Nursing

Models and

Community as Client

EFFIE S. HANCHETT, RN; PHD* Each of the four nursing frameworks discussed here represents worldviews that result in different meanings of the concepts of health, community, and, therefore, of community health. Orem’s framework reflects a causal model of the community as an aggregate of individuals and a concept of health that is most akin to Smith’s clinical and functional levels of health. Roy’s model broadens to allow for consideration of the community as a system. The community as a system is perceived from the perspective of behaviors in response to stimuli. Causality is time ordered and linear, although one must consider the context of continuing time through the mechanism of feedback loops. Smith’s adaptive level of health is most congruent with this perspective. King’s conceptual framework views the community as a system interacting with the personal and interpersonal systems it includes. Causality is necessarily symmetrical within a systems approach. Health includes both role performance and adaptive levels of health. Finally, Rogers’ model considers the community as a field in itself. That field is one of awareness, is integral with the environmental field, and is acausal in nature. Health as expanding awareness is most similar to Smith’s eudaimonistic concept of health. It is proposed that these four frameworks reflect increasingly integrated conceptions of community health by which to guide public health/community health nursing practice. Both the American Public Health Association (1980) and the American Nurses’ Association (1980) have called for a synthesis of public health and nursing knowledge. In order to do this, it is appropriate that nursing frameworks and theories are used to guide nursing practice for clients. This is no less true when considering the community as the client of nursing services. Public health nursing has traditionally seen its major role in the areas of health promotion and disease prevention (Sha-

mansky and Clausen, 1980). Smith (1983) divided the concept of health into four levels: clinical, role performance (functional), adaptive, and eudaimonistic. The definitions of health given in each of the nursing models (Orem, 1985, 1987; Roy, 1984; King, 1981, 1983; Rogers, 1970, 1986) discussed here are roughly consistent with Smith’s four categories. These categories can then be used to specify approaches to public health/community health nursing practice that are congruent with each model. ’

Key Words: Nursing Frameworks, Community, Health, Nursing Received February 1, 1989 Accepted May 25, 1989 Wayne State University, Detroit, MI. *

Public health nursing has traditionally dealt with the needs of individuals in the community. The public health nurse generalist provides care to individuals and families. Specialists in public health nursing may focus on either program planning for aggregates of high risk individuals or on the health and wellbeing of the community itself. In the latter approach, the community is viewed as a whole. The quality of the relationships among individuals and groups within the community is seen as essential to community well-being. There is increasing interest in involvement in broad scale health policy by public health/community health nurses. This role requires recognition of the many forces operating within the community and its environment. The frameworks of four nurse theorists, Orem, Roy, King, and Rogers, provide a continuum of perspectives for public health/community health nurses to use. This continuum reflects the traditional range of approaches in public health/community health nursing.

The Four Frameworks

Orem, Roy, King, and Rogers have provided frameworks for nursing research and practice. Each of these four perspectives was developed for nursing in an effort to provide a means to distinguish the discipline of nursing from other disciplines. However, they do reflect the 67

Downloaded from nsq.sagepub.com at Purdue University on June 5, 2015

overall trends of the times.

knowledge development

of

Orem’s (1985) framework combines a causal model with the whole movement toward selfcare. The Roy adaptation model (1984) grew out of the stress-adaptation approach but combines it with a human development and inter-

approach. Roy’s theory places more emphasis on and allows more room for discreet physiological content than any of the others. King’s ( 1981 ) conceptual framework grew out of general system theory combined with knowledge and emphasis on human interaction. Rogers’ (1970, 1986) model also grew out of system theory and field theory and has evolved into a field theory approach to the action

Orem The model Orem’s (1985, 1987) framework is a mechanistic causal model. Persons, objects, and events are seen as separate phenomena. The , influence of one thing upon another is the cause of change. For example, the nurse acts in some way, such as teaching, and the client becomes more able to meet his/her own selfcare demands. The focus is on the person’s capacity to engage in self-care behaviors. Theoretical statements would then be time ordered causal statements, if they were to be consistent with the model.

human-environmental field. All four frameworks attempt to address the person as a whole. For Orem, the focus is on the actions and on the behaviors of the person, rather than on parts of the person. Differentiation of items to be addressed is based on those universal, developmental, and health deviation needs which require action in order for self-care demands to be met. For Roy (1984), the focus is on the person as an adaptive system with the cognator and regulator coping mechanisms. Differentiation of items to be addressed is based on the behavior of the person in each of four adaptive modes; physiological function, self-concept, role function, and interdependence. For King ( 1981 ), the focus is on human systems-individual systems, interpersonal systems, and social systems, and their interactions. Differentiation of issues to be addressed is made according to concepts relevant to human interaction at each of these system levels. Accuracy of perception, for example, takes on great importance in all areas of human interaction. For Rogers (1986), the person is seen as an energy field that is integral with an environment that has no boundaries. Differentiation of areas to be addressed is made according to

For Orem (1985) &dquo;Health ... a state of being sound or whole, is a state of human perfection that includes continuing human development&dquo; (Orem, 1985, p. 177). Structural and functional integrity receive the greatest emphasis in her discussion of health. Clinical health, as defined by Smith (1983), is &dquo;the absence of disease&dquo; (p. 46) whereas health as role-performance is &dquo;the ability to fulfill one’s central roles&dquo; (p. 56). These roles are later referred to as &dquo;familial or occupational roles&dquo; (p. 57). Structural and functional integrity within Orem’s model appears to be most consistent with Smith’s concept of clinical health. Although there is some overlap with the concept of health as role performance, there are greater connotations of self-care as function in Orem’s model, as contrasted with interaction with others and responsibility for their wellbeing within Smith’s definition of role performance. Orem’s (1985) model requires that the nurse look either at individuals or at the community as an aggregate of individuals. The interaction between individuals is relevant only from the perspective of one individual meeting self-care demands, for example, solitude and social in-

descriptors of pattern diversity, rhythms, motion, the experience of time, sleep-wake patterns, and the level of knowing participation

munity health would be the structural and



in

change.

Health, community, and community health

teraction.

Therefore,

according to

Orem’s model,

com-

functional integrity of the aggregate of individuals living within a given community. The is probably the one which is most consistent with the traditional use of biostatistical data from which most community assessments are done. It is most consistent with the role of the community health

aggregate approach

Community Health Nursing Each model is presented according to its (a) the relationship of persons, objects, and events; (b) concepts of health and community, and consequently, of community health; and (c) the elements of the nursing process. No one model is &dquo;best&dquo; for public health/community health nursing any more than behaviorism is better than humanism for view of

psychology.

generalist who deals with individuals or specialist who focuses on program planning for disease prevention in high risk aggregates. nurse

the

Nursing

process

The assessment process is focused on identifying the self-care deficits related to Orem’s

68

Downloaded from nsq.sagepub.com at Purdue University on June 5, 2015

extensive list of universal, developmental, and health deviation self-care requisites. Many of the universal self-care requi-

(1985)

sites deal with traditional cerns

water,

of or

maintaining

an

public health conadequate supply of

elimination of wastes. Nutrition and

developmental needs are also addressed. The assessment process, organized according to the content of the model, is developed around these specific self-care requisites and designed to identify the relationship between self-care capabilities and self-care demands. The outcome of the assessment is the identification of areas of self-care deficit calculated as therapeutic self-care demand and stated as

nursing diagnoses (Taylor, 1988). Intervendesigned to either: (a) increase selfcare capability, (b) decrease self-care demands, or (c) provide dependent care.

tions are

Roy The model Roy’s model (1984) is a mechanistic systems model. It is based on causality, but it is causality with a feedback loop. Therefore, it is more in the nature of &dquo;interactive causality&dquo; in a sequential, time ordered pattern. For Roy, persons, objects, and events are separate. Change is caused by responses to internal and external stimuli. Theoretical statements would be time ordered and causal. However, research designs would require recognition that the responses studied occur within an overall process that includes a feedback loop with information from the outcomes of previous behavior that serve as stimuli for subsequent behaviors.

be dealt with at the level of the community. Effectiveness of the community’s ability to obtain and monitor data and implement programs to control communicable disease or violence within its borders as a whole would be relevant within Roy’s model. These abilities of the community itself to recognize stimuli and regulate behaviors would not be relevant within Orem’s (1985) model. In Orem’s model, only the individual (either alone or as a member of an aggregate) is relevant as the focus for intervention. Roy’s approach is most consistent with that of the public health nurse specialist whose major focus is on the effectiveness of community responses to those factors which threaten the integrity of the tions

community.

Nursing process Nursing process according to Roy’s model (1984) focuses on the effectiveness or ineffectiveness of responses. The content areas within this focus include client behaviors, adaptive mechanisms, and focal, contextual, and residual stimuli. The outcome of the twolevel assessment is nursing diagnoses or problems. Interventions are designed to alter the stimuli or the responses to stimuli (Smith, 1988). For example, news of increasing spouse abuse might constitute a significant stimulus to the community. The public health/community health nurse would then work with community groups to increase the effectiveness of community behaviors designed to deal with this problem.

King

Health, community, and community health Health, for Roy (1984), is most consistent with Smith’s (1983) concept of adaptive health. It &dquo;is a process and a state of being and becoming an integrated and whole person&dquo; (Roy, 1984, p. 28). For Roy, health is the outcome of adaptation (which frees energy for the pursuit of goals). For Smith, adaptive health is &dquo;the condition of the whole person engaged in effective and fruitful interaction with the physical and social environment&dquo; (1983, p.

58).

Roy’s (1984) systems approach to the individual would result in a systems approach to the community. Community health would, therefore, be a state (condition) of the community and the community process of becoming integrated and whole. Integrity is meant in the sense of soundness or unimpaired condition. It might be assumed that this means the structure and function of the community as a whole. Roy’s (1984) framework, therefore, allows more focus on the community as client than does Orem’s approach. The world view is a little more integrated, in that community fung-

can

The model The focus of

King’s ( 1981 ) conceptual model dynamic interacting human systems. King’s perspective is that of living systems in contrast to mechanistic systems. Persons, objects, and events are seen as interrelated phenomena. Change occurs by means of interaction beis

components of the system. Theoretical statements would therefore be symmetrical, rather than time ordered. For example, greater accuracy of perception would be expected to be related to or correlated with a high level of quality of communication. tween



Health, community, and community health In her theory of goal attainment, King defined health as a state &dquo;that permits functioning in social roles&dquo; (1981, p. 142). This concept of health is most consistent with Smith’s (1983) role performance concept of health. For King, health is also &dquo;dynamic life experiences, which implies continuous adjustment to stressors through the optimum use of one’s resources to achieve maximum potential for daily living&dquo; (1981, p. 5). This definition is ...

69

Downloaded from nsq.sagepub.com at Purdue University on June 5, 2015

consistent with Smith’s tive health. more

statements would be acausal and not include an effect of linear time. (The pattern is more of a sunburst than a road.)

concept of adap-

King’s general system perspective logically

demands that the community be considered a system. Interactions among individuals, groups, and the larger social system as a whole are essential to understanding the community. This approach is more consistent with that of the community health nurse specialist whose approach to community health focuses on the interactions among community groups as the means to enhance community health. Community health would therefore be seen as the continuous adjustment to stressors through the optimum use of community resources to achieve maximum potential. Community &dquo;health, as a goal, is reached through purposeful activity of individuals and groups who function as open systems in the exchange of energy through information&dquo; (King 1983, p.

Health, community, and cornmunity health

Rogers (1986), health

is the dynamic individual or of the group. It is also well-being manifested as expanding awareness. Therefore, the dilemmas of labeling persons as healthy or unhealthy in light of disabilities or terminal illness is not relevant within her system. This definition of health is most consistent with Smith’s (1983) notion of eudaimonistic health. Health, in her eudaimonistic model, is defined as &dquo;the condition of complete development of the individual’s potential&dquo; (p. 87). Smith’s concept of eudaimonistic health, however, is meant to include all of the other levels of health. Therefore, Rogers concept of

For

186).

awareness is not entirely consistent with Smith’s notion of eudaimonistic

expanding

Nursing process The focus of nursing assessment, according to King’s conceptual framework, is that of human interactions and goals. The content of the assessment is organized according to concepts for each system level. Communication is one of the most salient concepts at all levels. The outcome of the assessment is goal-setting, rather than problems. This reflects King’s recognition of the power of ideas in influencing interactions and consequent outcomes of intervention. Nursing interventions are designed to facilitate the quality of interaction though increas-

ing the accuracy of perception, and/or the quality of communication. Racism, sexism, and ageism are frequently addressed issues in community health nursing. Stereotyping, according to any criteria: age, sex, ethnicity, culture, or socioeconomic group, is seen as a major barrier to effective communication. These factors affect participation in the health planning process and consequent allocation of resources. Dealing with underserved populations and interactions within or between groups are major areas of public health/community health nursing which lend themselves to being addressed within King’s conceptual framework. Rogers

_

health. &dquo;The community as a group of persons can be considered as an irreducible, four-dimensional energy field in itself and manifests its own

unique pattern&dquo; (Rogers, personal

com-

munication, April 19, 1986). It is a groupenvironmental field phenomenon: &dquo;The community field is integral with its own unique environmental field&dquo; (Hanche~t, 1988, p. 128). That is, neither individuals, groups, nor the community itself is seen as an isolated phenomenon. Rather, the community and its environment are

of

perceived as

one

integrated unit

dynamic activity.

Rogers’ (1986) definition of health as dynamic well-being, in concert with her idea of community as a group-environmental field process, results in the meaning of community health being the dynamic well-being of the group-environmental field process. The particular expressions of that process may reflect variations in well-being. Rogers’ worldview leads to a perspective of public health/community health that is highly congruent with a broad national or international health policy role.

Nursing process nursing process according to Rogers’ (1986) model would focus on the unfolding potential of the community. Content is orgaThe

according to manifestations of the community-environmental field process. The outcome of the assessment is a description of the developmental pattern. No interventions as such are proposed or described. They emerge out of the pattern of the nurse-communitynized

The model worldview provides an orgatheory perspective of reality. Per-

Rogers’ (1986) nismic, field

sons, objects, and events are seen as part of a unified field of awareness. Change is manifested in patterns of evolving awareness. Theoretical statements derived from this perspective would be descriptions of patterns. These

environment. However, the intent is that of increasing the level of awareness in the com-

munity’s knowing participation in change.

70

Downloaded from nsq.sagepub.com at Purdue University on June 5, 2015

groups for the health of the community

Conclusion

as a

whole.

It is proposed that each of the nursing models in the order of discussion presents progressively higher level concepts of health as defined in Smith’s (1983) four categories of health, and that the four frameworks provide a continuum of increasingly integrated views. The level of integration of the view provided by each model is associated with the scope of (a) definition(s) of health it provides (clinical to eudaimonistic) and (b) the concept of community (aggregate mechanistic system, human system, or human-environmental field) and, therefore, (c) the resulting concepts of community health. The notions of community health, consequently, &dquo;can run the gamut from clinical health of the aggregate to dynamic well-being and expanding awareness&dquo; of the community environmental field (Hanchett, 1988, p. 10). The underlying concept of the totality paradigm was modified to reflect a continuous, rather than Parse’s (1987) categorical, approach. (Although many would disagree with the validity of a continuous rather than a categorical approach to integration.) For Orem ( 1985), the world is time ordered and causal. It is made up of individuals who are separated in space and time, and who are relevant primarily in terms of their own ability to be independent in meeting their self-care demands. Admittedly, self-care demands include inter- . action with others. However, the center of relevance is self. One element acts upon another element in order to create change. Health is most closely akin to clinical and functional models of health. Community health is the lack of illness and the presence of self-care abilities among the aggregate. For Roy (1984), the person and the environment act upon each other through the mechanisms of stimuli and behaviors. There is increased recognition of the environment, although it is relevant primarily as the source of stimuli to the person. A time ordered causality is moderated by the feedback loop of the effect of the person’s behaviors on the environment and the environmental response that serves as a further stimulus to the person. Health is adaptive health. Community health includes the ability of community mechanisms to respond effectively to stimuli. King’s ( 1981 ) conceptual framework focuses specifically on interactions between persons, groups, and social systems. It is the human environment that is most relevant from King’s perspective. The interaction between persons and groups of persons is the focus for nursing knowledge. Causality would necessarily be symmetrical. Health includes both role performance and adaptive health. Community health focuses on the interaction between I

Rogers’ (1986) model provides a view of reality as an integrated field of awareness. In such impossible to consider any individ(self or other) as the center of that reality. Causality and linear time are not relevant a

view it is

ual

within her perspective. The eudaimonistic concept of health as expanding awareness is coupled with the concept of the communityenvironmental field. Rogers’ perspective is most congruent with the community health nurse specialist whose focus is on increasing conscious participation of the community and environment. If one is content to deal with the community

aggregate of individuals, Orem’s (1985) perspective is relevant. Traditional biostatistas an

ical data, the numbers of life events of individuals, provides no inconsistency within Orem’s

framework. Accountability for the health of the community requires recognition of the effect of the community on the individual. Stimuli such as natural disasters or a threatened plant closing, for example, take on increasing relevance. In that case, a model that demands recognition of the influence of the environment on the welfare of the community as a community is required. Roy’s (1984) model allows for consideration of stimuli and responses. Furthermore, if the impact of human interactions on human health

and/or well-being

vant to community health,

accepted as releKing’s ( 1981 ) model

is

provides the concepts around which to organize material related to human interactions. Finally, if one sees the world in a way which

recognizes ena,

then

the

integral nature Rogers’ perspective

of all

phenom-

is most appro-

priate. Despite

these apparent differences, howthe human being is the focus for knowledge and practice in all models. Health, rather than disease, is the goal of nursing in all models. A community event, or community problem, should bring a response from public health nurses, no matter what model is used. The differences would be in the determination of what is relevant to nursing from the perever,

spective health

of the model used to

guide public

nursing practice.

In conclusion, all four models contribute to the understanding of community health from a nursing perspective. Public health/community health nursing practices range from that of the generalist who focuses on individuals through the specialist who deals with high risk aggregates within the community or with the community itself as the client of care. Although each professional nurse must base her practice on the nursing model that he/she judges to be most useful, the four models presented provide direction for different ap71

Downloaded from nsq.sagepub.com at Purdue University on June 5, 2015

proaches to public health/community nursing practice and research. References American Public Health Association. (1980). The definition and role of public health nursing in the delivery of health care. Washington, DC: Author. American Nurses’ Association. (1980). A conceptual model of community health nursing. (Publication No. CH-10 2M 5/80). Kansas City, MO: Author. Hanchett, E. S. (1988). Nursing frameworks and community as client. Norwalk, CT: Appleton & Lange. King, I. M. (1981). A theory for nursing. New York: Wiley. King, I. M. (1983). King’s theory of nursing. In I. W. Clements & F. B. Roberts (Eds.), Family Health: A theoretical approach to nursing care (pp. 177-188). New York:

Wiley. Orem, D. E. (1985). Nursing concepts of practice (3rd ed.). New York: McGraw-Hill.

Orem, D. E. (1987). Orem’s general theory of nursing. In

R. Parse, Nursing science: Major paradigms. theories. and critiques (pp. 67-89). Philadelphia: Saun-

R.

ders.

Parse, R. R. (1987). Nursing science: Major paradigms, theories, and critiques. Philadelphia: Saunders. Rogers, M. E. (1970). An introduction to the theoretical basis of nursing. Philadelphia: Davis. Rogers, M. E. (1986). Science of unitary human beings. In V. L. Malinski (Ed.), Exploration on Martha Rogers’ Science of Unitary Human Beings (pp. 3-8). Norwalk, CT: Appleton-Century-Crofts. Roy C. (1984). Introduction to nursing: An adaptation model (2nd ed.). Englewood Cliffs, NJ: Prentice Hall. Shamansky, S. L., & Clausen, C. L. (1980). Levels of prevention : Examination of the concept. Nursing Outlook

28, 104-108. Smith, J. A. (1983). The idea of health. New York: Teachers

College Press.

Smith, M. C. (1988). Roy’s adaptation model in practice.

Nursing Science Quarterly, 1, 97-98. Taylor, S. G. (1988). Nursing theory and nursing process: Orem’s theory in practice. Nursing Science Quarterly, (3), 111-119. 1

72

Downloaded from nsq.sagepub.com at Purdue University on June 5, 2015

Nursing models and community as client.

Each of the four nursing frameworks discussed here represents worldviews that result in different meanings of the concepts of health, community, and, ...
623KB Sizes 0 Downloads 0 Views