Nursing Models and Frameworks for Health Care Delivery A.

Terms commonly utilized when discussing conceptual models (paradigms) and frameworks for nursing I. concept a. a word or collection of words that bring forth mental pictures of the properties and meanings of some phenomenon b. concepts can be classified in two ways b.1 can be classified as observable concepts b.1.1 result of sensation b.1.2 immediately, or very close to being immediately, accessible to direct sensory observations e.g., patient, nurse b.2 can be classified as constructs b.2.1 result of thought b.2.2 not immediately accessible to direct sensory observation e.g., anxiety b.2.3 must be connected to an observable concept e.g., anxiety connected to the observable concepts of rapid heart rate, sweaty palms, hyperventilation II. definition a declarative statement of the intention to use a concept in a particular way III. 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 IV. metaparadigm a. the most global perspective of the phenomena of concern of a particular discipline i. provides the boundaries of the discipline ii. distinguishes the discipline from other disciplines iii. makes the discipline unique b. a discipline usually has one metaparadigm since there is general agreement among members of the discipline about the phenomena of concern of a discipline c. the phenomena of concern generally agreed upon among members of the discipline of nursing are the following: i. person/patient ii. environment iii. health/illness iv. nursing V. proposition a declarative statement that expresses the relationship between two or more concepts B. Seven elements of effective conceptual models (paradigms) and frameworks for nursing I. 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" II. 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" III. 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"

IV. 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" V. 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" VI. 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" VII. 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" C. Purposes of conceptual models (paradigms) or frameworks for nursing I. overall purpose a. provide direction and guidance for the following: i. structuring professional nursing practice, education, and research ii. differentiating the focus of nursing from other disciplines II. purpose in practice a. assist nurses to describe, explain, and predict everyday experiences b. serve to guide assessment, intervention, and evaluation of nursing care c. provide a rationale for collecting reliable and valid data about the health status of patients, which are essential for effective decision making and implementation III. purpose in education a. provide a general focus for curriculum design b. guide curricular decision-making IV. purpose in research a. offer a conceptual model (paradigm) or framework for generating knowledge and new ideas b. assist in discovering gaps in the specific field of study c. offer a systematic approach to identify questions for study, select variables, interpret findings, and validate interventions D. Arguments for the use of one conceptual model (paradigm) or framework versus several conceptual models (paradigms) or frameworks for nursing I. arguments for the use of one conceptual model (paradigm) or framework a. would further the development of nursing as a profession b. would give all nurses a common conceptual model (paradigm) or framework, enriching communication and research c. 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 II. arguments against the use of one conceptual model (paradigm) or framework a. most disciplines have several conceptual models (paradigms) or frameworks which allow members to explore phenomena in different ways and from different view points b. several conceptual models (paradigms) or frameworks increase an understanding of the nature of nursing and its scope c. several conceptual models (paradigms) or frameworks foster development of the full scope and potential of the discipline

E. Overview of Levine's model key terms a. holism b. wholeness c. change d. adaptation the process by which people maintain their wholeness or integrity as they respond to environmental challenges e. integrity f. internal environment i. homeostasis - static state ii. homeorhesis - integration of bodily functions that resembles a stabilized flow rather than a static state g. external environment i. 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 ii. 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 iii. 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 h. levels or organismic response i. fight or flight ii. inflammatory response iii. stress iv. perceptual awareness i. perceptual systems j. basic orienting system i. visual system ii. auditory system iii. haptic system iv. taste-smell system k, conservation l. health as patterns of adaptive change m. goal or nursing - promotion of wholeness n. trophicognosis - a nursing care judgment arrived at by the scientific method o. conservation principles i. conservation of energy a natural law found to hold everywhere in the universe for all animate and inanimate entities ii. conservation of structural integrity focuses attention on healing iii. conservation of personal integrity focuses attention on the patient as a person

iv. conservation of social integrity focuses attention on the individual's place in his or her family, community, and society p. theory of therapeutic intervention q. theory of redundancy F. Overview of Roger's model I. key terms a. unitary human beings b. energy fields i. human beings ii. environment c. helicy principle that asserts that human and environmental field patterns are continuous, innovative and probabilistic, and are characterized by increasing diversity and nonrepeating rhythmicities d. integrality principle that emphasizes the continuous mutual human field and environmental field process e. health an expression of the life process f. nursing - a learned profession - a science and an art g. openness h. pattern i. four dimensionality a nonlinear domain without spatial or temporal attributes j. resonancy principle that asserts that human and environmental fields are identified by wave patterns, that manifest continuous change from lower to higher frequencies k. goal of nursing to promote maximal well-being of the human and environmental energy fields l. nursing process m. theory of accelerating evolution n. theory of paranormal phenomena o. theory of rhythmical correlates of change G. Overview of Roy's model I. key terms a. adaptive system 1. cognator mechanism i. 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 ii. it then processes the changes through neural-chemical-endocrine channels to produce responses 2. regulator mechanism 1. 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 2. these stimuli then are processed through cognitive/emotive pathways, including perceptual/information processing, learning, judgment, and emotion b. adaptive modes 1. physiological the biological mode of adaptation that is concerned with basic needs requisite to maintaining the physical and physiological integrity of the human system

2. self-concept the psychosocial mode of adaptation that is concerned with individuals' conceptions of their physical and personal selves i. the physical self deals with body sensation and body image ii. the personal self encompasses self-consistency, self-ideal, and the moral-ethical-spiritual self 3. role function the psychosocial mode of adaptation that is concerned with individuals' performance of roles on the basis of their positions within society 4. interdependence the psychosocial mode of adaptatin that is concerned with the development and maintenance of satisfying affectional relationships with significant others c. environment 1. internal 2. external d. stimuli 1. focal are the stimuli most immediately confronting the individual 2. contextual are the contributing factors in the situation 3. residual i. are other unknown factors that may influence the situation ii. when the factors making up residual stimuli become known, they are considered contextual stimuli e. adaptation f. adaptation level g. adaptation zone h. adaptive 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 i. ineffective response are those that do not contribute to the goals of the human adaptive system j. goal of nursing to promote adaptation k. nursing process i. assessment of behavior ii. assessment of influencing factors (stimuli) iii. nursing diagnoses iv. goal setting v. intervention vi. evaluation l. theory of the person as an adaptive system m. theories of the adaptive modes H. Overview of Orem's model I. key terms a. 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 b. dependent care c. self-care requisites c.1 universal self-care requisites are associated with life processes and maintenance of the integrity of human structure and function

c.2 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 c.3 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 d. therapeutic self-care demand the action demand on individuals to meet some complex of universal, developmental, and health deviation self-care requisites e. 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 f. 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 g. power components h. self-care deficit defined as the expression of a relationship of inadequacy between self-care agency and the therapeutic self-care demand i. dependent-care deficit j. 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 k. goal of nursing to help people meet theor own therapeutic self-care demands l. nursing process i. diagnosis and prescription ii. designing and planning iii. producing care to regulate therapeutic self-care demandand self-care agency m. nursing systems a dynamic action system produced by nurses as they engage in the diagnostic, prescriptive, and regulatory operations of nursing practice n. wholly compensatory nursing system nursing system selected when the patient cannot or should not perform any self-care actions o. the partly compensatory nursing system nursing system selected when the patient can perform some, but not all, self-care actions p. the supportive-educative nursing system nursing system selected when the patient can and should perform all self-care actions q. methods of assisting 1. acting for or doing for another 2. guiding another 3. supporting another physically or psychologically 4. providing a developmental environment 5. teaching another r. theory of self-care s. theory of self-care deficits t. theory of nursing systems

I. Overview of Johnson's model A. key terms 1. behavioral system 2. subsystems a. 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 b. dependency subsystem functions are succoring behavior that call for a response of nurturance as well as approval, attention or recognition, and physical assistance c. 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 d. eliminative subsystem function is elimination, with regard to when, how, and under what conditions the individual eliminates waste e. 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 f. aggressive subsystem function is protection and preservation of self and society g. 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 3. subsystem functional requirements protection a. protection from noxious influences with which the system cannot cope b. nurturance nurturance through the input of appropriate supplies from the environment c. stimulation stimulation to enhance growth and prevent stagnation 4. subsystem structural elements a. drive or goal 1. refers to motivation for behavior 2. 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 b. set refers to the individual's predisposition to act in certain ways, rather than in other ways, to fulfill the function of the subsystem c. choice 1. refers to the individual's total behavior repertoire for fulfilling subsystem functions 2. the behavioral repertoire encompasses the scope of action alternatives from which the person can choose d. action or behavior 1. refers to the actual behavior in a situation and is the only structural element that can be observed directly 2. the ability of the subsystems to fulfill their functions depends upon certain requirements e. behavioral system balance and stability f. goals of nursing restore, maintain, or attain behavioral system balance and stability g. nursing as an external regulatory force

1. 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 2. change structural units examples of changing structural elements: altering set by instruction or counseling, adding choices by teaching and skills 3. fulfill functional requirements examples of fulfillment of functional requirements: protecting the patient from overwhelming noxious influences, supplying adequate nurturance, providing stimulation J. Overview of King's model I. key terms a. personal systems are individuals, who are regarded as rational, sentient, social beings b. 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 c. 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 d. 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 e. body image is a person's perceptions of his or her own body f. time is the duration between the occurrence of one event and the occurrence of another event g. space exists in all directions and is the physical area called territory h. learning i. interpersonal systems are composed of two, three, or more individuals interacting in a given situation j. interaction 1. are the acts of two or more persons in mutual presence 2. the process of interactions between two or more individuals represents a sequence of verbal and nonverbal behaviors that are goal directed k. communication 1. is the vehicle by which human relations are developed and maintained 2. this concept encompasses intrapersonal and interpersonal communication, as well as verbal and nonverbal communication l. transaction 1. is a process of interaction in which human beings communicate with the environment to achieve goals that are valued 2. transactions are goal-directed human behaviors m. role is a set of behaviors expected when occupying a position in a social system n. 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 o. coping

p. 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 q. organization is composed of human beings with prescribed roles and positions who use resources to accomplish personal and organizational goals r. 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 s. power is the process whereby one or more persons influence other persons in a situation t. status is the position of an individual in a group or a group in relation to other groups in an organization u. 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 v. control w. environment a. internal b. external x. health a. dynamic life experiences b. ability to function in social roles y. goal of nursing a. help individuals maintain their health so they can function in their roles z. nursing process 1. perception 2. judgment 3. action 4. reaction 5. interaction 6. transaction theory of goal attainment a. 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 b. the process follows a sequence whereby nurse and patient: 1. meet in some situation 2. perceive each other 3. make judgments about the other 4. take some mental action 5. react to each one's perceptions of the other 6. share information about their perceptions 7. identify special goals, problems, or concerns 8. explore means to achieve a goal and agree to means to the goal 9. transact as goals are attained K. Overview of Neuman's model I. key terms a. patient/patient systems 1. individual 2. family 3. community

b. variables 1. physiological refer to bodily structure and function 2. psychological refer to mental processes and relationships 3. sociocultural refer to social and cultural functionsdevelopmental 4. development refer to the developmental processes of life 5. spiritual refer to aspects of spirituality on a continuum from complete unawareness or denial to a consciously developed high level of spiritual understanding c. 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 d. flexible line of defense 1. the outermost ring is the FLEXIBLE LINE OF DEFENSE 2. this mechanism is a protective buffer for the patient's normal or stable state 3. ideally, it prevents invasion of stressors and keeps the patient system free from stressor reactions or symtomatology 4. 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 5. when the flexible line is expanded away from the normal line of defense, greater protection against stressor invasion is provided 6. when it draws closer to the normal line, less protection is provided e. normal line of defense 1. the NORMAL LINE OF DEFENSE 2. lies between the flexible line of defense and the lines of resistance 3. the normal line of defense is the patient system's normal or usual wellness state 4. 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 5. expansion of the normal line of defense reflects an enhanced wellness state; contraction, a diminished state of wellness f. lines of resistance 1. the innermost rings are the LINES OF RESISTANCE 2. these lines are involuntarily activated when a stressor invades the normal line of defense 3. the lines of resistance attempt to stabilize the patient system and foster a return to the normal line of defense 4. 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 g. environment 1. defined as all internal and external actors or influences surrounding the patient system 1. internal 1.1 consists of all forces or interactions influence internal to or contained solely within the boundaries of the defined patient system 1.2 it is the source of intrapersonal stressors 2. external 2.1 consists of all forces or interactions influence external to or exist outside the defined patient system 2.2 it is the source of interpersonal extrapersonal stressors

3. created 3.1 is subconsciously developed by the patient as a symbolic expression of system wholeness 3.2 it supersedes and encompasses the internal and external environments h. stressors 1. intrapersonal 2. interpersonal 3. extrapersonal i. patient system stability j. variances from wellness k. reconstitution l. goal of nursing retain, attain, and maintain optimal patient wellness m. nursing process 1. nursing diagnosis 2. nursing goals 3. nursing outcomes n. prevention as intervention format 1. primary prevention 1.1 the action required to retain patient system stability 1.2 Interventions involving primary prevention is selected when the risk of or hazard from a stressor is known but a reaction has not yet occurred 1.3 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 2. secondary prevention 2.1 the action required to attain system stability. Intervention involving secondary prevention is selected when a reaction to a stressor has already occurred 2.3 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 3. tertiary prevention 3.1 the action required to maintain system stability 3.2 interventions involving tertiary prevention are selected when some degree of patient system stability has occurred following secondary prevention interventions o. theory of optimal patient system stability