Journal of Advanced Nursing, 1990,15, 659-666
The e£Fect of Orem's self-care model on nursing care in a nursing home setting J FaucettRNPhD Assistant Chnical Professor, School of Nursing, Umversity of Caltfomta, San Francisco
V Ellis RN MS Clinical Nurse Speaalist, Veterans Administration Medical Center, Palo Alto
P Underwood RN DNS Clmical Professor. School of Nursmg, Umverstty of California, Sanfranctsco
A NaqviRNMS Assistew/ Chef Nurse, Veterans Administration Medical Center, Palo Alto
and D Wilson RN MN Co-ordtnator— Nursing Home Care Unit, Veterans Administration Medical Center, Palo Alto, California, USA
Accepted for publicahon 23 August 1989
FAUCETT J, ELLIS V, UNDERWOOD P, NAQVl A & WILSON D
(1990) Journal of Advanced Nursing 15, 659-666 The effect of Orem's self-care model on nursing care in a nursing home setting The need of the functionally disabled for nursmg care is a primary rationale for lnshtuhonahzahon m long-term care settings However, mamtenance of the selfcare abilities that nursmg home residents retam is an important component of their quality of life Nurses are m an important position to encourage and sustam residents' abihties to participate m their care Nevertheless, without specifying the role of the resident m care, nursmg mterventions may madvertently reinforce dependency and apathy at the expense of autonomy, control and well-being Data from nursmg home care records and interviews suggest that nursmg staff usmg Orem's Self-Care Dehat Nursmg Theory differ m their nursmg assessments and goals of care from staff on a control unit Further study is recommended of the influence of the model on staff perspectives of care and on mterventions which support nursmg home residents' self-care ability and well-bemg
INSTITUTIONALIZ ATION ,
,
ability for deasion-making (Goffman 1961, Wack & Rodin 1978) The maintenance of personal control among nursing
Admission to a 'total institution such as a nursing home v-iuiiussiuu lu a luiai " '^ ^^ i . increases the nsk of the syndrome or lnstitutionalization .wicu u USA P
,
^
^
allowing residents t o make deasions (Ryden 1985)
659
7 FauceH et al
independent behaviour Constraints related to care delivery structure as well as individual nursing perspechves about the pahent role m care may effect staff behaviour (Miller 1985, Wack & Rodin 1978) Pnonties and standards for daily-care deasions and delivery are lnffuenced by values, beliefs and athtudes m the care setting Beliefs about the goals of care m long-term settings differ from those in acute care The assessment of functional ability is valued on admission to a nursing home because it determmes the initial needs for nursing care and because it is reinforced by reimbursement and accreditation structures (Adams & Schlenker 1986, Fnes & Conroy 1985, Wack & Rodin 1978) When rewards of mcreased staffing are related to care-dependency levels or where mstituhonal accountability structures for the post-admission preservahon of functional abihty are lackmg, maintenance of the resident's self-care independence depends highly on the shared values of unit staff dehvenng the care (Kahana & Kiyak 1984, Miller 1985) The implementation on a nursing unit of a model emphasizmg self-care abihty and individual care demands may highlight the importance of maintaining or enhanang the resident's capability for mdependent behaviour and partiapation m care The purpose of the present study was to determine whether the lmplementahon of Orem's Self-Care Defiat Nursmg Theory (S-CDNT) (Orem 1985) alters the perspectives of staff canng for nursing home residents by changing the nature of nursmg assessments and patient-care goals
caregivers stated that they preferred increased control by residents, they were not found to support mdependence Observahonal studies have indicated that nursing staff selechvely reinforce dependent behaviour by residents and Ignore attempts at mdependent eatmg, dressing and toilehng(Baltesefa/ 1983, Miller 1984) Baitesetal (1983) additionally found that constructively-engaged activity by the resident was not consistently reinforced while nonengaged activity tended to receive no response at all Thus, achvihes related to indep)endent self-care, lncludmg appropnate sohtude and social mteraction, are less likely to eam reinforcement fi-om nursmg home staff than dependence and compliance Miller (1985) demonstrated that individualized nursing care, as opposed to task-allocation nursmg, significantly affected mortality as well as dependency, apathy, communication difficulhes, social disturbance and incontinence She suggested that the reduchon of nurse-induced dependency related to both structural and attitudmal factors would improve the quality of care of nursmg home residents (Miller 1984,1985) In the larger project from which the current study is drawn, Naqvi & Wilson (1988) demonstrated significantly less depression, apathy and communication dif&culhes over hme for nursing home residents receiving care from staff uhlizing Orem's S-CDNT model (Orem 1985) compared to a similar control group receiving routine nursing care Theirfindingssuggested that residents on the experimental umt suffered less from the effects of lnshtutionalizahon due to the implementation of the S-CDNT The current study seeks to validate their conclusions
The problem of institutionalization This study is part of a larger intervention study concemed vnih patient outcomes of lnshtutionalizahon m a nursing home setting Total institutions such as pnsons, the inihtary or state hospitals regulate and orgaruze basic hfe achvihes by group needs as opposed to individual ones Rewards, pnvileges and pumshments evolve m support of the aims and rules of orgaiuzahon of these inshtutions The milieu that anses from categoruong and idenhfjong individuals by homogeneous charactenshcs, treatmg them coUechvely, and assuming deasional authonty over broad aspects of daily life predisposes inmates, soldiers and pahents to depersonalizahon and dependence (Goffinan 1961) Ryden (1985) reported that prc^essional caregivers in nursmg home settmgs view themselves as the predominant deasion-makers regarding the eating, toileting, grocmung and dressing achvihes of pahents, while achvihes related to one-to-one mterachons and solitude were seen as more under the control of tiie nursmg home resident Although 660
INFLUENCING THE NURSING PROCESS Gordon (1982) has conceptualized the nursing process as a problem-identificahon and problem-solving process Problem ldenhfication is further sub-divided mto information gathering, diagnoshc judgement and labellmg In prachce, the nursing care perspechve of the individual staff member influences the collechon and mterpretahon of lnfomiahon and clinical deasion-making (Gordon 1982) Thus, the observahon of salient cues, clmical judgements about signs and symptoms and the ldenhfication of pahent problems vary with the values, beliefs and athtudes of the individual prachhoner Nurses prachsing in the nursing home settmg may not always be able to identify what underlies their working hypotheses about pahent problems or nursing soluhons As a result, their approaches to care may differ horn time to tune or from the approaches of other staff members, diminishing continuity and consistency of care A urut staff using an agreed-upon nursing model to discuss nursing
Nursmg process
Table 1 Orem's universal requisites of self-erspechves observed anecdotally by researchers on the two units or revealed by the interviews, six case vignettes were developed post hoc from the care records Dunng the staff mterviews, nurses selected resident cases m order to exemplify care delivery on their own uruts From these descnphve data, it was possible to ldenhfy three pahents from each unit Vignettes were then develof>ed from the
care records for the 6-inonth time penod under analysis All nursmg care data recorded for each pahent were summarized m the vignettes The six vignettes were reviewed by four nationally recognized experts m Orem's S-CDNT Each expert was asked to select which of the six vignettes was drawn from the expenmental unit and which from the control unit The experts correctly and unanimously agreed on four of the vignettes Votes on the other two, one from each of the units, were equivocal Two representahve case vignettes are presented below Representative case vignette from the experimental unit
M A IS 72-year-old white widowed former salesman with less than a high school education who was admitted to the NHCU 3 years ago followmg a CVA which has left him with lefbsided hemiparesis He also has a history of ulcers Although MA. reportedly suffers from dunmished appetite, he is a heavy man with little interest m weight loss His daughter, who is a nurse, visits at mealtimes He remams a smoker with a notable wheeze He uses a unnal without difficulty and wears a diaper to protect agamst acadents He needs assistance to go to the toilet for a bowel movement 663
/ J^uce^etal
He IS able to wash his upper body and face and shaves himself He needs assistance, which his daughter frequently provides, tofinishhis hygiene and to dress A reported goal of care is the mamtenance of his {jersonal-hygiene skills He sleeps well at night and naps occasionally His ability to transfer has recently diminished despite physical exerases He IS weak and unstable, weanng a knee brace that helps with transfers He IS a pleasant man, but reserved He is pnmanly a loner, although he hkes sports and likes to watch television He has a notable problem asking for help, e g he will not repwrt knee pam but will acknowledge it when asked The staff feel he would benefit from attendmg resident soaal events such as current-events discussions and a stress-management group He tends to procrastinate attendance at these events and requires encouragement Self-care summary This man tends to rely on his daughter for assistance and for soaalization He manages his care without askmg for help, even when help would minimize his discomfort Staff feel he would benefit from broadening his soaal mteraction with other residents and encourage group partiapation. Addihonally, staff actively support his self-care capability m hygiene
may clarify the philosophy and role of nursing, provide a common language leading to improved commurucahon and enhance consistency m care delivery and consensus about the goals and outcomes of nursmg (Chinn & Jacobs 1983, Meleis 1985) Addihonally, the process of implementatmg such a model may encourage discussion and analysis of the perspechves on care delivery held by nurses practismg withm a settmg This study sought to determine whether the lmplementahon of Orem's S-CDNT model m prachce would influence nurses' perspectives to be more consistent with the promotion of resident self-care abibty Due to the preliminary and exploratory nature of the study, findmgs must be considered only suggeshve In what they verbally report about their work, nurses from the experimental unit appear to utilize the language and SCDNT concepts consistently, to assess more comprehensive data about the personal capabihhes of residents, and to arhculate more speafic and more vaned roles for resident partiapahon m care Nonetheless, m documented data, they resemble control group nurses m the problem areas they idenhfy, m situations m which they chose to intervene and in thefirequencywith which they intervene
Representative case vignette from the control umt
G S IS a divorced 92-year-old ex-secretanal graduate of business college who suffers from osteoarthnhs, osteoporosis, hypothyroidism, CHF, and recently, respiratory failure She was admitted to the NHCU 3 years ago Oxygen is prescnbed for her recurrent shortness of breath She penodically has tumed the How up beyond medically prescnbed levels m response to her shortness of breath She uses a diaper for mcontmence She requires 'total care' for her hygiene care, but can brush her teeth if the equipment IS set up She has problems with pain control and has stated that treatment of her arthnhs with tylenol is an msuit because it is so ineffective She resists turns m bed occasionally, possibly because of the pam Her sleep is only fair because of her disruphve roommate, whom she does not like She takes naps and stays m bed dunng the day She IS pnmanly an isolate who is considered to be depressed, lmtable, and sometimes verbally abusive to staff She repeatedly expresses the wish to die She refuses group achvihes Self-care summary G S 's self-care skills are limited by her pam and physical disabibties and probably by her mood problems as well Pam control and encouragmg her to do thmgs for herself are primary goak of care for tlus pahent
Documentation
The structure of documentahon forms and the inshtution or unit's formal and lnfomial values for documentahon may well influence the actual record of care The experimental urut was found to have completed fewer monthly summary forms and mulh-disaplinary care plans This limited the amount of data available for the study and is felt to reflect a continued state of transition related to the lmplementahon process That the types of problems identified on the care records are nonetheless similar for both units may reflect the influence of the pobaes and procedures of the inshtuhon rather than the nature of the care delivered on each umt It IS more likely that the similanty cA resident problems identified by both units in the care records reflects the therapeuhc care demands of a homogenous cogmhvely and physically impaired populahon The problons identified by the nurses in the study are similar to those r^orted in other nursing home samples (Rantz & Miller 1987, Rantz eial 1985) Stopping at care demands, it would appear that the effect of the model on nursing problem ldenhfication is minimal However, the two-step cfaagnoshc process of the S-CDNT balances care demands against self-care capability TTuis, it IS important to detemune if the S-CDNT leads to DISCUSSION vanahons m nursn^ approaches related to tlw emphasis on Theorehcal models such as Orem's applied on the unit level pahent parhopahon in care The interview data stror^ly have potential value for nursing prachce because they suggest that difier«ices in assessing and planning for 664
Nursmg process
resident partiapahon exist S-CDNT nurses are more likely to specify residents' capabilities for self-care and residents' roles in goal attainment Variations in the vignettes appear to demonstrate additionally such specification on the part of the S-CDNT nurses This generates assumptions for future study that interventions which support residents' independent self-care capabilities will be more likely when nurses have assessed those capabilities m detail and are able to articulate appropnate resident roles m care Statements that can be made about the type and quality of interventions and the effect of the model on problemsolving, including actual residents' partiapahon in care, must necessanly be restncted due to limitations on the type of data on interventions we were able to collect in this study TTie findings on changes m nursing assessment and plaruung recommend more thorough study of documented as well as observed interventions m order to fully evaluate the effects of the model Interventions which reinforce residents' independence should be evaluated along with those which compensate for their functional disability
CONCLUSION While this study demonstrates consensus about the types of nursing-home resident problems that are amenable to nursing intervention, it also shows that Orem's S-CDNT model can be used to reinforce nursing perspectives regarding residents' self-care Further study utilizing longitudinal and observational data as well as wntten and interview data will be required to determine the influence of model implementation on the performance of interventions
Acknowledgements This study was funded by the National Institutes for Health, National Center for Nursing Research, as part of a larger grant to D WdsonandA Naqvi (1R12-NR0I213)
Fnes B & Conroy L (1985) Resource utilization groups A patient classification system for long term care h4edical Care
23,110-122 GofiEmanE (1961) Asylums Doubleday, New York. Gordon M (1982) Nursmg Diagnosis Process and Application McGraw-Hill, New York. Kahana E & Kiyak H (1984) Attitudes and behavior of stafif in faalities for the aged Research on Aging 6,395-416 Meleis A (1985) Theoretical Nursing Development & Progress Lippincott, New York Miller A (1984) Nurse-patient dependency — a review of different approaches with particular reference to studies of the dependency of elderly patients Joumal of Advanced Nursing 9, 479-486 Miller A (1985) Nurse-patient dependency — is it latrogenic? Journal of Advanced Nursing 1 0 , 6 3 - 6 9 Naqvi A & Wilson D (1988) A 3-year history of implementation in a nursmg home care unit Paper presented at The Self-Care Model of Nursmg Coming of Age Conference VA Medical Center, Palo Alto, CA Orem D (1985) Nursing Concepts of Practice 3rd edn McGrawHill, New York. Rantz M & Miller T (1987) How diagnoses are changmg in long-term care Amencan Joumal of Nursing 87,360—361 Rantz M , Miller T & Jacobs C (1985) Nursmg diagnosis m longterm care Amencan Joumal of Nursing 85, 916—917 Rodin J (1986) Agmg and health Effects of the sense of control Saence 233,127I-1276 Ryden M (1985) Environmental support for autonomy m the institutionalized elderly Research m Nursing and Health 8, 363-371 Underwood P (1980) Facilitatmg self-care In Psychatnc Nursing (P Pothier ed), Lttle, Brown, Boston Wack J & Rodm J (1978) Nursmg homes for the aged The human consequences of legislation-shaped environments Joumal of Sociai Issues 34(4), 6-21
APPENDIX: NURSING-CARE QUESTIONNAIRE
1 References Adams K & Schlenker R (1986) Case-mix reimbursement for nursmg home sources Simulation approach Health Care Finanang Review 8 , 3 5 - 4 5 Baltes M , Honn S, Barton E, Orzech M & U g o D (1983) On the soaal ecology of dependence and mdependence m elderly nursmg home residents A replication and extension Joumal of Gerontology 3 8 , 5 5 6 - 5 6 4 Chmn P & Jacobs M (1983) Theory and Nursmg A Systematic Approach C V Mosby, St Louis
2
3
When someone is newly admitted to the NHCU, what are thefiveor six most important features or characteristics of the patient or his/her background that you would want to know m order to plan nursing care? When the new patient amves on the uiut, what are the three or four most important thmgs for them to leam about the unit and livmg m the NHCU? In order to make a complete nursing-care plan for a patient and to be relatively sure that you haven't missed an important functional area, what are &ve or so major categones of patient
The e£Fect of Orem's self-care model on nursing care in a nursing home setting J FaucettRNPhD Assistant Chnical Professor, School of Nursing, Umversity of Caltfomta, San Francisco
V Ellis RN MS Clinical Nurse Speaalist, Veterans Administration Medical Center, Palo Alto
P Underwood RN DNS Clmical Professor. School of Nursmg, Umverstty of California, Sanfranctsco
A NaqviRNMS Assistew/ Chef Nurse, Veterans Administration Medical Center, Palo Alto
and D Wilson RN MN Co-ordtnator— Nursing Home Care Unit, Veterans Administration Medical Center, Palo Alto, California, USA
Accepted for publicahon 23 August 1989
FAUCETT J, ELLIS V, UNDERWOOD P, NAQVl A & WILSON D
(1990) Journal of Advanced Nursing 15, 659-666 The effect of Orem's self-care model on nursing care in a nursing home setting The need of the functionally disabled for nursmg care is a primary rationale for lnshtuhonahzahon m long-term care settings However, mamtenance of the selfcare abilities that nursmg home residents retam is an important component of their quality of life Nurses are m an important position to encourage and sustam residents' abihties to participate m their care Nevertheless, without specifying the role of the resident m care, nursmg mterventions may madvertently reinforce dependency and apathy at the expense of autonomy, control and well-being Data from nursmg home care records and interviews suggest that nursmg staff usmg Orem's Self-Care Dehat Nursmg Theory differ m their nursmg assessments and goals of care from staff on a control unit Further study is recommended of the influence of the model on staff perspectives of care and on mterventions which support nursmg home residents' self-care ability and well-bemg
INSTITUTIONALIZ ATION ,
,
ability for deasion-making (Goffman 1961, Wack & Rodin 1978) The maintenance of personal control among nursing
Admission to a 'total institution such as a nursing home v-iuiiussiuu lu a luiai " '^ ^^ i . increases the nsk of the syndrome or lnstitutionalization .wicu u USA P
,
^
^
allowing residents t o make deasions (Ryden 1985)
659
7 FauceH et al
independent behaviour Constraints related to care delivery structure as well as individual nursing perspechves about the pahent role m care may effect staff behaviour (Miller 1985, Wack & Rodin 1978) Pnonties and standards for daily-care deasions and delivery are lnffuenced by values, beliefs and athtudes m the care setting Beliefs about the goals of care m long-term settings differ from those in acute care The assessment of functional ability is valued on admission to a nursing home because it determmes the initial needs for nursing care and because it is reinforced by reimbursement and accreditation structures (Adams & Schlenker 1986, Fnes & Conroy 1985, Wack & Rodin 1978) When rewards of mcreased staffing are related to care-dependency levels or where mstituhonal accountability structures for the post-admission preservahon of functional abihty are lackmg, maintenance of the resident's self-care independence depends highly on the shared values of unit staff dehvenng the care (Kahana & Kiyak 1984, Miller 1985) The implementation on a nursing unit of a model emphasizmg self-care abihty and individual care demands may highlight the importance of maintaining or enhanang the resident's capability for mdependent behaviour and partiapation m care The purpose of the present study was to determine whether the lmplementahon of Orem's Self-Care Defiat Nursmg Theory (S-CDNT) (Orem 1985) alters the perspectives of staff canng for nursing home residents by changing the nature of nursmg assessments and patient-care goals
caregivers stated that they preferred increased control by residents, they were not found to support mdependence Observahonal studies have indicated that nursing staff selechvely reinforce dependent behaviour by residents and Ignore attempts at mdependent eatmg, dressing and toilehng(Baltesefa/ 1983, Miller 1984) Baitesetal (1983) additionally found that constructively-engaged activity by the resident was not consistently reinforced while nonengaged activity tended to receive no response at all Thus, achvihes related to indep)endent self-care, lncludmg appropnate sohtude and social mteraction, are less likely to eam reinforcement fi-om nursmg home staff than dependence and compliance Miller (1985) demonstrated that individualized nursing care, as opposed to task-allocation nursmg, significantly affected mortality as well as dependency, apathy, communication difficulhes, social disturbance and incontinence She suggested that the reduchon of nurse-induced dependency related to both structural and attitudmal factors would improve the quality of care of nursmg home residents (Miller 1984,1985) In the larger project from which the current study is drawn, Naqvi & Wilson (1988) demonstrated significantly less depression, apathy and communication dif&culhes over hme for nursing home residents receiving care from staff uhlizing Orem's S-CDNT model (Orem 1985) compared to a similar control group receiving routine nursing care Theirfindingssuggested that residents on the experimental umt suffered less from the effects of lnshtutionalizahon due to the implementation of the S-CDNT The current study seeks to validate their conclusions
The problem of institutionalization This study is part of a larger intervention study concemed vnih patient outcomes of lnshtutionalizahon m a nursing home setting Total institutions such as pnsons, the inihtary or state hospitals regulate and orgaruze basic hfe achvihes by group needs as opposed to individual ones Rewards, pnvileges and pumshments evolve m support of the aims and rules of orgaiuzahon of these inshtutions The milieu that anses from categoruong and idenhfjong individuals by homogeneous charactenshcs, treatmg them coUechvely, and assuming deasional authonty over broad aspects of daily life predisposes inmates, soldiers and pahents to depersonalizahon and dependence (Goffinan 1961) Ryden (1985) reported that prc^essional caregivers in nursmg home settmgs view themselves as the predominant deasion-makers regarding the eating, toileting, grocmung and dressing achvihes of pahents, while achvihes related to one-to-one mterachons and solitude were seen as more under the control of tiie nursmg home resident Although 660
INFLUENCING THE NURSING PROCESS Gordon (1982) has conceptualized the nursing process as a problem-identificahon and problem-solving process Problem ldenhfication is further sub-divided mto information gathering, diagnoshc judgement and labellmg In prachce, the nursing care perspechve of the individual staff member influences the collechon and mterpretahon of lnfomiahon and clinical deasion-making (Gordon 1982) Thus, the observahon of salient cues, clmical judgements about signs and symptoms and the ldenhfication of pahent problems vary with the values, beliefs and athtudes of the individual prachhoner Nurses prachsing in the nursing home settmg may not always be able to identify what underlies their working hypotheses about pahent problems or nursing soluhons As a result, their approaches to care may differ horn time to tune or from the approaches of other staff members, diminishing continuity and consistency of care A urut staff using an agreed-upon nursing model to discuss nursing
Nursmg process
Table 1 Orem's universal requisites of self-erspechves observed anecdotally by researchers on the two units or revealed by the interviews, six case vignettes were developed post hoc from the care records Dunng the staff mterviews, nurses selected resident cases m order to exemplify care delivery on their own uruts From these descnphve data, it was possible to ldenhfy three pahents from each unit Vignettes were then develof>ed from the
care records for the 6-inonth time penod under analysis All nursmg care data recorded for each pahent were summarized m the vignettes The six vignettes were reviewed by four nationally recognized experts m Orem's S-CDNT Each expert was asked to select which of the six vignettes was drawn from the expenmental unit and which from the control unit The experts correctly and unanimously agreed on four of the vignettes Votes on the other two, one from each of the units, were equivocal Two representahve case vignettes are presented below Representative case vignette from the experimental unit
M A IS 72-year-old white widowed former salesman with less than a high school education who was admitted to the NHCU 3 years ago followmg a CVA which has left him with lefbsided hemiparesis He also has a history of ulcers Although MA. reportedly suffers from dunmished appetite, he is a heavy man with little interest m weight loss His daughter, who is a nurse, visits at mealtimes He remams a smoker with a notable wheeze He uses a unnal without difficulty and wears a diaper to protect agamst acadents He needs assistance to go to the toilet for a bowel movement 663
/ J^uce^etal
He IS able to wash his upper body and face and shaves himself He needs assistance, which his daughter frequently provides, tofinishhis hygiene and to dress A reported goal of care is the mamtenance of his {jersonal-hygiene skills He sleeps well at night and naps occasionally His ability to transfer has recently diminished despite physical exerases He IS weak and unstable, weanng a knee brace that helps with transfers He IS a pleasant man, but reserved He is pnmanly a loner, although he hkes sports and likes to watch television He has a notable problem asking for help, e g he will not repwrt knee pam but will acknowledge it when asked The staff feel he would benefit from attendmg resident soaal events such as current-events discussions and a stress-management group He tends to procrastinate attendance at these events and requires encouragement Self-care summary This man tends to rely on his daughter for assistance and for soaalization He manages his care without askmg for help, even when help would minimize his discomfort Staff feel he would benefit from broadening his soaal mteraction with other residents and encourage group partiapation. Addihonally, staff actively support his self-care capability m hygiene
may clarify the philosophy and role of nursing, provide a common language leading to improved commurucahon and enhance consistency m care delivery and consensus about the goals and outcomes of nursmg (Chinn & Jacobs 1983, Meleis 1985) Addihonally, the process of implementatmg such a model may encourage discussion and analysis of the perspechves on care delivery held by nurses practismg withm a settmg This study sought to determine whether the lmplementahon of Orem's S-CDNT model m prachce would influence nurses' perspectives to be more consistent with the promotion of resident self-care abibty Due to the preliminary and exploratory nature of the study, findmgs must be considered only suggeshve In what they verbally report about their work, nurses from the experimental unit appear to utilize the language and SCDNT concepts consistently, to assess more comprehensive data about the personal capabihhes of residents, and to arhculate more speafic and more vaned roles for resident partiapahon m care Nonetheless, m documented data, they resemble control group nurses m the problem areas they idenhfy, m situations m which they chose to intervene and in thefirequencywith which they intervene
Representative case vignette from the control umt
G S IS a divorced 92-year-old ex-secretanal graduate of business college who suffers from osteoarthnhs, osteoporosis, hypothyroidism, CHF, and recently, respiratory failure She was admitted to the NHCU 3 years ago Oxygen is prescnbed for her recurrent shortness of breath She penodically has tumed the How up beyond medically prescnbed levels m response to her shortness of breath She uses a diaper for mcontmence She requires 'total care' for her hygiene care, but can brush her teeth if the equipment IS set up She has problems with pain control and has stated that treatment of her arthnhs with tylenol is an msuit because it is so ineffective She resists turns m bed occasionally, possibly because of the pam Her sleep is only fair because of her disruphve roommate, whom she does not like She takes naps and stays m bed dunng the day She IS pnmanly an isolate who is considered to be depressed, lmtable, and sometimes verbally abusive to staff She repeatedly expresses the wish to die She refuses group achvihes Self-care summary G S 's self-care skills are limited by her pam and physical disabibties and probably by her mood problems as well Pam control and encouragmg her to do thmgs for herself are primary goak of care for tlus pahent
Documentation
The structure of documentahon forms and the inshtution or unit's formal and lnfomial values for documentahon may well influence the actual record of care The experimental urut was found to have completed fewer monthly summary forms and mulh-disaplinary care plans This limited the amount of data available for the study and is felt to reflect a continued state of transition related to the lmplementahon process That the types of problems identified on the care records are nonetheless similar for both units may reflect the influence of the pobaes and procedures of the inshtuhon rather than the nature of the care delivered on each umt It IS more likely that the similanty cA resident problems identified by both units in the care records reflects the therapeuhc care demands of a homogenous cogmhvely and physically impaired populahon The problons identified by the nurses in the study are similar to those r^orted in other nursing home samples (Rantz & Miller 1987, Rantz eial 1985) Stopping at care demands, it would appear that the effect of the model on nursing problem ldenhfication is minimal However, the two-step cfaagnoshc process of the S-CDNT balances care demands against self-care capability TTuis, it IS important to detemune if the S-CDNT leads to DISCUSSION vanahons m nursn^ approaches related to tlw emphasis on Theorehcal models such as Orem's applied on the unit level pahent parhopahon in care The interview data stror^ly have potential value for nursing prachce because they suggest that difier«ices in assessing and planning for 664
Nursmg process
resident partiapahon exist S-CDNT nurses are more likely to specify residents' capabilities for self-care and residents' roles in goal attainment Variations in the vignettes appear to demonstrate additionally such specification on the part of the S-CDNT nurses This generates assumptions for future study that interventions which support residents' independent self-care capabilities will be more likely when nurses have assessed those capabilities m detail and are able to articulate appropnate resident roles m care Statements that can be made about the type and quality of interventions and the effect of the model on problemsolving, including actual residents' partiapahon in care, must necessanly be restncted due to limitations on the type of data on interventions we were able to collect in this study TTie findings on changes m nursing assessment and plaruung recommend more thorough study of documented as well as observed interventions m order to fully evaluate the effects of the model Interventions which reinforce residents' independence should be evaluated along with those which compensate for their functional disability
CONCLUSION While this study demonstrates consensus about the types of nursing-home resident problems that are amenable to nursing intervention, it also shows that Orem's S-CDNT model can be used to reinforce nursing perspectives regarding residents' self-care Further study utilizing longitudinal and observational data as well as wntten and interview data will be required to determine the influence of model implementation on the performance of interventions
Acknowledgements This study was funded by the National Institutes for Health, National Center for Nursing Research, as part of a larger grant to D WdsonandA Naqvi (1R12-NR0I213)
Fnes B & Conroy L (1985) Resource utilization groups A patient classification system for long term care h4edical Care
23,110-122 GofiEmanE (1961) Asylums Doubleday, New York. Gordon M (1982) Nursmg Diagnosis Process and Application McGraw-Hill, New York. Kahana E & Kiyak H (1984) Attitudes and behavior of stafif in faalities for the aged Research on Aging 6,395-416 Meleis A (1985) Theoretical Nursing Development & Progress Lippincott, New York Miller A (1984) Nurse-patient dependency — a review of different approaches with particular reference to studies of the dependency of elderly patients Joumal of Advanced Nursing 9, 479-486 Miller A (1985) Nurse-patient dependency — is it latrogenic? Journal of Advanced Nursing 1 0 , 6 3 - 6 9 Naqvi A & Wilson D (1988) A 3-year history of implementation in a nursmg home care unit Paper presented at The Self-Care Model of Nursmg Coming of Age Conference VA Medical Center, Palo Alto, CA Orem D (1985) Nursing Concepts of Practice 3rd edn McGrawHill, New York. Rantz M & Miller T (1987) How diagnoses are changmg in long-term care Amencan Joumal of Nursing 87,360—361 Rantz M , Miller T & Jacobs C (1985) Nursmg diagnosis m longterm care Amencan Joumal of Nursing 85, 916—917 Rodin J (1986) Agmg and health Effects of the sense of control Saence 233,127I-1276 Ryden M (1985) Environmental support for autonomy m the institutionalized elderly Research m Nursing and Health 8, 363-371 Underwood P (1980) Facilitatmg self-care In Psychatnc Nursing (P Pothier ed), Lttle, Brown, Boston Wack J & Rodm J (1978) Nursmg homes for the aged The human consequences of legislation-shaped environments Joumal of Sociai Issues 34(4), 6-21
APPENDIX: NURSING-CARE QUESTIONNAIRE
1 References Adams K & Schlenker R (1986) Case-mix reimbursement for nursmg home sources Simulation approach Health Care Finanang Review 8 , 3 5 - 4 5 Baltes M , Honn S, Barton E, Orzech M & U g o D (1983) On the soaal ecology of dependence and mdependence m elderly nursmg home residents A replication and extension Joumal of Gerontology 3 8 , 5 5 6 - 5 6 4 Chmn P & Jacobs M (1983) Theory and Nursmg A Systematic Approach C V Mosby, St Louis
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When someone is newly admitted to the NHCU, what are thefiveor six most important features or characteristics of the patient or his/her background that you would want to know m order to plan nursing care? When the new patient amves on the uiut, what are the three or four most important thmgs for them to leam about the unit and livmg m the NHCU? In order to make a complete nursing-care plan for a patient and to be relatively sure that you haven't missed an important functional area, what are &ve or so major categones of patient
