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research-article2014

NSQXXX10.1177/0894318414558609Nursing Science QuarterlyFawcett / Essays on Nursing Science

Essays on Nursing Science

Thoughts about Conceptual Models of Nursing and Health Policies

Nursing Science Quarterly 2015, Vol. 28(1) 88­–91 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318414558609 nsq.sagepub.com

Teri Aronowitz, RN; PhD,1 and Jacqueline Fawcett, RN; PhD; FAAN2

Abstract In this essay, we present a conceptual framework for analysis and evaluation of sexuality education health policies based on the conceptual model of nursing and health policy and the Neuman systems model. The framework is intended to facilitate understanding of sexuality education policies promulgated by the governments of any country in the world. Keywords conceptual model of nursing and health policy, health policies, Neuman systems model, sexuality education Health policy is becoming an increasingly important topic for the discipline of nursing. For example, Nursing Science Quarterly includes an occasional column for articles about Health and Public Policy; a recent article for that column focused on social determinants of health (Mahony & Jones, 2013). Furthermore, in a recent Scholarly Dialogue column in the same journal there was a discussion of two nurse leaders’ views about current public health policies in the United States (Clarke, Swider, & Bigley, 2013). In addition, Policy, Politics, and Nursing Practice, which is entirely devoted to scholarly work about health policy, began publication in 2000. Nurse researchers have progressed from no to some mention of the implications of their research findings for development or refinement of health policies to articulation and application of specific nursing conceptual models for analysis and evaluation of health policies. For example, the Cloutterbuck model was developed to analyze consumer health status, behaviors, and outcomes within the context of personal, situational, and structural dimensions. This nursing conceptual model identifies health policy as a particularly salient structural dimension variable (Cloutterbuck & Cherry, 1998). The Conceptual Model of Nursing and Health Policy (CMNHP) addresses the intersection of nursing and health policy (Fawcett & Russell, 2001; Russell & Fawcett (2005) and offers guidelines for analysis and evaluation of health policies. Some nursing conceptual models initially developed as guides for nursing practice also can be used to guide analysis and evaluation of health policies. For example, Hickson (2012) used Roy’s adaptation model (Roy, 2009) to guide her evaluation of a health policy addressing military veterans’ access to postoperative care following lower extremity arterial bypass in the Veterans Administration Healthcare System. Neuman’s systems model (NSM) also can be used to

examine health policies within the context of the client system as a social issue (Neuman & Fawcett, 2011). The purpose of this essay is to discuss development of a conceptual framework for the analysis and evaluation of health policies that combines the CMNHP with the NSM. The framework is targeted to enhancing understanding of sexuality education promulgated by various governments throughout the world. Sexuality education is defined as a comprehensive approach that seeks to equip young people with the knowledge, skills, attitudes, and values they need to determine and enjoy their sexuality physically and emotionally, individually, and in relationships (International Planned Parenthood Federation, 2010). The governments of some countries have implemented policies that support this comprehensive approach to sexuality education whereas the governments of other countries have implemented more restrictive approaches.

The Conceptual Framework The starting point for our conceptual framework was the NSM (Neuman & Fawcett, 2011). This conceptual model of nursing focuses on the responses of client systems, including individuals, families and other groups, communities, and social issues, to intrapersonal (within the client system), interpersonal (between two or more client systems), and extrapersonal (between the client system and some external environmental circumstance) stressors. The impact of stressors on the central core of the client system, where responses are manifested, depends on the strength of metaphorical lines of defense and resistance that protect the central core of the 1

Assistant Professor, University of Massachusetts Boston Professor, University of Massachusetts Boston

2

Fawcett / Essays on Nursing Science client system. Central core responses to stressors are manifested in one or more of five interacting variables–physiological, psychological, sociocultural, developmental, and spiritual. For the purposes of our framework, the NSM client system is the social issue of sexuality education policies. We added the CMHHP to the NSM to expand understanding of components that need to be considered when analyzing and evaluating policies. The CMNHP (Fawcett & Russell, 2001; Russell & Fawcett, 2005) includes three concepts—policy source (public, organizational, or professional), policy components (personnel, services, and expenditures), and the four interacting levels of nursing and health policy focus and outcomes—(a) efficacy of practice processes, (b) effectiveness of practice processes, (c) equity of access to practice processes, and (d) social justice. For the purposes of our framework, the policy source is public, namely the governmental policies of various countries about sexuality education. The policy component is services, specifically, sexuality education available to the citizens of a country. Level c of the CMNHP is most relevant for our framework, given our interest in equity of access to sexuality education. We returned to the NSM to build our framework though further delineation of equity of access to sexuality education. Extrapersonal stressors that influence sexuality education are the historical, sociological, political, and economic factors that undergird the development and implementation of any policy (Ellenbecker, Fawcett, & Glazer, 2005). Historical factors are the events in a country that lead to the development and implementation of a specific policy as well as the chronological history of the development and implementation of the policy. The historical factors especially important for analysis and evaluation of sexuality education policies include history pertaining to human rights and liberties. Sociological factors are the strengths and limitations of all socially constructed groups within a country as well as the values and norms among these groups. The sociological factors that pertain specifically to analysis and evaluation of sexuality education policies include attitudes toward young people’s sexuality and information about the country’s values disseminated by the media. Political factors encompass the ways in which a specific health policy addresses concerns of different stakeholders that influenced the health policy. The political factor of central interest for analysis and evaluation of sexuality education policies is the legislation specific to family planning, including contraception, abortion, and legal age of consent, and when and how sexuality education begins in schools. Economic factors are the ways in which material resources of countries are distributed to directly or indirectly influence health policy, as well the costs of implementing or not implementing the policy. The economic factors that are relevant for

89 analysis and evaluation of sexuality education policies are funding for development, implementation, and evaluation of the policies by governmental agencies and estimates of costs of not implementing a sexuality education policy. The strength of the metaphorical flexible and normal lines of defense and the lines of resistance facilitates or prevents historical, sociological, economic, and political factors from influencing development and implementation of sexuality education policies. The strength of the normal line of defense is evident in the usual level and type of sexual activity across the lifespans of the citizens of a country. The strength of the flexible line of defense is reflected in the extent of changes in citizens’ and legislators’ ideas about sexual activity. The strength of the lines of resistance is manifested in ingrained and evolving family connectedness in a country. Within the context of the NSM, the central core is the social contract about sexuality education that is enacted between the government of a country and its citizens. A social contract may be considered a NSM sociocultural variable in that the contract is a summary of what a particular society and the various cultures within the society value most. The philosophical orientation of the society, representing a negotiated agreement between the government and citizens of a country on the responsibilities and duties of both, influences the social contract. A philosophical orientation is a systematic way of answering three important questions. The ontological question is “What is real?” The epistemological question is “What is true and how do we know what is true?” The axiological question is “What is good or ethical?” (Rothe, 2000). Each of the three questions is answered in a different way for each philosophical orientation. The three philosophical orientations that are most relevant for understanding the social contract for sexuality education of a country are realism, idealism, and pragmatism. Realism is concerned with the realm of physical things, which constitute reality. Realists believe that nature operates according to certain laws and principles that constitute ultimate truth, which has existed for all time and is potentially knowable. They also believe that good or ethical conduct is that which emulates the law of nature and, therefore, look to nature for clues about the “rightness” or “wrongness” of actions. Inasmuch as truth is understood by perceiving nature through the five senses (Bassin, 2003), realists rely on empirical data from observations and experiments to discover truth. The social contract of a country with a realist orientation emphasizes collection of empirical data to inform policies, such as sexuality education. Idealism is concerned with the realm of ideas such that ideas, rather than things, constitute what is truly real. Idealists rely on insight as the way to know (Cook & Moos, 1952). Thus, idealists turn inward, are introspective, and open their minds to the truth. They believe that knowing what is good

90 or ethical is discovered in attempts to imitate the example of the Absolute Self. The social contract of a country with an idealistic orientation is influenced by its idea of what is right. The importance of individuals is paramount for truth is within the self. Therefore, an individualistic approach to societal problems prevails, and citizens believe that sexuality education is a function of families rather than of governments. Pragmatism avoids the conflict about whether reality is in the realm of ideas or physical things and instead asserts that ordinary everyday human experience is as close as we can get to reality. Pragmatists believe that truth is always defined in terms of relativeness, that is, that truth is relative to the circumstances that surround it at a particular time in history. If an idea works or has demonstrated utility, a pragmatist calls it truth (Apel, 1995). Pragmatists believe that good or ethical conduct is determined by putting actions to the test in public. If the outcome of an action appears to cause suffering, for example, a pragmatist might then consider such an action as “wrong.” If the outcome produces beneficial effects, the action is regarded as “right.” The social contract of a country with a pragmatic orientation has a high degree of universality and institutionalization; citizens acknowledge a need and work together to rectify a social issue without the need for laws. For example, adults residing in a country with a pragmatic orientation know that adolescents are sexually active and need information to keep them safe. Therefore, the citizens would find a solution such as early sexuality education so that young children have the knowledge they need to keep them healthy as they enter adolescence.

Nursing Science Quarterly 28(1) Table 1.  Guidelines for Analysis and Evaluation of Sexuality Education Policies across Countries. Questions for Analysis of Sexuality Education Policies across Countries What is the content of the sexuality education policy? What historical factors are evident in the sexuality education policy? What sociological factors are evident in the sexuality education policy? What political factors are evident in the sexuality education policy? What economic factors are evident in the sexuality education policy? What is the philosophical orientation of the country? Questions for Evaluation of Sexuality Education Policies across Countries What historical factors helped development and implementation of the sexuality education policy? What historical factors hindered development and implementation of the sexuality education policy? What sociological factors helped development and implementation of the sexuality education policy? What sociological factors hindered development and implementation of the sexuality education policy? What political factors helped development and implementation of the sexuality education policy? What political factors hindered development and implementation of the sexuality education policy? What economic factors helped development and implementation of the sexuality education policy? What economic factors hindered development and implementation of the sexuality education policy? To what extent is the philosophical orientation of the country reflected in the social contract for sexuality education? To what extent is the sexuality education policy implemented? What are the intended consequences of implementation of the sexuality education policy? What are the unintended consequences of implementation of the sexuality education policy?

Conclusion Analysis of any sexuality education policy must examine the actual content of the policy, along with the historical, sociological, political, and economic factors that are evident in the policy, as well as the philosophical orientation of the country. Evaluation of any sexuality education policy must consider the ways in which historical, sociological, economic, and political factors help or hinder the development and implementation of the policy. Evaluation also must consider the extent to which the policy reflects the philosophical orientation of the country, the extent to which the policy actually is implemented, and the intended and unintended consequences of the policy (Fawcett & Russell, 2001). Our framework is summarized in the questions for analysis and evaluation that are listed in Table 1. We invite readers to share their thoughts about the merits of the content of our framework and their own ideas about conceptual frameworks for analysis and evaluation of health policies. We also invite readers to extend our conceptual framework to other social issues that may be considered NSM client systems.

Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this editorial.

Funding The author received no financial support for the research, authorship, and/or publication of this editorial.

References Apel, K. O. (1995). Charles S. Peirce: From pragmatism to pragmaticism. Newark, N.J.: Humanities Press. Bassin, M. (2003). Between realism and the ‘New Right’: Geopolitics in the 1990s. Transactions of the Institute of British Geographers, 28, 350-366. Clarke, P. N., Swider, S., & Bigley, M. B. (2013). Nursing leadership and health policy: A dialogue with nurse leaders. Nursing Science Quarterly, 26,136-142. Cloutterbuck, J. C., & Cherry, B. S. (1998). The Cloutterbuck minimum data matrix: A teaching mechanism for the new millennium. Journal of Nursing Education, 37, 385-393.

Fawcett / Essays on Nursing Science Cook, T. I., & Moos, M. (1952). Foreign policy: The realism of idealism. American Political Science Review, 46, 343-356. Ellenbecker, C. H., Fawcett, J., & Glazer, G. (2005). A nursing PhD specialty in health policy: University of Massachusetts Boston. Policy, Politics, and Nursing Practice, 6, 229-235. Fawcett, J., & Russell, G. (2001). A conceptual model of nursing and health policy. Policy, Politics, and Nursing Practice, 2, 108-116. Hickson, K. P. (2012). The relationship between distance to care and readmission for reintervention following lower extremity arterial bypass: An exploratory study. Dissertation Abstracts International, 72B(08). International Planned Parenthood Federation [IPPF] (2010). IPPF framework for comprehensive sexuality education (CSE). London, United Kingdom: IPPF No. 229476, Pp 1-12.

91 Mahony, D., & Jones, E. J. (2013). Social determinants of health in nursing education, research, and health policy. Nursing Science Quarterly, 26, 280-284. Neuman, B., & Fawcett, J. (2011). The Neuman systems model (5th ed.). Upper Saddle River, NJ: Pearson. Roy, C. (2009). The Roy adaptation model (3rd ed.). Upper Saddle River, NJ: Pearson. Rothe, J. P. (2000). Understanding qualitative research: Concepts and cases in inquiry, health, and social life. Edmonton, Alberta, Canada: University of Alberta Press. Russell, G., & Fawcett, J. (2005). The conceptual model for nursing and health policy revisited. Policy, Politics, and & Nursing Practice, 6, 319-326.

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Thoughts about conceptual models of nursing and health policies.

In this essay, we present a conceptual framework for analysis and evaluation of sexuality education health policies based on the conceptual model of n...
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