UNIT 2

Nursing theories

- help guide and define nursing care

- provide a foundation for clinical decision-making

- some have been around for hundreds of years in public health but many are still being used in today's hospitals and healthcare settings

Metaparadigm

- a set of ideas that provide structure for how a healthcare discipline should function

- In nursing, this refers to the four main concepts that are tied to nursing theory

Metaparadigms of Nursing

1. Person

2. Health

3. Environment

4. Nursing

Person

- receiver of care, as well as the people in their life, and takes into consideration the patient's social, spiritual, and healthcare needs

- The theory is that a person can be more empowered to manage their health when they have positive personal connections

Health

realizes the multiple factors that go into a patient's well-being—including physical, emotional, intellectual, spiritual, and social components—and how they can be integrated to achieve maximum health outcomes

Environment

- focuses on the surroundings that affect the patient and how those surroundings can influence their health and wellness

- It theorizes that a person can alter their environment to improve their health

Nursing

- recognizes the relationship between a nurse and patient

- It focuses on the nurse's role in providing a safe and caring environment and values the high degree of service necessary to provide the best patient health outcomes

Three Levels of Nursing Theories

1. Grand Nursing Theories

2. Middle-Range Nursing Theories

3. Practice-Level Nursing Theories

Grand Nursing Theories

- any theory based on broad, abstract, or more complex concepts will fall under this category

- typically provide a high-level framework for nursing ideas rather than diving into the details

Middle-Range Nursing Theories

- get into more specific areas of nursing as opposed to grand theories

- can come from day-to-day nursing practice, research, or from theories of similar disciplines

Practice-Level Nursing Theories

- Theories categorized in this level are the most focused.

- They deal with very situation-specific concepts that are narrow in scope and home in on a specific patient population.

Importance of Nursing Theories

- provide a foundation for all professions, and health care theories provide the same foundation for nursing students and professionals

- As the field of nursing continues to grow, theories are key in structuring patient care

- Provide nurses with rationale in making healthcare decisions

- Guide evidence-based research, which then leads to best practices and policies

Importance of Nursing Theories

- Help nurses evaluate patient care

- Give nurses a better understanding of their purpose and role in a healthcare setting

- Ensure nursing best practices are being used

- Provide an identity to nurses that differentiates nursing practice from the medical practice

- Help patients and other healthcare professional recognize the contribution nurses make

Importance of Nursing Theories

- provides nurses with a perspective with which to view client situations, a way to organize the hundreds of data bits encountered in the day-to-day care of clients, and a way to analyse and interpret the information

Theoretical Perspective

allows the nurse to plan and implement care purposefully and proactively

fit

- between the philosophical assumptions of the organization and the theory

- Example: Hospice care illustrates the excellent 'fit' between an existing philosophy of care and theory-based nursing practice. The 'fit' is based on the similarity of the philosophical assumptions of hospice and the nursing theory of modelling and role-modelling

6 basic elements of nursing practice

(1) promotion of healthful living;

(2) prevention of health problems;

(3) treatment of disorders;

(4) rehabilitation;

(5) evaluation; and

(6) research.

7 major roles of a CHN

(1) care provider;

(2) educator;

(3) advocate;

(4) manager;

(5) collaborator;

(6) leader; and

(7) researcher.

6 Categories of CHN Settings

(1) homes;

(2) ambulatory care settings;

(3) schools;

(4) occupational health settings;

(5) residential institutions; and

(6) the community at large.

**Community health nursing practice is not limited to a specific area, but can be practiced anywhere.

Theories And Models For CHN

1. Nightingale's theory of environment

2. Orem's Self care model

3. Neuman's health care system model

4. Roger's model of the science and unitary man

5. Roy's adaptation model

Theories And Models For CHN

6. Mark Salmon White's Construct for Public health nursing

7. Derryl Block and Lavohn Josten's Ethical Theory of population focused nursing

8. Canadian Model - The community health nursing process involves the traditional nursing process but is enhanced by community health nurses.

9. General systems theory

10. Social Learning Theory

Theories And Models For CHN

11. Health Belief Model

12. Nancy Milio's Framework of Prevention

13. Nola Pender's Health Promotion Model

14. The Transtheoretical Model

15. Self-Efficacy Theory

16. Precede-Proceed Model

General Systems Theory

- by Karl Ludwig von Bertalanffy

- came to relate to finding a general theory to explain all systems in all scientific fields

- emerged as a corollary of biological studies

- theorists first analyzed ecological systems in nature then subsequently applied the basic logic of systems to non-ecological phenomena

Karl Ludwig von Bertalanffy

- an Austrian biologist

- one of the early founders of general systems theory

- "There exist models, principles, and laws that apply to generalized systems or their subclasses, irrespective of their particular kind, the nature of their component elements, and the relations or 'forces' between them." "It seems legitimate to ask for a theory, not of systems of a more or less special kind, but of universal principles applying to systems in general."

Academic Kids

- "Early systems theorists aimed at finding a General systems theory that could explain all systems in all fields of science. The term goes back to Bertalanffy's basic work 'General Systems Theory'."

- "Sociologists like Niklas Luhmann also worked towards a general systems theory, but as of today no systems theory can live up to this claim."

General Systems Theory

- hypothesis: there is a basic logic within every system

- proposes that complex systems share several basic organizing principles

- focuses on the structure of systems rather than what they do

- focuses on the relationships between and arrangement of the parts which connect them into a whole

- proposes that the same concepts and principles of organizations underlie different disciplines

General Systems Theory

- provides a basis for the unification of biology, chemistry, physics, sociology, management, psychotherapy, etc.

- concepts include process, output, input, system- environment boundary, and goal-directedness. The concepts also include information as well as hierarchy

- proposes that the structure of any system is often as important in determining its behavior as its individual components.

Social Learning Theory

- Suggests that social behavior is learned by observing and imitating the behavior of others

- by Albert Bandura

- put forth that individuals can learn behavior through observation

4 Elements of Social Learning Theory

1. Attention

2. Retention

3. Reproduction

4. Motivation

Attention

- The degree to which we notice the behavior.

- A behavior must grab our attention before it can be imitated.

- Considering the number of behaviors we observe and do not imitate daily indicates attention is crucial in whether a behavior influences imitation.

Retention

- How well we remember the behavior.

- We cannot perform the behavior if we do not remember the behavior. So, while a behavior may be noticed, unless a memory is formed, the observer will not perform the behavior. And, because social learning is not immediate, retention is vital to behavior modeling.

Reproduction

- The ability to perform the behavior.

- the ability to reproduce a behavior we observe.

- It influences our decision about whether to try performing the behavior. Even when we wish to imitate an observed behavior, we are limited by our physical abilities.

Motivation

- The will to emulate the behavior.

- This mediational process is referred to as vicarious reinforcement.

- It involves learning through observing the consequences of actions for other people, rather than through direct experience.

Rewards and Punishment

- studied in addition to the behavior

- studied by the observer

- If the observer perceives the rewards to be greater than the costs (punishment) then they will most likely imitate the behavior. If, however, the vicarious reinforcement is not valued enough by the observer, they will not model the behavior.

Assumptions of Social Learning Theory

- People learn through observation.

- Reinforcement and punishment have indirect effects on behavior and learning.

- Mediational processes influence our behavior.

- Learning does not necessarily lead to change.

Health Belief Model (US Public Health Service)

- A social psychological health behavior change model developed to explain and predict health-related behaviors, particularly in regard to the uptake of health services.

- developed by social psychologists at the U.S. Public Health Service

- one of the best known and most widely used theories in health behavior research

- suggests that people's beliefs about health problems, perceived benefits of action and barriers to action, and self-efficacy explain engagement (or lack of engagement) in health-promoting behavior

- stimulus, or cue to action, must also be present in order to trigger the health-promoting behavior

Framework of Prevention

- by Nancy Milio

- includes concepts of community-oriented, population focused care

- The basic treatise is that behavioral patterns of populations and individuals who make up populations are a result of habitual selection from limited choices.

- challenged the common notion that a main determinant for unhealthful behavioral choice is lack of knowledge.

- Governmental and institutional policies set the range of options for personal choice making. It neglected the role of community health nursing, examining the determinants of community health and attempting to influence those determinants through public policy.

Health Promotion Model

- by Nola J. Pender

- Complementary counterpart to models of health protection

- defines health as a positive dynamic state rather than simply the absence of disease

- Health promotion is directed at increasing a patient's level of well-being

- describes the multidimensional nature of persons as they interact within their environment to pursue health

3 Areas of Health Promotion Model

- individual characteristics and experiences,

- behavior-specific cognitions and affect, and

- behavioral outcomes.

Health Promotion Model

- The theory notes that each person has unique personal characteristics and experiences that affect subsequent actions. The set of variables for behavior specific knowledge and affect have important motivational significance. The variables can be modified through nursing actions. Health promoting behavior is the desired behavioral outcome, which makes it the end point

- These behaviors should result in improved health, enhanced functional ability and better quality of life at all stages of development. The final behavioral demand is also influenced by the immediate competing demand and preferences, which can derail intended actions for promoting health.

4 Assumptions of Health Promotion Model

- Individuals seek to actively regulate their own behavior.

- Individuals, in all their biopsychosocial complexity, interact with the environment, progressively transforming the environment as well as being transformed over time.

- Health professionals, such as nurses, constitute a part of the interpersonal environment, which exerts influence on people through their life span.

- Self-initiated reconfiguration of the person- environment interactive patterns is essential to changing behavior.

Transtheoretical Model/Stages of Change Model

- Developed by Prochaska and DiClemente

- focuses on the decision-making of the individual and is a model of intentional change

- operates on the assumption that people do not change behaviors quickly and decisively. Rather, change in behavior, especially habitual behavior, occurs continuously through a cyclical process

- not a theory but a model

6 stages of change

- precontemplation

- contemplation

- preparation

- action

- maintenance

- termination

*For each stage of change, different intervention strategies are most effective at moving the person to the next stage of change

Termination

not part of the original model and is less often used in application of stages of change for health-related behaviors

Precontemplation

- people do not intend to take action in the foreseeable future (defined as within the next 6 months)

-People are often unaware that their behavior is problematic or produces negative consequences. People in this stage often underestimate the pros of changing behavior and place too much emphasis on the cons of changing behavior.

Contemplation

- people are intending to start the healthy behavior in the foreseeable future (defined as within the next 6 months).

- People recognize that their behavior may be problematic, and a more thoughtful and practical consideration of the pros and cons of changing the behavior takes place, with equal emphasis placed on both.

- Even with this recognition, people may still feel ambivalent toward changing their behavior.

Preparation/Determination

- people are ready to take action within the next 30 days.

- People start to take small steps toward the behavior change, and they believe changing their behavior can lead to a healthier life.

Action

- people have recently changed their behavior (defined as within the last 6 months) and intend to keep moving forward with that behavior change.

- People may exhibit this by modifying their problem behavior or acquiring new healthy behaviors.

Maintenance

- people have sustained their behavior change for a while (defined as more than 6 months) and intend to maintain the behavior change going forward.

- People in this stage work to prevent relapse to earlier stages.

- ideal stage of behavior

Termination

- people have no desire to return to their unhealthy behaviors and are sure they will not relapse.

- Since this is rarely reached, and people tend to stay in the maintenance stage, this stage is often not considered in health promotion programs.

Self-Efficacy Theory

- by Albert Bandura

- A personal judgment of how well or poorly a person is able to cope with a given situation based on the skills they have and the circumstances they face

- A strong sense of self efficacy promotes human accomplishment and personal well-being. A person with high self-efficacy views challenges as things that are supposed to be mastered rather than threats to avoid. In contrast, people with a low sense of self-efficacy view difficult tasks as personal threats and shy away from them. Low self-efficacy can be linked to higher levels of stress and depression.

Theoretical Approaches of Self-Efficacy Theory

1. Social Cognitive theory

2. Social Learning theory

3. Self-concept theory

4. Attribution theory

Sources of Self-Efficacy

1. Mastery Experiences

2. Vicarious Experiences of Social Models

3. Belief in Success

How self-efficacy affects human function

1. Choices regarding behavior

2. Motivation

3. Work performance

4. Thought patterns and responses

5. Health behaviors

6. Relationship it locus of control

Factors affecting self-efficacy

1. Experience, or "enactive attainment"

2. Modeling, or "vicarious experience"

3. Social persuasion

4. Physiological factors

Precede-Proceed Model

- by Lawrence W. Green

- A cost-benefit evaluation framework that can help health program planners, policy makers and other evaluators, analyze situations and design health programs efficiently.

- One purpose and guiding principle is to direct initial attention to outcomes, rather than inputs. It guides planners through a process that starts with desired outcomes and then works backwards in the causal chain to identify a mix of strategies for achieving those objectives

Fundamental Assumption of Proceed-Precede Model

the active participation of its intended audience — that is, that the participants ("consumers") will take an active part in defining their own problems, establishing their goals and developing their solutions.

Precede-Proceed Model

a comprehensive structure for assessing health needs for designing, implementing, and evaluating health promotion and other public health programs to meet those needs.

Precede

- provides the structure for planning a targeted and focused public health program

- stands for Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation.

Precede Assessment

- Social assessment

- Epidemiological assessment

- Ecological assessment

- Identify administrative and policy factors that influence implementation and match appropriate interventions that encourage desired and expected changes.

- Implementation of interventions.

Social Assessment

Determine the social problems and needs of a given population and identify desired results.

Epidemiological Assessment

Identify the health determinants of the identified problems and set priorities and goals.

Ecological Assessment

Analyze behavioral and environmental determinants that predispose, reinforce, and enable the behaviors and lifestyles are identified.

Proceed

- provides the structure for implementing and evaluating the public health program

- stands for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development

Proceed

involves the identification of desired outcomes and program implementation:

- Implementation

- Process Evaluation

- Impact Evaluation

- Outcome Evaluation

Implementation

Design intervention, assess availability of resources, and implement program.

Process Evaluation

Determine if program is reaching the targeted population and achieving desired goals.

Impact Evaluation

Evaluate the change in behavior.

Outcome Evaluation

Identify if there is a decrease in the incidence or prevalence of the identified negative behavior or an increase in identified positive behavior.

Implementation Considerations of Proceed-Precede Model

- The PRECEDE-PROCEED model provides a structure that supports the planning and implementation of health promotion or disease prevention programs.

- This model has worked well for many health promotion topics, and can effectively support one-time interventions or long-running programs.

- Like the Community Readiness Model, PRECEDE- PROCEED invites participation from community members, and has the potential to increase community ownership of the program.

Implementation Considerations of Proceed-Precede Model

- When determining whether to use PRECEDE-PROCEED as a model for health promotion or disease prevention programs, it is important to consider whether all parts of the model are appropriate for the program and the resources available to support implementation.

- It is also important to remember that components of the plan may be adapted over time, as needed.