physical, and emotional. To use community resources as an aid in resolving problems arising from illness. To understand the role of social problems as influencing factors in the cause of illness. Virginia Henderson An early nursing theorist who contributed a lot to the nursing profession. Attempted to define nursing in its unique focus. Contributions: The unique function of a 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 had the necessary strength, will, or knowledge. And to this in such a way as to help him gain independence as rapidly as possible. Wrote one of the first nursing textbooks, “Textbook of the Principles and Practice of Nursing”. The 14 components of basic human needs: Breathe normally. Eat and drink adequately. Eliminate body wastes. Move and maintain desirable postures./ Sleep and rest. Select suitable clothing, dress, and undress. Maintain body temperature within normal range by adjusting clothing and modifying the environment. Keep the body clean and well-groomed and protect the integument. Avoid dangers in the environment and void injuring others. Communicate with others in expressing emotions, needs, fears, and opinions. Worship according to one's faith. Work in such a way that there is a sense of accomplishment. Play or participate in various forms of recreation. Learn, discover, or satisfy the curiosity that leads to normal development and health and use of the available health facilities. Ernestine Wiedenbach nursing is caring for someone in fashion nursing is a helping service that is rendered with compassion skills and understanding to those in need of care, counsel and confidence in area of health. the practice of nursing comprises a wide variety of services towards attainment of 3 components. Identification of patient need for health. Ministration of the health needed. Validation that the help provided was indeed helpful to the patient. Characteristics of professional person that are essential for the professional nurse Clarity of purpose. Mastery of skills and knowledge. Ability Interest Dedication Wiedenbach prescriptive theory a situation-producing theory Is the one that conceptualize both the desired situation and the prescription used to bring about the desired situation. 3 Factors Central factors- which the practitioner recognizes essential to the particular discipline. Prescription- for the fulfillment of the central purpose. Realities in the immediate situation- that influence the fulfillment of the central purpose. Wiedenbach second concept of Respect for individual she believes Each human being is with unique potential to develop himself, the resources that enable him to maintain and sustain himself. The human being basically strives toward self-direction and relative independence and desires not only the best use of his capabilities and potentialities but to fulfill his responsibilities as well. The human being needs stimulation in order to make the best use of his capabilities well. Whatever the individual does represents his best judgment at the moment of doing it. The Prescription: directive activity may indicate the broad general action appropriate to implementation of the basic concept, as well as suggest the kind behavior needed to carry out those action in accordance with the central purpose. Voluntary action – an intended response Involuntary action – unintended responses 3 kinds of voluntary action Mutually understood and agreed upon action Recipient directed action Practitioner directed action The realities the matrix w/c the action occurs. 5 Realities the agent the recipient the goal the means the framework Realities – offer uniqueness in every situation Wiedenbach conceptualization of the nursing process Nursing action is the visible portion of nursing practice in w/c the nurse interacts by the word, look, manner or deed with the another person. Energized phenomenon. Nursing process – is the essentially an internal personalized mechanism. Wiedenbach’s 7 levels of awareness Sensation – experience sensory impression Perception – the interpretation of the sensory impression Assumption – the meaning the nurse attaches to the perception Realization – in w/c the nurse begins to validate the assumption she had previously made about the patient behavior Insight – w/c includes joint planning and additional knowledge about the cause of the problem Design – the plan of action decided upon by the nurse and confirmed by the patient Decision – the nurse performance of action Comparison of Wiedenbachs theory and the nursing process Nursing Process Assessment – consider the patient holistically and requires extensive data collection Wiedenbach Model The nurse is stimulated, then assess at the sensation and perception level w/c is involuntary and intuitive Goal – Weidenbach does not directly incorporate the concept of goal as part of a nursing process Implementation phase Goal as part of prescriptive theory as a component of nurse central purpose Design level – the nurse plan a course of action. Nursing diagnosis - made after much conscious thought and deliberation about the assessment data Assumption – compared to the nursing diagnosis •should be validated by gathering more data •voluntary Insight level – includes joint planning Planning Evaluation After the plan decided on, the nurse confirmed it with the patient. Once the plan has been decided it on and confirmed the nurse perform the action Wiedenbach and the concept of man, health, society and nursing Wiedenbach – emphasize that the human being process unique potential, strives towards self-direction, need stimulation and whatever the individual does represent his best judgment at that moment. Nurse – central purpose determines that her role will be that of a helper. is the application of knowledge end shall toward meeting a need for health express by a patient. is a helping process with action directed toward providing something the patient requires on desire. a process that will restore on extend the patient ability to cope with demand implicit in his healthy situation. Hildegard Peplau Theories of Nursing Theories Hildegard Peplau used the term, psychodynamic nursing, to describe the dynamic relationship between a nurse and a patient, and it is also called as the nurse-patient relationship orientation, in which the person and the nurse mutually identify the person's problem identification, in which the person identifies with the nurse, thereby accepting help exploitation, in which the person makes use of the nurse's help resolution, in which the person accepts new goals and frees herself or himself from the relationship. The six nursing roles of a nurse Counseling Role - working with the patient on current problems Leadership Role - working with the patient democratically Surrogate Role - figuratively standing in for a person in the patient's life Stranger - accepting the patient objectively Resource Person - interpreting the medical plan to the patient Teaching Role - offering information and helping the patient learn Callista Roy Callista Roy At age 14 she began working at a large general hospital, first as a pantry girl, then as a maid, and finally as a nurse's aid. After a soul-searching process of discernment, she decided to enter the Sisters of Saint Joseph of Carondelet, of which she has been a member for more than 40 years. Her college education began in a liberal arts program, where she earned a Bachelor of Arts with a major in nursing at Mount St. Mary's College, in Los Angeles. Callista Roy Dr. Roy is best known for developing and continually updating the Roy Adaptation Model as a framework for theory, practice, and research in nursing. Two recent publications that Dr. Roy considers of great significance are The Roy Adaptation Model (second edition) written with Heather Andrews (Appleton & Lange) and The Roy Adaptation Model-Based Research: Twenty-five Years of Contributions to Nursing Science being published as a research monograph by Sigma Theta Tau. Theory of Callista Roy The Roy Adaptation Model has some of the characteristics of systems theory and some of the characteristics of interaction theory. The model was first presented in periodical literature (Roy, 1970) and has been used as a conceptual framework for nursing curriculum, nursing practice, and nursing research. Roy borrowed and expanded on theories from other disciplines: Erickson, Selye, Lazarus (coping concept), Helson's (1964) theory of adaptation, Maslow's hierarchy of needs, Raprot's systems theory and other biological and behavioral sciences (Marriner & Tomey;"Nursing theorist & their works, 2nd ed, p. 325-327) Sister Callista Roy has continuously expanded her model form it's inception to the present. Her work is studied and utilized frequently in nursing education. Roy focuses on the individual (person) as a biopsychosocial adaptive system and describes nursing as a humanistic discipline that "places emphasis on the person's own coping abilities" (1984, p. 32). She believes hat the person's own coping abilities will enhance wellness (health). Roy's Adaptation Model of nursing relies heavily on the stress theory, the concept of adaptation, and the ability of the nurse to facilitate adaptation to stress. The term adaptation appears frequently throughout the model and is used to describe that which promotes the integrity of the person in terms of survival, growth, reproduction and mastery. According to Roy, environment is all conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups. Environment has both internal and external components, and is constantly changing. Health results with adaptation to reach optimal levels of individual potential in meeting physical, psychosocial, and self actualization needs. The individual is in constant interaction with the changing environment and to respond positively that person must adapt. The person's adaptation level is determined by combined effect of three classes of stimuli (input): 1) Focal stimuli, 2) contextual stimuli, and 3) residual stimuli. Focal stimuli--immediate threats/confrontations. Contextual stimuli--all other stimuli present that precipitated or contributed to the focal stimuli. Residual stimuli--relevant factors that cannot be validated (subjective), e.g. beliefs, values, etc..... The individual uses both innate and acquired biological, psychological, or social adaptive mechanisms. Roy's Model postulates that there is an interchange between the adaptive system (individual) and various stimuli (input) from the environment and itself. The response to stimuli (stress) is processed through subsystems that include two control mechanisms (coping processes) and four adaptive modes. First subsystem: Two Control Mechanisms (coping processes) Regulator--(physiological responses) concerned with the neuroendocrine responses. Receives input from external environment and from changes in the person's internal state. Cognator--(psychological responses) concerned with the process of perception (the link between the regulator/cognator), learning, judgment, and emotion. Receives input from external and internal stimuli that involve psychological, social, physical factors and processes it though cognitive pathways Second subsystem: Effect or (Adaptive) Modes Additionally, four modes for effecting adaptation of the system include: Physiological function--determined by physiological integrity derived from the basic physiological needs. Self-Concept--determined by need of interaction with others and psychic integrity regarding perception of self. Role function--determined by need for social integrity, refers to the performance of duties based on given positions within society. Interdependence--involves ways of seeking help, affection, and attention. Involves relationships with significant others and support systems. The major focus of Roys theory is on behavioral science concepts with the individual described as participants in bio-psycho-social adaptive systems. Patients are described as being under varying degrees of stress and their goal is to adopt to that stress. Roys identifies four adaptive modes which are used in this circumstance. The role of the nurse in this system is to identify the stress in the patients life: classify the adaptive mode being used and help patients adapt to stress by manipulating the environment. Orlando’s nursing process Theory in nursing process Overview of Orlando’s Nursing Process Theory A theory organizes a phenomenon and identifies the salient features, separating the critical elements from the non essential. It is like a road map that highlights the important parts to guide the user. Each theory uses a different map. Different theories use alternate ways to categorize and make sense of the phenomenon. However, each nursing theory influences the nurses thoughts and action in his approach in nursing. Frame work of her theory As a reflective practice theory, Orlando’s theory contains concepts that are interrelated but are described separately. professional nursing function organizing principle. the patient’s presenting behavior-problematic situation. immediate reaction-internal response deliberative nursing process reflective inquiry improvement resolution. Professional nursing function-organizing principle. She conceptualized the nurse’s unique function of meeting patient’s immediate needs for help. Which constitutes the nursing organizing principle. Thus the patient is the local point of the nurse’s investigation. Orlando states that: “nursing is responsive to individuals who suffer or anticipate a sense of helplessness; it is focused on the process of care in an immediate experience; It is concerned with providing direct assistance to individuals in whatever setting they are found, for the purpose of avoiding, relieving, diminishing, or curing of the individual’s sense of helplessness.” The patient’s presenting behavior-problematic situation Nursing practice comprises frequent patient-nurse contacts in which the patient manifests verbal and/or non-verbal behavior, these come in verbal forms (e.g. requests, comments, complains, questions, moaning, crying, wheezing,) in the non-verbal forms, (e.g. skin, respirations, color, silence, clinching fists, reddened face…) these situations disrupt the equilibrium and make the nurse take a notice; they are cues to the nurse. Immediate reaction-internal response The problematic situation, in the form of the patient’s presenting behaviors, triggers and automatic immediate reaction to the nurse that is both cognitive and affective. The reaction comprises the nurse’s perceptions, thoughts about the perceptions and feelings evoked from the thoughts they cannot be controlled. These separate items reside within an individual and at any given moment occur in the following automatic, sometimes instantaneous sequence; the person perceives with any one of his five sense organs an object or objects; the perceptions stimulate automatic thought; each thought stimulates an automatic feelings; and then the person acts. Deliberative nursing process-reflective inquiry Deliberative nursing process views the nurse-patient situation as a dynamic whole. The nurse’s behavior affects the patient, and the nurse is affected with the patient’s behavior. To be successful, the nurse focus must be on the patient rather than on an assumption that he or she knows what the patient’s problem is and on arbitrary decisions about what action to take. Use of this process requires that there is a shared communication process between the nurse and patient. The action process in a person to person contact functioning in secret. The perception, thought and feelings of each individual are not directly available to another person through the observable action. the action process in a person to person contact functioning by open disclosure. The feelings of each other are directly available to another person. Action based on the nurse’s conclusion, without the patient’s participation, are often not helpful. Therefore, the nurse decides for reasons other than the meaning of the patients behavior. Thus if actions are carried out automatically, even though they could be correct, they are ineffective in helping the patient because the patient was not involved. Improvement-resolution When a situation becomes clear, it loses its problematic character and a new equilibrium is established. When the patient’s immediate needs for help have been determined and met, there is improvement. This change is observable in both the patient’s verbal and non verbal behavior. This allows the nurse to conclude that the patient’s sense of helplessness has been relieved, prevented or diminished. Assessing a patient using Orlando’s theory in nursing process Guiding principle finding out and meeting patients immediate need for help. Problematic situation and immediate reactions. The nurses focus is on the patient. The nurse’s mind is free from distracting thoughts. The nurse recognizes cues that a patient problem may exist before the next step in the process Inquiry problem determination The nurse uses terms the patient can understand and explores immediate reactions with the patient to discover physical and non physical problems. Identifying specific plans for each problem With patient, the nurse determines action, needed and develop plans for each action. Nurse explores if patient will agree o refuse. Implement The nurse implements the plan and ask patient whether the action is helpful, if not, the nurse explores the basis. Improvement The nurse ask patient if action did helped and observes verbal and non verbal behavior. If he or she improve then the needs has been met, if not, nurse continues to use the contents of immediate reaction to explore if patient’s positive change is evident. Comparison Of Ida Jean Orlando’s Nursing Theory to Nursing Process NURSING THEORY Dorothy Johnson Johnson’s first paper on this topic outlined her philosophy of nursing, arguing that the key element was hands-on nursing services. She defined these services as caring for, rather then curing the patient. The definition of caring Johnson used defined caring as basic nursing procedures: comfort measures, environmental management, emotional support, and teaching. She believe that the physicians could be as kind as nurses but they focused their work on curing, rather than sustaining the patient. CENTRAL THEME Nursing problems arise when there are disturbances in the system or subsystem or the behavioral function is below an optimal level. APPLICATION TO CLINICAL PRACTICE Nursing interventions are designed to support/maintain, educate, counsel, and modify behaviors. Dorothy Johnson and the University of California Group Contemporary with the Yale theorist were a group of grand theorist of nursing who defined nursing in broad outlines. They intended to be concentrated in certain centers, with the University of California at Los Angeles (UCLA) and New York University (NYU) furnishing the leadership to the movement. Dorothy Johnson, a UCLA faculty member, started working on a theoretical framework for nursing in the 1950’s. Her most important contribution was probably not her Grand theory which was published later, but her definition of nursing as focusing on the “caring elements of patient management”, in this distinction to the physician’s role, which was said to be the treatment of illness. Johnson’s Behavioral System Model Dorothy Johnson used her observations of behavior over many years to formulate a general theory of man as a behavioral system. The theory was originally resented orally in 1968 but was not published until 1980. Johnson defines a system as a whole that functions as a whole by virtue of the interdependence of its part. Individuals strive to maintain stability and balance in these parts through adjustments and adaptations to the forces that impinge on them. A behavioral system is patterned, repetitive, and purposeful. Johnson’s Behavioral System Model Johnson’s key concepts describe the individual as a behavioral system composed of seven subsystems: The attachment-affiliative subsystem provides survival and security. Its consequences are social inclusion, intimacy, and the formation and maintenance of a strong social bond. The dependency subsystem promotes helping behavior that calls for a nurturing response. Its consequences are approval, attention or recognition, and physical assistance. The ingestive subsystem satisfies appetite. It is governed by social and physiologic consideration as well as biologic. The eliminative subsystem excretes body wastes. The sexual subsystem functions dually for procreation and gratification. The achievement subsystem attempts to manipulate the environment. It controls or masters an aspect of the self or environment to some standard of excellence. The aggressive subsystem protects and preserves the self and society within the limits imposed by society. Each of the above subsystems has the same functional requirements: protection, nurturance, and stimulation. The subsystems’ responses are developed through motivation, experience, and learning and are influenced by biopsychosocial factors. Other concepts associated with Johnson’s model are equilibrium, a stabilized but more or less transitory resting state in which the individual is in harmony with the self and environment; tension, a state of being stretched or strained; the stressor, internal or external stimuli that produce tension and result in a degree of instability. Dorothy E. Johnson BSN, MPH (1919-1999) Dorothy Johnson’s professional nursing career began in 1942 when she graduated from Vanderbilt University School of Nursing. She was the top student in her class and received the prestigious Vanderbilt Founder’s medal. She worked briefly as a public health nurse and in 1944 returned to Vanderbilt as an instructor in Pediatric Nursing. In 1949 she joined the faculty of UCLA where she and Lulu K. Wolf Hassenplug developed the “ first four year generic basic nursing program” in the United States. Dorothy Johnson was a prolific writer on the subject of nursing theory. Her many publications on this subject profoundly influenced theoretical thinking in nursing during the second half of the 20th century. She held a strong conviction that continuing improvement of care was the ultimate goal of nursing. Her 1968 paper, entitled, “ One Conceptual Model of Nursing “ is a classic contribution to Nursing Literature. After her retirement from UCLA she moved to the Florida coast to pursue her hobby of the study of sea shells. She remained active in retirement as a speaker and advocate for nursing education. KATHERINE KOLCABA THEORY OF COMFORT Credentials and Background of the Theorist Catherine Kolcaba was born in Cleveland Ohio, where she spent most of her life. In 1965 she received her diploma in nursing from St. Luke’s Hospital School of Nursing in Cleveland. She practiced part time for many years in medical-surgical nursing, long term care and home care before returning to school. In 1987, she graduated in the first RN to MSN class at the Frances Payne Bolton School of Nursing, Case Western Reserved University, with a specialty in gerontology. While going to school, Kolcaba job shared a head nurse position on a dementia unit. In the context of that unit, she begun theorizing about the outcome of comfort. Following graduation with her master’s degree in nursing, Kolcaba joined the faculty at the University of Akron College of Nursing. Since that time she has maintained American Nurses Association Certification in Gerontology. She returned to Case Western Reserved University to pursue her doctorate in nursing on a part time basis while continuing to teach full time. Over the next ten years, she used coursed work from her Doctoral program to develop and explicate her theory. During that time, Kolcaba published a concept analysis of comfort with her philosopher husband, diagrammed the aspects of comfort, operationalized comfort as an outcome of care, contextualized comfort in a midrange theory and tested the theory in an intervention study. Theoretical Sources Kolcaba originally begun her theoretical work when she diagrammed her nursing practiced early in her Doctoral work. When Kolcaba presented her framework for dementia care, an audience member asked, “have you done a concept analysis of comfort?” Kolcaba’s reply was “No but that is my next step.” This begun her long investigation on the concept of comfort. The first step, the promised concept analysis, begun with an extensive review of the literature about comfort from the disciplines of nursing, medicine, psychology, psychiatry, ergonomics and English ( specifically Shakespeare’s use of comfort and the Oxford English dictionary, which traces origins of words.) from 1900 to 1929, comfort was the central goal of nursing and medicine because, through comfort recovery achieved. The nurse was duty bound to attend to details influencing patient comfort. Comfort of the patient was the nurse’s first and last consideration. A good nurse made patients comfortable and the provision of comfort was the primary determining factor of the nurse ability and character. Comfort is positive, it is achieved with the help of nurses and in some cases, in indicates an improvement from previous state or condition. Intuitively, comfort is associated with a nurturing activity. From its origins, Kolcaba explicated its strengthening features and from ergonomics, comforts direct link to job performance. However, often its meaning is implicit, hidden in context and ambiguous. The concept varies semantically as a verb, noun, adjective, adverb, process and outcome. Four Major Tenets about the Nature of Holistic Comfort Comfort is generally state specific. The outcome of comfort is sensitive to changes over time. Any consistently applied holistic nursing intervention with established history for effectiveness enhances comfort over time. Total comfort is greater than the sum of its part. Major Concepts and Definitions Health Care Needs Kolcaba defines health care needs as needs for comfort, arising from a stressful healthcare situations, that cannot be met by recipient’s traditional support systems. These needs include physical, psychospiritual, social and environmental needs made apparent through monitoring and verbal or non verval reports, needs related to pathophysiological parameters, needs for education and support and needs for financial counseling and intervention. Comfort Measures Comfort measures are defined as nursing interventions designed to address specific comfort needs of recipients, including physiological, social, financial, psychological, spiritual, environmental and physical. Intervening Variables Intervening variables are defined as interacting forces that influence recipients perception of total. These consist of variables such as past experiences, age, attitude, emotional state, support system, prognosis, finances and the totality of elements in recipients experience. Comfort Comfort is defined as the state that is experienced by recipients of comfort measures. It is the immediate and holistic experience of being strengthened through having the needs met for the three types of comfort ( relief, ease, and transcendence) in four context of experience ( physical, psychospiritual, social and environmental) TYPES OF COMFORT ARE DEFINED AS: Relief: the state of a recipient who has had a specific need met. Ease: the state of calm or contentment. Transcendence: the state in which an individual rises above his or her problem or pain. Kolcaba derived the context on which comfort is experienced from the literature on holism and she defined them as: Physical: pertaining to bodily sensation. Psychospiritual: pertaining to internal awareness of self, including esteem, self concept, sexuality and meaning in life; relationship to a higher order or being. Environmental: pertaining to external surroundings, conditions and influences. Social: pertaining to interpersonal, family, and societal relationship. The Mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires. The need for Nurse Mentors Causes of this decline includes: “Inadequate salary increases in nursing.” “Dissatisfaction with the hospital work environment.” “Opening of traditionally male dominated professions to women” From Novice to Expert In her landmark work From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Dr. Patricia Benner introduced the concept that expert nurses develop skills and understanding of patient care over time through a sound educational base as well as a multitude of experiences. She proposed that one could gain knowledge and skills (“knowing how”) without ever learning the theory (“knowing that”). Her premise is that the development of knowledge in applied disciplines such as medicine and nursing is composed of the extension of practical knowledge (know how) through research and the characterization and understanding of the “know how” of clinical experience. In short, experience is a prerequisite for becoming an expert. What does an Expert Nurse look like in the Clinical setting ? 5 Levels of Development : Novice Advanced Beginner Competent Proficient Expert Mentors Wanted Mentors do more than teach skills They facilitate new learning experiences Help new nurses make career decisions Introduce them to networks of colleagues who can provide new professional challenges and opportunities Mentors are interactive sounding boards who help others make decisions 5 CORE competencies of Leaders and Mentors Self-Knowledge Strategic Vision Risk-Taking and Creativity Interpersonal and Communication Effectiveness Inspiration