Nursing Theory

Mr. Ted Alexander, a 50 year old white divorced salesman from Las Vegas, was on a business trip to Atlantic City when he developed pain in the right lower abdominal quadrant.  He took Alka –Seltzer with little relief, and the pain persisted for the next two days.  He was busy with appointments during the day and evening and was able to ignore the pain.  He ate very little and took two sleeping pills at night.  On the afternoon of the third day, the pain became much more intense, and when it continued for several hours and he began to vomit repeatedly, he went to the emergency department. Nursing Theory

Physical examination and laboratory data at this time revealed an alert, well-groomed male with generalized abdominal tenderness, rigidity of the abdominal wall, presence of a palpable mass in the right inguinal area, absent bowel sounds, and a WBC of 20,000/mm’ (normal = 5000-9000).  The diagnosis of ruptured appendix was made.  He was admitted to the hospital for initial medical management, with surgery anticipated at a later date.

Your examination of the patient reveals the following: B/P = 140/80, P=116, Resp=26 and temp 101.2.  The patient indicates that he is 6 ft. 2 inches tall and weighs 196 lbs.  He is alert and oriented and states, “My gut is killing me.” His skin is warm to the touch and slightly diaphoretic.  The patient states that he had been a heavy drinker for 15 years and was admitted to the hospital with cirrhosis two years ago by his family doctor, Dr. Manland, but has never had surgery.  He denies drinking for the past two years but smokes two packs of cigarettes daily. Nursing Theory

Mr. Alexander is tense throughout your conversation and shares a number of concerns with you, including his separation from his two teenage children who live with him.  He is also anxious about being cared for by an unfamiliar physician.  The ED Nurse indicates that he wears contact lenses and is concerned because he has left his case and supplies as well as his glasses in his hotel.  He gives you $750 in cash and traveler’s checks to deposit in the hospital safe.  He has a partial lower plate of dentures and caps on his four front teeth.  Further inquiry reveals that the patient prefers a low-fat diet, occasionally uses laxatives, and has had several occurrences of urinary urgency and nocturia in the last six months.

The physician states that his treatment plan includes gastric suction, antibiotics and IV fluid therapy with electrolytes and vitamins until the patient is stabilized enough for exploratory surgery.  Mr. Alexander agrees to this plan but is concerned about his job demands and wonders how he will deal with “getting back home when all of this is over.”

Mr. Ted Alexander, a 50 year old white divorced salesman from Las Vegas, was on a business trip to Atlantic City when he developed pain in the right lower abdominal quadrant.  He took Alka –Seltzer with little relief, and the pain persisted for the next two days.  He was busy with appointments during the day and evening and was able to ignore the pain.  He ate very little and took two sleeping pills at night.  On the afternoon of the third day, the pain became much more intense, and when it continued for several hours and he began to vomit repeatedly, he went to the emergency department. Nursing Theory

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Physical examination and laboratory data at this time revealed an alert, well-groomed male with generalized abdominal tenderness, rigidity of the abdominal wall, presence of a palpable mass in the right inguinal area, absent bowel sounds, and a WBC of 20,000/mm’ (normal = 5000-9000).  The diagnosis of ruptured appendix was made.  He was admitted to the hospital for initial medical management, with surgery anticipated at a later date.

Your examination of the patient reveals the following: B/P = 140/80, P=116, Resp=26 and temp 101.2.  The patient indicates that he is 6 ft. 2 inches tall and weighs 196 lbs.  He is alert and oriented and states, “My gut is killing me.” His skin is warm to the touch and slightly diaphoretic.  The patient states that he had been a heavy drinker for 15 years and was admitted to the hospital with cirrhosis two years ago by his family doctor, Dr. Manland, but has never had surgery.  He denies drinking for the past two years but smokes two packs of cigarettes daily.

Mr. Alexander is tense throughout your conversation and shares a number of concerns with you, including his separation from his two teenage children who live with him.  He is also anxious about being cared for by an unfamiliar physician.  The ED Nurse indicates that he wears contact lenses and is concerned because he has left his case and supplies as well as his glasses in his hotel.  He gives you $750 in cash and traveler’s checks to deposit in the hospital safe.  He has a partial lower plate of dentures and caps on his four front teeth.  Further inquiry reveals that the patient prefers a low-fat diet, occasionally uses laxatives, and has had several occurrences of urinary urgency and nocturia in the last six months.

The physician states that his treatment plan includes gastric suction, antibiotics and IV fluid therapy with electrolytes and vitamins until the patient is stabilized enough for exploratory surgery.  Mr. Alexander agrees to this plan but is concerned about his job demands and wonders how he will deal with “getting back home when all of this is over Nursing Theory

Nursing Theory

Grand theories are comparatively more abstract than middle-range theories since they are at a higher level of abstraction. Compared to grand theories, middle-range theories are made up of limited number of concepts that lend themselves to empirical testing. All theories help to explain human health behavior.

· Sister Callista Royï’s adaptive model theory is built on the conceptual foundation of adaptation. It identifies the positive role that nursing plays in the promotion and enhancement of client adaptation to environments that facilitate the healing process.

· Leiningerï’s culture care theory is pertinent in the current multicultural healthcare environment where nurses are exposed to diverse cultures.

· Penderï’s health promotion and disease prevention theory can be called as a “direction setting exercise” for nursing professionals. It believes in fostering the spirit of health promotion and disease and risk reduction.

From the chapter, Models and Theories Focused on Nursing Goals and Functions, read the following: The Health Promotion Model: Nola J. Pender

From the chapter, Models and Theories Focused on a Systems Approach, read the following:

The Roy Adaptation Model Nursing Theory

From the chapter, Models and Theories Focused on Culture, read the following:

Leininger’s Cultural Care Diversity and Universality Theory and Model

SO, THAT IS WHY I ASSUMED THAT HAS TO BE ONE OF THEM (Pender, Roy Adaptation or Leininger)

ANYWAY, I AM PUTTING INFORMATION TOGETHER.

Week 4 Chapter 17

Models and Theories Focused on Nursing Goals and Functions

The Health Promotion Model: Nola J. Pender

Background

Nola J. Pender was born in 1941 in Lansing, Michigan. She graduated in 1962 with a diploma in nursing. In 1964, Pender completed a bachelor’s of science in nursing at Michigan State University. By 1969, she had completed a doctor of philosophy in psychology and education. During this time in her career, Pender began looking at health and nursing in a broad way, including defining the goal of nursing care as optimal health.

In 1975, Pender published a model for preventive health behavior; her health promotion model first appeared in the first edition of the text Health Promotion in Nursing Practice in 1982. Pender’s health promotion model has its foundation in Albert Bandura’s (1977) social learning theory (which postulates that cognitive processes affect behavior change) and is influenced by Fishbein’s (1967) theory of reasoned action (which asserts that personal attitudes and social norms affect behavior). Nursing Theory

Pender’s Health Promotion Model

McCullagh (2009) labeled Pender’s health promotion model as a middle-range integrative theory, and rightly so. Fawcett (2005) decisively presented the difference between a conceptual model for nursing and a model for middle-range theory. A model for middle-range theory is usually a graphic representation or schematic diagram of a middle-range theory. McCullagh’s (2009) rationale for labeling Pender’s model a middle-range integrative theory is that it portrays the multi dimensionality of persons interacting with their interpersonal and physical environments as they pursue health while integrating constructs from expectancy-value theory and social cognitive theory with a nursing perspective of holistic human functioning (Pender, 1996). With the third edition of Health Promotion in Nursing Practice (1996), Pender revised the health promotion model significantly. This revised model is the subject of the discussion in this chapter.

Pender’s health promotion model includes three major categories: (1) individual characteristics and experiences, (2) behavior-specific cognitions and affect, and (3) behavioral outcome. Each of these categories will be considered here separately.

The first category includes each person’s unique personal characteristics and experiences, which affect that individual’s actions. Significant components within this category are prior related behavior and personal factors. Prior related behavior is important in influencing future behavior. Pender proposed that prior behavior has both direct and indirect effects on the likelihood of engaging in health-promoting behaviors. In particular, past behavior has a direct effect on the current health-promoting behavior through habit formation: Habit strength increases each time a behavior occurs. Prior behavior is proposed to indirectly influence health-promoting behavior through perceptions of self-efficacy, benefits, barriers, and activity-related affect or emotions (Pender, Murdaugh, & Parsons, 2006). Personal factors include biological factors such as age, body mass index, pubertal status, menopausal status, aerobic capacity, strength, agility, or balance; psychological factors include self-esteem, self-motivation, and perceived health status; and sociocultural factors include race, ethnicity, acculturation, education, and socioeconomic status. Some personal factors are amenable to change, whereas others are immutable (Pender et al., 2006).

The second category encompasses behavior-specific cognitions and affect, which serve as behavior-specific variables within the health promotion model. Behavior-specific variables are considered to have motivational significance. In the health promotion model, nursing interventions target these variables because they are amenable to change. The behavior-specific cognitions and affect identified in the health promotion model include (1) perceived benefits of action, (2) perceived barriers to action, (3) perceived self-efficacy, and (4) activity-related affect. Other cognitions fall into the category of interpersonal influences and situational influences. Sources of interpersonal influences on health-promoting behaviors include family, peers, and healthcare providers. Interpersonal influences include norms, social support, and modeling; they shape the person’s tendency to participate in health-promoting behaviors. Situational influences on health-promoting behavior include perceptions of available options, demand characteristics, and aesthetic features of the environment. Within Pender’s model, nursing plans are tailored to meet the needs of diverse patients based on assessment of prior behavior, behavior-specific cognitions and affect, interpersonal factors, and situational factors (Pender et al., 2006, pp. 54–56). Nursing Theory

The third category within Pender’s model is the behavioral outcome. Commitment to a plan of action marks the beginning of a behavioral event. This commitment propels the person into the behavior unless that action is confounded by a competing demand that cannot be avoided or a competing preference that is not resisted. Interventions in the health promotion model focus on raising consciousness related to health-promoting behaviors, promoting self-efficacy, enhancing the benefits of change, controlling the environment to support behavior change, and managing the barriers to change. Health-promoting behavior, which is ultimately directed toward attaining positive health outcomes, is the product of the health promotion model (Pender et al., 2006, pp. 56–63).

Major Concepts of Nursing According to Pender

Person

The person in the health promotion model refers to the individual who is the primary focus of the model. In Pender’s model, each person has unique personal characteristics and experiences that affect subsequent actions. It is recognized that individuals learn health behaviors within the context of the family and the community, which explains why the model for assessment includes components and interventions at the family and community levels, as well as the individual level (Pender, Murdaugh, & Parsons, 2002, 2006). This is taken a step further in the latest edition (Pender, Murdaugh, & Parsons, 2011), in which the term client refers to individuals, families, and communities who are all viewed as active participants in health promotion.

Environment

In the health promotion model, the environment encompasses the physical, interpersonal, and economic circumstances in which persons live. The quality of the environment depends on the absence of toxic substances, the availability of restorative experiences, and the accessibility of human and economic resources needed for healthful living. Socioeconomic conditions such as unemployment, poverty, crime, and prejudice have adverse effects on health, whereas environmental wellness is manifested by balance between human beings and their surroundings (Pender et al., 2006, p. 9; Pender et al., 2011, p. 8).

Health

Health is viewed as a positive high-level state. According to Pender, the person’s definition of health for himself or herself is more important than any general definition of health (Pender et al., 2006; Sakraida, 2010). Health is viewed in the context of health promotion and disease prevention. Health promotion is behavior that is motivated by a desire to increase well-being and optimize human health potential, whereas disease prevention or health protection is behavior motivated by a desire to actively avoid illness, detect illness early, or maintain functioning within the constraints of illness (Pender et al., 2011, p. 5). Health promotion is viewed as a multidimensional concept that includes the dimensions of the individual, the family, the community, socioeconomic status, cultural factors, and environmental factors (Pender et al., 2011, pp. 6–8). Nursing Theory

Nursing

The role of the nurse in the health promotion model revolves around raising consciousness related to health-promoting behaviors, promoting self-efficacy, enhancing the benefits of change, controlling the environment to support behavior change, and managing the barriers to change (Pender et al., 2006, pp. 57–63). A major function of the APN role is the focus on health promotion. This model serves as a significantly pragmatic process for APNs to use to encourage health-promoting behaviors by patients and to address the benefits of change.

Analysis of the Health Promotion Model

The analysis and critique presented here comprise an examination of assumptions and propositions, as well as the analysis of clarity, simplicity, generality, empirical precision, and derivable consequences of Pender’s health promotion model.

Assumptions of the Health Promotion Model

Assumptions of the health promotion model reflect both nursing and behavioral science perspectives. The seven major assumptions emphasize the active role of the patient in shaping and maintaining health behaviors and in modifying the environmental context for health behaviors:

1. Persons seek to create conditions of living through which they can express their unique human potential.

2. Persons have the capacity for reflective self-awareness, including assessment of their own competencies.

3. Persons value growth in directions viewed as positive and attempt to achieve a personally acceptable balance between change and stability.

4. Persons seek to actively regulate their own behavior.

5. Persons in all their biopsychosocial complexity interact with the environment, both progressively transforming the environment and being transformed over time.

6. Health professionals constitute a part of the interpersonal environment, which influences persons throughout their life span.

7. Self-initiated reconfiguration of person–environment interactive patterns is essential for behavior change (Pender et al., 2002, p. 63).

Propositions of the Health Promotion Model

The health promotion model is based upon 14 theoretical propositions. These theoretical relationship statements provide a basis for research related to health behaviors:

1. Prior behavior and inherited and acquired characteristics influence health beliefs, affect, and enactment of health-promoting behavior.

2. Persons commit to engaging in behaviors from which they anticipate deriving personally valued benefits.

3. Perceived barriers can constrain commitment to action (a mediator of behavior), as well as actual behavior.

4. Perceived competence or self-efficacy to execute a given behavior increases the likelihood of commitment to action and actual performance of behavior.

5. Greater perceived self-efficacy results in fewer perceived barriers to a specific health behavior.

6. Positive affect toward a behavior results in greater perceived self-efficacy, which can, in turn, result in increased positive affect.

7. When positive emotions or affect are associated with a behavior, the probability of commitment and action are increased. Nursing Theory

8. Persons are more likely to commit to and engage in health-promoting behaviors when significant others model the behavior, expect the behavior to occur, and provide assistance and support to enable the behavior.

9. Family, peers, and healthcare providers are important sources of interpersonal influence who can increase or decrease commitment to and engagement in health-promoting behavior.

10. Situational influences in the external environment can increase or decrease commitment to or participation in health-promoting behavior.

11. The greater the commitment to a specific plan of action, the more likely health-promoting behaviors will be maintained over time.

12. Commitment to a plan of action is less likely to result in the desired behavior when competing demands over which persons have little control require immediate attention.

13. Commitment to a plan of action is less likely to result in the desired behavior when other actions are more attractive and thus preferred over the target behavior.

14. Persons can modify cognitions, affect, and the interpersonal and physical environments to create incentives for health actions (Pender et al., 2002, pp. 63–64).

Analysis: Clarity, Simplicity, Generality, Empirical Precision, and Derivable Consequences

Pender’s health promotion model was formulated using inductive reasoning with existing research, which is a common approach to the building of middle-range theories. The research used to derive the model was based on adult samples that included male, female, young, old, well, and ill populations; this design allows the model to be generalized easily to adult populations (Sakraida, 2010).

The health promotion model is simple to understand, because it uses language familiar to nurses. The concept of health promotion is also popular in nursing practice and, therefore, is a practical principle for APNs’ use. The relationships among the factors are linked, and relationships are identified and consistently defined. Considering all of these factors, it is not difficult to see why Pender’s model is popular with practicing nurses and is frequently used as a tool in research. Nevertheless, it has not been used extensively in nursing education, where the emphasis is on illness care in acute care settings (Sakraida, 2010).

Discussion

Pender identified health promotion as a key global goal for the 21st century (Pender et al., 2011) and, through development of the health promotion model, has assisted in the delineation of the role of nursing in meeting that goal. Although Pender has now retired, her work on the health promotion model continues. Pender views the nurse’s role in health promotion as more important than ever considering existing health disparities and the challenges of our current healthcare system (Pender et al., 2011). The current scenario of increasing costs for health care associated with episodic illness treatment increases in chronic, preventable conditions within the population, and the focus on managing healthcare costs provide ample incentive to further explore the concepts of the health promotion model as APNs strive to improve health outcomes in patient populations.

Summary

Although the four nursing models described in this chapter were conceived by four very different nurses whose careers spanned more than a century, they share a common thread: All place emphasis on the function of nursing practice in relation to health outcomes. For Nightingale, the function of nursing is to alter the environment to allow for action on the person by natural laws of health; for Henderson, the function of nursing is to assist the person to perform activities to gain independence; for Johnson, the function of the nurse is to impose external regulatory mechanisms in order to facilitate restoration of system balance; and for Pender, the nurse functions to raise consciousness, promote self-efficacy, and control the environment to allow for behavior change resulting in high-level health. All four of these nursing models also conceptualize the goal of nursing care as a restoration of the health of the patient, however differently the concept of health—or, for that matter, the concept of the patient—may be defined in their respective theories.

Discussion Questions

1. Nightingale and Henderson considered the discipline of nursing to be both an art and a science. Esthetic patterns of knowing and empirical patterns of knowing both constitute complex yet divergent ways of thinking. How can the APN perform simultaneously from an esthetic perspective and a perspective based on empiricism?

2. Johnson’s behavioral system model has been used in practice and research; as a result, multiple adaptations of this model have appeared in the literature. In response to these additions and alterations, Johnson (1990, p. 27) stated, “[T]hese changes are such that they alter the fundamental nature of the behavioral system as originally proposed, and I do not agree with them.” Does a theory belong to the nurse theorist or to the discipline of nursing? Who has the right to add to or alter a theory? Should a theory be altered based on research evidence even if the original nurse theorist is not in agreement, or should the theory be maintained intact as a historical record?

3. Considering a patient scenario from advanced nursing practice and using a middle-range theory such as the health promotion model, demonstrate the connection and reciprocal relationship between theory, practice, and research.

4. The theories presented in this chapter, although they view nursing from various perspectives, have brought to light these theorists’ identification and development of the concepts of interest, thereby influencing the evolution of nursing as a discipline and framing nursing knowledge. How has the development of these and other nursing theories helped to frame knowledge and shape the role of the APN?

References

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Fishbein, M. (1967). Readings in attitude theory and measurement. New York, NY: Wiley.

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Leininger’s Cultural Care Diversity and Universality Theory and Model

Leininger’s cultural care diversity and universality theory and the sunrise model that depicts her theory are perhaps the most well known in nursing literature on culture and health (Leininger & McFarland, 2006). The theory draws from anthropological observations and studies of culture and cultural values, beliefs, and practices. The theory of transcultural nursing promotes understanding of both the universally held and common understandings of care among humans and the culture-specific caring beliefs and behaviors that define any particular caring context or interaction. According to Leininger, this theory is intended to be holistic: Culture is the specific pattern of behavior that distinguishes any society from others and gives meaning to human expressions of care (Leininger, 2002).

The theory of cultural care diversity and universality is heavily used in education and research. It incorporates the following assumptions about care and caring as they relate to cultural competency (Leininger, 2002):

• Care (caring) is essential to curing and healing, for there can be no curing without caring.

• Every human culture has generic, folk, or indigenous care knowledge and practices and usually some professional care knowledge and practices that vary transculturally.

• Culture care values, beliefs, and practices are influenced by and tend to be embedded in the worldview, language, philosophy, religion and spirituality, kinship, social, political, legal, educational, economic, technological, ethno-historical, and environmental contexts of cultures.

• A client who experiences nursing care that fails to be reasonably congruent with his or her beliefs, values, and caring life ways will show signs of cultural conflict, noncompliance, stress, and ethical or moral concern.

• Within a cultural care diversity and universality framework, nurses may take any or all of three culturally congruent action modes: (1) cultural preservation/maintenance, (2) cultural care accommodation/negotiation, and (3) cultural care repatterning/restructuring.

According to Leininger, cultural care preservation/maintenance refers to assistive, supportive, facilitative, or enabling professional actions and decisions that help individuals, families, and communities of a particular culture retain and preserve care values so that they can maintain well-being, recover from illness, or face possible handicap or death. Cultural care accommodation/negotiation refers to assistive, supportive, facilitative, or enabling professional actions and potential decisions that help individuals, families, and communities of a particular culture adapt to or negotiate with others for satisfying healthcare outcomes with professional caregivers. Cultural care repatterning/restructuring refers to the assistive, supportive, facilitative, and enabling roles filled by nurses and other healthcare providers to promote actions and decisions that may help the person, family, or community change or modify behaviors affecting their life ways, thereby achieving a new and different health pattern (Leininger & McFarland, 2006). These three action modes are sometimes used with other cultural theories and models.

Leininger recognized the comparative aspects of caring within and between cultures—hence the theory’s acknowledgment of similarities as much as differences in caring in diverse cultures. Her transcultural model has implications for how nurses assess, plan, implement, and evaluate care of people from diverse cultural backgrounds. The sunrise model and theory have clarity, but they are complex. The model has generality for nursing, empirical precision, and derivable consequences. The sunrise model can be found on the Transcultural Nursing Society’s website (http://tcns.org/Theories).

The Roy Adaptation Model

The History

Sister Callista Roy recalled that the origins of her adaptation model date back to 1964, when she was a master’s-level student at Mount St. Mary’s College in Los Angeles. In 1970, she published the basic ideas of her conceptual model in an article titled “Adaptation: A Conceptual Framework for Nursing” in Nursing Outlook. In 1971 and 1973, the model was further explained in a chapter of Riehl and Roy’s (1974) book, Conceptual Models for Nursing Practice. A more comprehensive explanation of the model can be found in Roy’s (1976) book, Introduction to Nursing: An Adaptation Model. Further refinements of the model were published in the second edition of that book (Roy, 1984). Roy’s clinical experiences in pediatric nursing and neurological nursing were important influences in the development of her model (Roy, 2009) Nursing Theory