Organizing Frameworks applied to Community Health Nursing

Community Assessment and Nursing Diagnosis, Data Collection, Analysis and Synthesis

By the end of this lecture you will be able to: explain what is meant by a theory

and a model of nursing understand the main features of at

least two models of nursing understand how to critically review

a model Identify how the application of

models to practice influences the activity of the nurse and the experience for the patient or client

Additional References………….

Models of nursing practice. McGee P. Stanley Thornes 1998

Conceptual bases of professional nursing. Leddy S. Pepper J. Lippincott 4th ed.. 1998

Foundations of nursing practice. Hogston R & Simpson P. Macmillan 1999 (Ch 14)

Nature of theory:

“represent a scientist’s best effort to describe and explain phenomena”

Pollitt & Hungler 1997

Theory……

“…is a general statement that summarizes and organizes knowledge by proposing a general relationship between events - if it is a good one it will cover a large number of events and predict events that have not yet occurred or been observed”

Robson C.

“an internally consistent group of relational statements (concepts, definitions & propositions) that present a systematic view about phenomenon and that is useful for description, explanation, prediction and control. A theory ….is the primary means of meeting the goals of the nursing profession concerned with a clearly defined body of knowledge”Walker & Avant 1996 (cited by Jasper M in Hogston & Simpson))

Purpose of theory

Support the development of knowledge through thesis and contestability

Explains and predicts outcomes Supports decision making Embeds goals and outcomes for the

client and by implication for the nurse Supports modeling of processes of

nursing

Classifying theories

Meta-theory (Theory building - values etc) Grand theory (Broad conceptual

frameworks - not testable e.g. Leininger theory of transcultural care)

Middle range theory (Narrower and testable e.g. Peplau)

Practice Theory (situational theory - focuses on the way in which nursing is practised e.g. Norton’s theory of nursing elderly people)

Typology:

Descriptive theory: Explains through describing relationships and patterns within the framework (e.g. Roper et al)

Predictive Theories: Address the consequences of interventions (e.g. Noddings theory of care)

The medical model

Bio-reductionist Differential diagnosis: signs &

symptoms Provision of treatment Scientific theory - testable and not

contestable Goals - cure and therapy Evaluation of treatment efficacy

Nursing models

Located in social science Constructed Contestable knowledge Capable of change and

development Embed values and culture

What sort of theories would you use?

Tony Archer (18 years) underwent surgery to have a below knee amputation of his left leg

Peggy Mountford is 82 years old, lives alone with no family and is becoming increasingly confused and depressed

What sort of theories did you identify?

Physiology Psychology Sociological theory Nursing theories Descriptive theory Predictive theory

Metaparadigm: constructs in all nursing theories

The person the environment health nursing

Commonly used models

Roper, Logan & Tierney (ADL) Peplau (interpersonal

communication) Orem (Self-Care) Roy (adaptation model) Wolfensberger (social role

valorisation) Carper (personal explanations)

Roper, Logan & Tierney Developmental model - emphasises

growth & development Person oriented Focus on change Sees process over time Sees a range of activities of daily

living changing with maturation Supporting and enabling Draws on Henderson’s work strongly

Callister Roy’s model Systems model - person is made up of

systems Systems interact with the

environment Health is equilibrium and managed

systems Nursing is supporting adaptation to

environment Is holist, purposeful and unifying Adaptive modes: physiologic, self

concept, role function, interdependence

Health is a process of responding positively to environmental changes

Model and Nursing Model

A conceptual model

A nursing model is a representation of nursing, not a reality.

A nursing model is an abstract of reality from the nursing perspective.

The purpose of nursing model (1)

Provide a map for the nursing process

*Guide assessment (What do you assess?)

*Guides analysis *Dictates nursing diagnoses *Assists in planning *Facilitates evaluation

The purpose of nursing model (2)

Provide a curriculum outline for education

Represents a framework for research Provides a basis for development of

theory A model not only describe what is but

also provides a framework for making decisions about what would be.

Community-as-partner model Neuman’s model of a total-person approach

Community-as-client model: public health and nursing

Community-as-partner model: primary health care with two central factors

The first factor the focus on the community as partner represented by the community assessment wheel at the top.

The second factor is the use of nursing process.

The core of assessment

People who make up the community

*Demographic data *Values, beliefs, and history

Lines of defense

Normal line of defense: level of health of a community

Eight subsystems

Flexible line of defense: a buffer zone of a community

The selection of eight subsystem

Examining the selection of subsystems that have been identified. Can you think of any that have been omitted?

Line of resistance Line of resistance: community’s strength

Stressors: tension-producing stimuli

The degree of reaction: the amount of disequilibrium or disruption that results from stressors impinging on the community’s lines of defense.

Analyze data Compare and contrast your data

with the neighbor areas and the national data.

Compare and contrast your data for 3 to 5 years.

Interpret your data

Nursing diagnosis Stressors and degree of reaction

become part of the community nursing/health diagnosis (health problem).

Example: the increased rate of respiratory illness (a degree of reaction) related to air pollution (a stressor)

Stressors leading to??

The outcome of a stressor impinging on a community is not always negative. Can you think of an example that stressors may lead to positive outcomes?

Community health diagnosis (1)

Comparing nursing diagnosis and community health diagnosis (see handout)

Community health diagnosis is preferred over community nursing diagnosis

Community health diagnosis (2)

The community health diagnosis gives direction to both nursing goals and its interventions.

The goal is derived from the stressors

The goal may include * the elimination or alleviation of the stressor * strengthening of the community’s resistance

through strengthening the lines of defense.

Community health diagnosis (3)

The goal should state the degree of reaction

Intervention

Three modes of prevention: primary prevention, secondary prevention, and tertiary prevention

Primary vs. tertiary prevention

In the case of 921 earthquake will you give an example of primary vs. tertiary prevention?

Evaluation

Feedback from the community

Final note Health may not be a primary goal of the

community, It is, however, an important resource for the community to meet its goals.

The consequences intended in this model include a strengthened normal line of defense, increased resistance to stressors, and a diminished degree of reaction to stressors by the community.