OREM’S GENERAL THEORY OF NURSING
Orem’s general theory of nursing is in three related parts:
• Theory of self care
• Theory of self care deficit
• Theory of nursing system
1. Theory of Self Care,this theory includes:
Self care – practice of activities that the individuals initiate and perform on their own in maintaining life, health and well being. Such as; dietary precautions, physical activities, and regular checkups
Self care agency – is a human ability which is “the ability for engaging in self care” -conditioned by age, developmental state, life experience, sociocultural orientation, health and available resources. However, the following may affect self-care; lack of family support, lack of awareness of basic health needs and unhealthy diet.
OREM’S GENERAL THEORY OF NURSING
Nursing Agents; this is seen as; health education; mind diversion therapy and volunteers training.
Therapeutic self care demand– “totality of self care actions to be performed for some duration in order to meet self care requisites by using valid methods and related sets of operations and actions”
Self care requisites -are actions directed towards provision of self care. Such as management and prevention of hypertension, diabetes, stress and obesity etc.
3 categories of self care requisites are;
• Universal self care requisites
• Developmental self care requisites
• Health deviation self care requisites
1. Universal self care requisites: this is associated with life processes and the maintenance of the integrity of human structure and functioning
• Common to all , ADL
Identifies these requisites as:
• Maintenance of sufficient intake of air ,water, food
• Provision of care associated with elimination process
• Balance between activity and rest, between solitude and social interaction
• Prevention of hazards to human life and well being
• Promotion of human functioning
Developmental self care requisites: this is associated with developmental processes derived from a condition, or associated with an event, e.g. adjusting to a new job, adjusting to body changes.
Health deviation of self care
• Required in conditions of illness, injury, or disease .these include:- Seeking and securing appropriate medical assistance
• Being aware of and attending to the effects and results of pathologic conditions
• Effectively carrying out medically prescribed measures
• Modifying self concepts in accepting oneself as being in a particular state of health and in specific form of health care.
• Learning to live with effects of pathologic conditions
1. Theory of self care deficit
Specifies when nursing is needed. Nursing is required when an adult (or in the case of a dependent, the parent) is incapable or limited in the provision of continuous effective self care. Nursing meets these self-care needs through five methods of help;
Orem identifies 5 methods of helping the client with self-care deficit:
• Acting for and doing for others
• Guiding others
• Supportingone another
• Providing an environment that promotes personal development in relation to meeting future demands
• Teaching another person and others
Theory of Nursing Systems
• The nurse compensates for what the patient cannot do for him/herself while teaching him how to care for himself.
• Nursing system is conceptualised as the providers’s resources, structures, methods and processes essential for efficient and effective delivery of nursing care to different groups of individuals.
• The theory concentration is directed towards preparing nurse scientists with expertise in evaluating theoretical and empirical knowledge about inter and intra- organizational phenomena relevant to the delivery of nursing care.
• Develop and validate new theoretical constructs and models that explains nursing phenomena from a systems perspective.
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Orem’s Compensatory Nursing System
It describes how the patient’sself care needs will be met by the nurse , the patient, or both
• Wholly Compensatory Nursing System
The nurse supports and protects the client, compensates for the client’s inability to care for himself and attempts to provide care for the client e.g. caring for a newborn child, when giving a postoperative care to a client who is recovering from anaesthesia or an eclamptic woman in the labour ward. These clients are completely unable to provide care for themselves.
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• Partially Compensatory Nursing System
Both the nurse and the client perform care measures, for example the nurse can assist the post operative client to ambulate. The nurse may bring a meal in a tray for the client who is able to feed him/herself. The nurse compensate for what the client cannot do. The client is cpable of performing selected self-care activities but also accepts care by the nurse for needs the client is unable to meet independently.
• The Supportive Educative Nursing System
In this phase the nurse’s action is to help the client develop their own self-care abilities through knowledge, support and encouragement. Client must learn and perform their own self-care activities. The supportive educative nursing system is used when a nurse guides a newborn mother to breastfeed her baby.
The client: is a human being who has “health related /health derived limitations that render him/her incapable of continuous self care or dependent care or limitations that result in ineffective / incomplete care. The human being is the focus of nursing only when a self –care requisites exceeds self care capabilities.
(D) Betty Neuman’s System Model
Betty Neuman was a theorist – born in 1924, in Lowel, Ohio. Had BS in nursing in 1957; MSc in Mental health and Public health consultant, from UCLA in 1966; Ph.D. in clinical psychology. Her theory was published in: “A Model for Teaching Total Person Approach to Patient Problems” in Nursing Research – 1972. “Conceptual Models for Nursing Practice”, first edition in 1974, and second edition in 1980. Betty Neuman’s system model provides a comprehensive flexible holistic and system based perspective for nursing.
Development of The Model
Neuman’s model was influenced by: Philosophy writers deChardin and Cornu (on wholeness in system). Von Bertalanfy, and Lazlo on general system theory; Selye on stress theory and Lararus on stress and coping.
Neuman’s System Model; Its Philosophy and Assumptions
• Neuman focused her model on client’s response to environmental stressors and multiple levels of nursing preventions.
• Which is based on wholeness and the gestalt concept of reality, which says that the whole of an object is greater or important than its individual parts.
• It concentrated on dynamic equilibrium where parts of the system work together as a whole, therefore if one part of the system is diseased the whole system will be sick.
• This model proposed that wellness is a negotiation between the client and the nurse.
Major Concepts (Neuman, 2002)
Content:the variables of the person in interaction with the internal and external environment comprises the whole client system.
Basic structure/Central core:
• The common client survival factors in unique individual characteristics representing basic system energy resources.
• The basis structure, or central core, is made up of the basic survival factors which include: normal temperature range, genetic structure; response pattern, organ strength or weakness, and ego structure.
• Stability occurs when the amount of energy that is available exceeds that being used by the system.
• A homeostatic body system is constantly in a dynamic process of input, output, feedback, and compensation, which leads to a state of balance.
Degree To Reaction
• The amount of system instability resulting from stressor invasion of the normal LOD( Line of defence)
Entropy: this is a process of energy depletion and disorganization moving the system toward illness or possible death.
Circles within the Neuman System Model
The Neuman model is illustrated by multiple circles which demonstrates the client’s line of defense.
• Line of Resistance LOR
• Flexible line of defense FLD
• Normal line of defense NLD
Flexible LOD- is a protective, accordion like mechanism that surrounds and protects the normal LOD from invasion by stressors.
Normal LOD- It represents what the client has become over time, or the usual state of wellness. It is considered dynamic because it can expand or contract over time.
Line of Resistance-LOR- The series of concentric circles that surrounds the basic structure.
• Protection factors are activated when stressors have penetrated the normal LOD, causing a reaction symptomatology. E.g. mobilization of WBC and activation of immune system mechanism
Input- output- The matter, energy, and information exchanged between client and environment that is entering or leaving the system at any point in time.
Open system- A system in which there is continuous flow of input and process, output and feedback. It is a system of organized complexity where all elements are in interaction.
Prevention as intervention- Interventions modes for nursing action and determinants for entry of both client and nurse in to health care system.
Reconstitution- This is the return and maintenance of system stability, following treatment for stressor reaction, which may result in a higher or lower level of wellness.
Stability- is a state of balance of harmony requiring energy exchanges as the client adequately copes with stressors to retain, attain, or maintain an optimal level of health thus preserving system integrity.
Stressors – are environmental factors, which are intra (emotion, feeling), inter (role expectation), and extra personal (job or finance pressure) in nature, that have potential for disrupting system stability. A stressor is any phenomenon that might penetrate both the F and N LOD, resulting either in a positive or negative outcome.
Neuman’s Category of Stressors
Stressors are capable of producing either a positive or negative effects on the client’s system. A stressor is any environmental force which can potentially affect the stability of the system.
Stressors can be;
1. Intrapersonal- this occurs within a person e.g. infection, thought and feelings
2. Interpersonal- occurs between individuals e.g. role expectations.
3. Extrapersonal- occurs outside the individual e.g. job or financial concerns
A person’s reaction to stressors depends on the strength of the lines of defense, when the lines of defense fails the resulting reaction depends on the strength of the lines of resistance. As part of the reaction, a person’s system can adapt to a stressor whichis an effect known as reconstitution.
Wellness/Illness- Wellness is the condition in which all system parts and subparts are in harmony with the whole system of the client. while illness is a state of insufficiency with disrupting needs unsatisfied (Neuman, 2002).
Systems Model of Neuman identified three levels of Prevention
The primary nursing intervention focuses on keeping stressors and the stress response from having a detrimental effect on the body.
Primary Prevention occurs before the system reacts to a stressor this strengthens the person (primary the flexible LOD) to enable him to dealbetter with stressors this includes health promotion and maintenance of wellness.
Secondary Prevention occurs after the system has reacted to an invading stressor and it focuses on preventing damage to the central core by strengthening the internal lines of resistance and/or removing the stressor.
Tertiary Prevention occurs after the system has been treated through secondary prevention strategies and offers support to the client and attempts to add energy to the system or reduce energy needed in order to facilitate reconstitution.
FOUR NURSING PARADIGMS
PERSON- Human being is a total person as a client system and the person is a layered multidimensional being. Each layer consists of five person variables or subsystems:
Physiological – Refers to the physicochemical structure and function of the body.
Psychological – Refers to the mental processes and emotions.
Socio-cultural – Refers to relationships and social/cultural expectations and activities.
Spiritual – Refers to the influence of spiritual beliefs.
Developmental – Refers to those processes related to development over one’ lifespan.
The human being is in constant change, moving toward a dynamic state of system stability or toward illness of varying degrees.
ENVIRONMENT- ” is the totality of the internal and external forces (intrapersonal, interpersonal and extra-personal stressors) which surround a person and with which they interact at any given time.”
The internal environment exists within the client system.All forces and interactive influences that are solely within boundaries of the client’s system make up the internal environment.
The external environment exists outside the client system. The environment may be viewed as all factors that affect and are affected by the system. The created environment is an environment that is created and developed unconsciously by the client and is symbolic of system wholeness.
HEALTH – Health is equated with wellness. “the condition in which all parts and subparts (variables) are in harmony with the whole of the client (Neuman, 1995)”. The client system moves toward illness and death when more energy is needed than is available. The client’s system moves toward wellness when more energy is available than is needed. When system needs are met, optimal wellness exists, when energy needed to support life is not available death occurs.
NURSING is a unique profession that is concerned with all of the variables which influence the response a person might have, to a stressor. A person is seen as a whole, and it is the task of nursing that addresses 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.’’ The role of the nurse is seen in terms of degree of reaction to stressors, and the use of primary, secondary and tertiary interventions. These aimed at helping the system adapt or adjust and to retain, restore or maintain some degree of stability between and among the client’s system variables and environmental stressors with a focus on conserving energy.
NEUMAN’S MODEL & CHRACTERISTICS
• interrelated concepts
• logically consistent.
• logical sequence
• fairly simple and straightforward in approach.
• easily identifiable definitions
• provides guidelines for nursing education and practice
• applicable in the practice
(E) Martha Rogers of Science of Unitary Man.
Martha Rogers was born in Dallas, Texas on May 12, 1914, and she believed that Nursing is an art and science that is humanistic and humanitarian. which is directed toward the unitary human and is concerned with the nature and direction of human development. The goal of nurses is to participate in the process of; nursing interventions seeking to promote harmonious interaction between persons and their environment, and strengthen the weakness of the individual and direct human and environmental patterns or organization to achieve maximum health.
Rogers’s 5 Basic Assumption
1. Man is a unified whole possessing his/her own integrity and manifesting characteristics more than and different from the sum of his parts.
2. Man and environment are continuously exchanging matter and energy with one another.
3. The life process evolves irreversibly and unidirectional along the space-time continuum.
4. Pattern and organization identify man and reflect on his innovative wholeness.
5. Man is characterized by the capacity for abstraction and imagery, language and thought, sensation and emotion.
Person- a unitary human being develops through three principles helicy/expert,Helicy is the “continuous innovative, unpredictable, increasing diversity of human and environmental ﬁeld patterns”(Rogers,1990a,p.8). Resonancy/resound Resonancy specifies the “continuous change from lower to higher frequency wave patterns in human and environmental ﬁelds”(Rogers, 1990a, p. 9). Resonancy presents the way change occurs and integrality/complete,describe the nature of change in the human-environmental field process.
Environment- encompasses all that is outside any given human field. Person exchanging matter and energy.
Health- it emerges out of interaction between human and environment, moves forward and maximizes human potential.
Nursing- the professional practice of nursing is creative and imaginative and exists to serve people.
(F) Sister Calista Roy Adaptation Model
Human beings are viewed as biopsychosocial beings constantly interacting with a changing environment and cope with their environment through biopsychosocial adaptation mechanisms. The individual as an adaptive system, functions as a whole through interdependence of its parts. The system consists of input, control processes, output and feedback. Adaptation leads to optimum health and well-being, to quality of life and to death with dignity.