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  1. 1. | Amethyst Vic C. Mergal, RN
  3. 3. DOROTHEA OREM: Who is she??? ⚫Born: 1914, Baltimore, Maryland. ⚫Father: construction, fishing ⚫Mother: homemaker , reading ⚫ Youngest of two girls ⚫Died: June 22, 2007
  4. 4. Education ⚫Degrees:  Diploma (1930's), Providence Hospital School of Nursing, Washington DC  BSN Ed. (1939) and MSN Ed. (1945), Catholic University of America, Washington DC. ⚫Honorary Doctorates:  Doctor of Science (1976) Georgetown University, (1980) Incarnate Word College in San Antonio, Texas  Doctor of Humane Letters (1988) Illinois Wesleyan University, Bloomington, Illinois  Doctor of Nursing Honoris Causae, (1998) University of Missouri- Columbia
  5. 5. Special Awards ⚫ Catholic University of America Alumni Achievement Award for Nursing Theory (1980) ⚫Linda Richards Award, National League for Nursing (1991) ⚫Honorary Fellow of the American Academy of Nursing (1992).
  6. 6. Nursing Experiences ⚫OR nurse ⚫Hospital staff nurse (pedia & adult MS units) ⚫Private duty nurse ⚫Night supervisor in the ER ⚫Biological science teacher ⚫Professor of nursing education
  7. 7. Nursing Experiences ⚫ 1940 – 49 = directorship: both nursing school and department at Providence Hospital, Detroit ⚫ 1949 – 57(Indiana) = Division of Hospital and institutional Services (Indiana State Board of Health) ⚫ 1957 –curriculum consultant: Office of Education, US DHEW ⚫ 1958 – 60 = project (Guides for Developing Curricula for the Education of Practical Nurses) ⚫ CUA    Member of the Nursing Models Committee (CUA) Improvement in Nursing Group 1971 – Nursing: Concepts of Practice
  8. 8. Her Story ⚫…she was asked a substantive question and didn’t have an answer because she “had no conceptualization of nursing” (McLaughlin-Renpenning & Taylor, 2002, p. xii). ⚫she noted (Indiana University) that nurses had  difficulty articulating needs to hospital administrators in the face of demands made upon them regarding such issues as length of stay, scheduling admissions and discharges, etc.
  9. 9. Her Thoughts ⚫What is nursing?” ⚫“What is the domain and what are the boundaries of nursing as a field of practice and a field of knowledge?” ⚫Orem (cited in Fawcett 2005) commented that the task required identification of the domain and boundaries of nursing as a science and an art (1978).
  10. 10. Theoretical Sources ⚫Orem says her ideas are primarily the result of reflecting upon her experiences and she was not influenced by any one person (Hartweg, 1991). ⚫Parsons’ structure of social action ⚫Von Bertalnfy’s System Theory ⚫Eugenia K. Spalding = a friend and teacher ⚫Other nursing theorists ⚫Moderate realism (Kantian Philosophy)
  11. 11. Assumptions □ Human beings require continuous, deliberate inputsto themselves and their environments to remain alive and function according to their capacity. o Human agency is exercised in the form of care for self and others in identifying and meeting needs. m Mature human beings experience privations in the form of limitations for action and care for self and others involving life-sustaining and function regulating inputs.
  12. 12. Assumptions □ s Human agency is exercised in discovering, developing, and transmitting ways and means to identify needs and make inputs to self and others. Groups of human beings with structured relationships of clustered tas ksand allocate respons ibilitiesfor providing careto group members who experience privations for making required deliberate input to self and others.
  13. 13. Orem’s General Theory of Nursing Three Interrelated Theories: e Theory of Self-Care = why and how people care for themselves MTheory of Self-Care Deficit = why people can be helped through nursing MTheory of Nurs ing Systems= describes and explains relationships that must be made and maintained for nursing to be produced
  14. 14. Theory #1: Self-Care Theory ⚫Based on the concepts of:  SELF-CARE  SELF-CARE AGENCY  SELF-CARE REQUISITES  THERAPEUTIC SELF-CARE DEMAND
  15. 15. Self Care Theory Concepts Self Care ⚫Definition: the performance of activities that individuals initiate and perform on their behalf to maintain life, health, and well- being.
  16. 16. Self Care Theory Concepts Self-Care Agency ⚫Definition: the individual’s ability to perform self- care activities ⚫Consists of TWO agents:  Self-care Agent - person who provides the self-care  Dependent Care Agent - person other than the individual who provides the care (such as a parent) ⚫Affected by basic conditioning factors
  17. 17. Basic Conditioning Factors
  18. 18. Self Care Theory Concepts Self-Care Requisites ⚫Definition: reasons for which self-care is done; these express the intended or desired results ⚫Consists of THREE categories:  Universal - requisites/needs that are common to all individuals (e.g. air, water, food, elimination, rest, activity, etc.)  Developmental - needs resulting from maturation or develop due to a condition or event (e.g. adjustment to new job, puberty)  Health Deviation - needs resulting from illness, injury & disease or its treatment (e.g. learning to walk with crutches after a leg fracture)
  19. 19. Self Care Theory Concepts Therapeutic Self-Care Demand ⚫Definition: the totality of “care measures” necessary at specific times or over a duration of time for meeting an individuals self-care requisites by using appropriate methods and related sets and actions.”
  20. 20. Theory #2: Self-Care Deficit Nursing Theory “The condition that validates the existence of a requirement for nursing in an adult is the health associated absence of the ability to maintain continuously the amount and quality of therapeutic self-care in sustaining life and health, in recovering from disease or injury, or in coping with their effects.”
  21. 21. Self-Care Deficit Nursing Theory ⚫FOR CHILDREN: “…the condition is the inability of the parent (or guardian) associated with the child’s health state to maintain continuously for the child the amount and quality of therapeutic care.”
  22. 22. Self-Care Deficit Nursing Theory ⚫Is the central focus of Orem’s grand theory of nursing ⚫Nursing is required when adults (parent/guardian) are incapable of or limited in their ability to provide continuous effective self-care. ⚫Describes and explains how people can be helped through nursing ⚫Nursing meets these self-care needs through five methods of help
  23. 23. Five Methods of Nursing Help N o c h l Acting or doing for another Guiding and directing Providing physical or psychological support Providing and maintaining an environment that supports personal development Teaching
  24. 24. Theory #3: Theory of Nursing Systems ⚫This describes:  How the patient’s self care needs will be met by the nurse , the patient, or both  Nursing responsibilities  Roles of the nurse and patient  Rationales for the nurse-patient relationship  Types of actions needed to meet the patient’s demands ⚫Designed by the nurse ⚫Based on the assessment of patient’s ability to perform self-care activities
  25. 25. The Nursing Agency Concept ⚫A complex property of people educated and trained as nurses that enables them to act, to know, and to help others meet their therapeutic self-care demands by exercising or developing their own self-care agency.
  26. 26. Three Classifications of Nursing Systems t s - Wholly Compensatory: a patient’s self-care agency is so limited that s/he depends on others for well-being. Unable to engage in any form of action (e.g. coma) Aware and who may be able to make observations or judgments, and decisions about self-care but cannot/should not perform actions requiring ambulation and manipulative movements (e.g. patients with C3-C4 vertebral fractures) Unable to attend to themselves and make reasonable judgments about self-care but who can be ambulatory and able to perform some self-care with guidance (e.g. severely mentally retarded)
  27. 27. Wholly Compensatory Nursing System
  28. 28. Three Classifications of Nursing Systems t  Partly Compensatory: a patient can meet some self-care requisites but needs a nurse to help meet others; either the nurse or the patient have the major role in the performance of self-care E.g. a patient with recent abdominal surgery
  29. 29. Partly Compensatory Nursing System Nurse action Performs some self-care measures for patient Compensates for self-care limitations of patient Assists patient as required Regulates self-care agency Patient Action Performs some self-care agency Accepts care and assistance from nurse
  30. 30. Three Classifications of Nursing Systems t  Supportive-educative: a patient can meet self- care requisites but needs help in decision-making, behavior control, or knowledge acquisition; the nurse’s role is to promote the patient as a self-care agent (teacher/consultant) E.g. a 16-year-old who is requesting birth control information
  31. 31. Supportive-Educative Nursing System
  32. 32. Orem’s General Theory of Nursing Self care Nursing Agency Deficit R R R R R Conditioning factors Conditioning factors Conditioning factors Therapeutic Self care demands Self Care / Dep. Care Agency
  33. 33. Orem’s Theory & Nursing’s Metaparadigm - PERSON ⚫“…an integrated whole composed of an internal physical, psychologic, and social nature with varying degrees of self-care ability (1971 def.)” (Chinn & Kramer, 2004)
  34. 34. Orem’s Theory & Nursing’s Metaparadigm - PERSON ⚫ The recipient of nursing care ⚫ A being who functions biologically, symbolically, and socially ⚫ Has the potential for learning & development ⚫ Is subject to the forces of nature ⚫ Has a capacity for self-knowledge ⚫ Can engage in deliberate actions, interpret experiences, and perform beneficial actions ⚫ Can learn to meet self-care needs (requisites) ⚫ also referred to as individual, patient, multiperson unit, sel f - car e agent , dependent-care agent
  35. 35. Orem’s Theory & Nursing’s Metaparadigm - ENVIRONMENT ⚫“…prevailing internal and external conditions in some time and place frame of reference.” ⚫encompassed by two dimens ions---  Environmental: physical, chemical and biologic features ⯍atmosphere, pollutants, weather conditions, pets, infectious organisms, etc.  Developmental: socioeconomic features ⯍ family & community ⯍gender and age roles, cultural roles, and cultural prescriptions of authority
  36. 36. Orem’s Theory & Nursing’s Metaparadigm - ENVIRONMENT ⚫terms used are environment and environment features
  37. 37. Orem’s Theory & Nursing’s Metaparadigm - HEALTH ⚫“a state of phys ical, mental, and s ocial well-being, and not merely the absence of disease or infirmity” ⚫a state of well-being, which refers to a person’s perceived condition of existence, characterized by experiences of contentment, pleasure, happiness, and movement toward self ideals and continuing personalization
  38. 38. Orem’s Theory & Nursing’s Metaparadigm - HEALTH ⚫Includes promotion & maintenance of health, treatment of disease and prevention of complications ⚫also referred to as health, health state, and well- being
  39. 39. Orem’s Theory & Nursing’s Metaparadigm - NURSING ⚫ “an art through which the practitioner of nursing gives s pecialized as s is tance to persons with disabilities of such a character that greater than ordinary assistance is necessary to meet daily needs for self care and to intelligently participate in the medical care they are receiving from the physician”
  40. 40. Components of NURSING ⚫ NURSING ART  The intellectual quality of nurses which allows them to make creative investigations, analyses, and syntheses of variables and conditioning factors in nursing situations ⚫ NURSING PRUDENCE  The quality that enables the nurse to seek advice in new or difficult situations, to make correct judgments, to decide to act in a particular manner, and/or to act ⚫ NURSING SERVICE  A human service that focuses on a person’s inabilities to maintain health care ⚫ NURSING AGENCY
  41. 41. Orem’s Nursing Process Consists of 3 steps: ⚫Step 1: determine why a patient needs care ⚫Step 2: design a nursing system & plan the delivery of care ⚫Step 3: management of nursing systems - planning, initiating, & controlling nursing actions
  43. 43. APPLICATION OF OREM’S THEORY Areas Patient details Name Age Sex Education Occupation Marital status Religion Diagnosis Theory applied Mrs. X 56 years Female No formal education House hold Married Hindu Rheumatoid arthritis Orem’s theory of self care deficit.
  44. 44. CASE STUDY ⚫ For Mrs. X…. ⚫ She came to the hospital with complaints of pain over all the joints, stiffness which is more in the morning and reduces by the activities. ⚫ She has these complaints since 5 years and has taken treatment from local hospital. ⚫ The symptoms were not reducing and came to --MC, Hospital for further management. ⚫ Patient was able to do the ADL by herself but the way she performed and the posture she used was making her prone to develop the complications of the disease. ⚫ She also was malnourished and was not having awareness about the deficiencies and effects.
  45. 45. BASIC CONDITIONING FACTORS Age 56 year Gender Female Health state Disability due to health condition, therapeutic self care demand Development state Ego integrity vs despair Sociocultural orientation No formal education, Indian, Hindu Health care system Institutional health care Family system Married, husband working Patterns of living At home with partner Environment Rural area, items for ADL not in easy reach, no special precautions to prevent injuries Resources Husband, daughter, sister’s son
  46. 46. UNIVERSAL SELF-CARE REQUISITES Air Breaths without difficulty, no pallor cyanosis Water Fluid intake is sufficient. Edema present over ankles. Turgor normal for the age Food Hb – 9.6gm%, BMI = 14.Food intake is not adequate or the diet is not nutritious. Elimination Voids and eliminates bowel without difficulty. Activity/ rest Frequent rest is required due to pain. Pain not completely relieved, Activity level ha s come down. Deformity of the joint secondary to the disease process and use of the joints. Social interaction Communicates well with neighbors and calls the daughter by phone Need for medical care is communicated to the daughter. Prevention of hazards Need instruction on care of joints and prevention of falls. Need instruction on improvement of nutritional status. Prefer to walk bare foot. Promotion of normalcy Has good relation with daughter
  47. 47. DEVELOPMENTAL SELF-CARE REQUISITES Maintenance of developmental environment Able to feed self , Difficult to perform the dressing, toileting etc Prevention/management of the conditions threatening the normal development Feels that the problems are due to her own behaviors and discusses the problems with husband and daughter.
  48. 48. HEALTH DEVIATION SELF CARE REQUISITES Adherence to medical regimen Reports the problems to the physician when in the hospital. Cooperates with the medication, Not much aware about the use and side effects of medicines Awareness of potential problem associated with the regimen Not aware about the actual disease process. Not compliant with the diet and prevention of hazards. Not aware about the side effects of the medications Modification of self image to incorporates changes in health status Has adapted to limitation in mobility. The adoption of new ways for activities leads to deformities and progression of the disease. Adjustment of lifestyle to accommodate changes in the health status and medical regimen. Adjusted with the deformities. Pain tolerance not achieved
  49. 49. MEDICAL PROBLEM AND PLAN ⚫ Physician’s perspective of the condition: Diagnosed with rheumatoid arthritis and is on the following medications:  T. Valus SR OD  T. Pan 40 mg OD  T. Tramazac 50 mg OD  T. Recofix Forte BD  T. Shelcal BD  Syp. Heamup 2tsp TID ⚫ Medical Diagnosis: Rheumatoid arthritis ⚫ Medical Treatment: Medication and physical therapy.
  51. 51. Area of Inadequacy!!!! Air Breaths without difficulty, no pallor cyanosis Water Fluid intake is sufficient. Edema present over ankles. Turgor normal for theage Food Hb – 9.6gm%, BMI = 14.Food intake is not adequate or the diet is not nutritious. Elimination Voids and eliminates bowel without difficulty. Activity/ rest Frequent rest is required due to pain. Pain not completely relieved, Activity level ha s come down. Deformity of the joint secondary to the disease process and use of the joints. Social interaction Communicates well with neighbors and calls the daughter by phone Need for medical care is communicated to the daughter. Prevention of hazards Need instruction on care of joints and prevention of falls. Need instruction on improvement of nutritional status. Prefer to walk bare foot. Promotion of normalcy Has good relation with daughter
  52. 52. NURSING CARE PLAN ⚫Therapeutic self care demand: Deficient area: food ⚫Adequacy of self care agency: Inadequate
  53. 53. NURSING DIAGNOSIS ⚫Inability to maintain the ideal nutrition related to inadequate intake and knowledge deficit
  54. 54. OUTCOMES AND PLAN Outcome:  improved nutrition  Maintenance of a balanced diet with adequate iron supplementation. Nursing Goals and objectives  Goal: to achieve optimal levels of nutrition.  Objectives: Mrs. X will:   state the importance of maintaining a balanced diet. List the food items rich in iron , that are available in the locality. Design of the nursing system:  supportive educative Method of helping:  guidance  Support  Teaching  Providing developmental environment
  55. 55. IMPLEMENTATION ⚫Mutually planned and identified the objectives and the patient were made to understand about the required changes in the behavior to have the requisites met.
  56. 56. EVALUATION ⚫Mrs. X understood the importance of maintaining an optimum nutrition. ⚫She verbalized that she will select the iron rich diet for her food. ⚫She listed the foods that are rich in iron and that are locally available. ⚫The self care deficit in terms of food is decreased with the initiation of the nutritional intake. ⚫The supportive educative system was useful for Mrs. X .
  57. 57. Usefulness of Theory: RESEARCH evelopment of research instruments  Exercise of Self Care Agency (Yamashita, Japan)  Appraisal of Self Care Agency  Self-As-Carer Inventory tudies that test elements of the theory in various populations  Children and adolescents  Diabetes mellitus  Hemodialysis patients
  58. 58. Usefulness of Theory: EDUCATION ⚫Laying out of the structure of nursing knowledge and explicating the domains of nursing knowledge ⚫Strong and effective framework for curricular design  45 schools in the US use the SCDNT as the basis for their curriculum
  59. 59. Usefulness of Theory: PRACTICE ⚫ Health promotion and care of the sick ⚫ Teaching self-care to individuals     Renal failure, hemo/peritoneal dialysis, renal transplant Post-stroke conditions Malignancies Elderly ⚫ Definition and description of various roles for nurses     Clinical nurse-specialist role Case-management role Advanced practice role Primary-care role
  60. 60. Theory Analysis: Simplicity ⚫Presented in a straightforward manner ⚫Relationship among entities can be presented in a simple diagram
  61. 61. Theory Analysis: Clarity ⚫Precisely defined ⚫Consistent with the language used in action theory and philosophy ⚫Congruent
  62. 62. Theory Analysis: Generality ⚫All of those who need nursing care ⚫All of situations in which individuals (including children) cannot meet all their self- care needs ⚫Appears that the theory is illness oriented rather with no indication of its use in wellness settings
  63. 63. Theory Analysis: Empirical Precision ⚫Generates hypotheses ⚫Gives additional knowledge ⚫Extremely contagious
  64. 64. Theory of Goal Attainment IMOGENE KING, RN, MSN, EdD, FAAN
  65. 65. HER LIFE ⚫Born in January 30, 1923 (West Point, Iowa) ⚫Youngest of three children ⚫Died on December 24, 2007, two days after suffering stroke
  66. 66. EDUCATIONAL BACKGROUND ⚫ 1945 – Nursing diploma from St. John’s Hospital of Nursing, St. Louis, Missouri ⚫ 1948 – BS Nursing & Education with minors in philosophy & chemistry from St. Louis University, St. Louis, Missouri ⚫ 1957 – MS Nursing from St. John’s University ⚫ 1961 – Ed.D. from Teachers College, Columbia University ⚫ 1980 – Honorary Ph. D from Southern Illinois University ⚫ Postdoctoral study in research design, statistics and computer
  67. 67. WORK EXPERIENCES ⚫Administrator (Ohio State University) ⚫Educator (St. John’s Hospital School of Nursing; Loyola University; University of South Florida) ⚫Practitioner (Adult Medical-Surgical Nursing) ⚫Assistant chief of the Research Grants Branch, Division of Nursing, Department of Health, Education and Welfare ⚫Professor emeritus at University of South Florida
  68. 68. ACHIEVEMENTS ⚫Founder of King International Nursing Group (KING) (1998) ⚫Jessie M. Scott award (ANA convention) ⚫Award presented to a registered nurse whose accomplishments in a field of practice, education, or research with significance for the improvement of nursing and health care
  69. 69. MAJOR FACTORS OF THE TIME THAT INFLUENCED KING’S THEORY ⚫Environment ⚫Knowledge Explosion ⚫Social Changes ⚫Educational Changes ⚫Scope of the Nursing Practice ⚫Current Goals ⚫Dimensions …nursing was striving for status as a science and a legitimate profession.
  70. 70. HER STORY ⚫1963.. challenged by her philosophy professors with a question, “Have you or any other nurses defined the ‘nursing act’?” ⚫1972.. reading course work led King to the Literature Systems analysis and General Systems Theory and hence to another set of questions
  71. 71. HER THOUGHTS ⚫What is the goal of nursing? ⚫What are the functions of nurses? ⚫How can nurses continue to expand their knowledge to provide quality care?
  72. 72. THEORETICAL SOURCES ⚫1971, 1981.. students, academic colleagues, nurse researchers, and clinicians  thinking ⚫1981.. General System Theory (Von Bertalanffy)  conceptual framework ⚫1988 .. Kaufman, Orlando and Peplau  thinking ⚫1988.. Kaufman’s 1958 doctoral dissertation  explore concepts of perception, time and stress ⚫…research conducted at Yale University School of Nursing to test Orlando’s (1961) theory of the deliberative nursing process  thinking
  73. 73. THEORETICAL SOURCES ⚫King and Peplau (as cited in Takahashi, 1992) pointed out the connections between their works with regard to patient outcome. ⚫1988.. a review of her 1971 book by Rosemary Ellis encouraged her to continue her work by deriving a theory from the General Systems Framework. The result…the Theory of Goal Attainment.
  74. 74. ASSUMPTIONS Human Beings  Open systems in constant interaction with environment ⚫ Individuals are social beings. ⚫ Individuals are sentient beings. ⚫ Individuals are rational beings. ⚫ Individuals are reacting beings. ⚫ Individuals are perceiving beings. ⚫ Individuals are controlling beings. ⚫ Individuals are purposeful beings. ⚫ Individuals are action-oriented beings. ⚫ Individuals are time-oriented beings.
  75. 75. King’s Theory and Nursing’s Metaparadigm - PERSON ⚫…social beings who are rational and sentient ⚫…communicate their thoughts, actions, customs, and beliefs through language ⚫…exhibit common characteristics like ability to perceive, to think, to feel, to choose between alternative courses of action, to set goals, to select means to achieve goals, and to make decisions
  76. 76. HUMAN NEEDS ⚫According to King, human being has three fundamental needs: (a)The need for the health information that is unable at the time when it is needed and can be used (b)The need for care that seek to prevent illness, and (c)The need for care when human beings are unable to help themselves.
  77. 77. ASSUMPTIONS Nursing ⚫The care of human beings ⚫Perceiving, thinking, relating, judging, and acting of same behaviors of patients ⚫Nursing situation: the immediate environment in which two individuals establish a relationship to cope with situational events ⚫Goal of Nursing: help individuals and groups attain, maintain, restore health or help individuals die with dignity.
  78. 78. King’s Theory and Nursing’s Metaparadigm - NURSING ⚫…a process of action, reaction, and interaction whereby nurse and client share information about their perceptions in the nursing situation ⚫… nurse and patient share goals, problems, and concerns and explore means to achieve a goal.
  79. 79. NURSING ⚫Goal of nurse: “To help individuals to maintain their health so they can function in their roles.” ⚫Domain of nurse: “includes promoting, maintaining, and restoring health, and caring for the sick, injured and dying. ⚫Function of professional nurse: “To interpret information in nursing process to plan, implement and evaluate nursing care.
  80. 80. ASSUMPTIONS Nurse-Client Interactions ⚫Perceptions of nurse & client influence interaction process. ⚫Goals, needs & values of nurse & client influence interaction. ⚫Individuals have a right to knowledge about themselves. ⚫Individuals have a right to participate in decisions that influence their life, their health, and community services.
  81. 81. ASSUMPTIONS Nurse-Client Interactions ⚫Health professionals have responsibility to share information to helps individuals make decisions about their health care. ⚫Individuals have a right to accept or to reject health care. ⚫Goals of health professionals and goals of recipients of health care may be incongruent.
  82. 82. King’s Theory and Nursing’s Metaparadigm - HEALTH ⚫…dynamic life experience of a human being ⚫…implies continuous adjustment to stressors in the external and internal environment through optimum use of one’s resources to achieve maximum potential for daily living
  83. 83. King’s Theory and Nursing’s Metaparadigm - ENVIRONMENT ⚫…the background for human actions ⚫Internal environment: transforms energy to enable person to adjust to continuous external environmental changes ⚫External environment: involves formal and informal organizations. Nurse is a part of the patient’s environment.
  84. 84. DYNAMIC INTERACTING SYSTEMS ⚫Three systems in the conceptual framework: ⚫Personal System (the individual) ⚫Interpersonal Systems (individuals interacting with one another) ⚫Social System (groups of people in a community/society sharing common goals, interests, and values) ⚫Study systems as a whole rather than as isolated parts of a system
  85. 85. DYNAMIC INTERACTING SYSTEMS Elements of each System ⚫Goal: Health ⚫Structure: 3 open systems ⚫Functions: identified in the reciprocal relationships as they interact ⚫Resources: essential to keep systems in harmony ⚫ People & money ⚫Decision making: critical to perform functions and attain goals
  86. 86. Personal System Concepts ⚫ Perception ⚫ Self ⚫ awareness of being a person separate from others ⚫ Growth and Development ⚫ Body Image ⚫ personal & subjective; acquired or learned; dynamic and changing ⚫ includes how person sees self & other’s reactions to one’s appearance) ⚫ Space ⚫ Time ⚫ Learning (1986, not defined)
  87. 87. Interpersonal System Concepts ⚫Interaction ⚫Communication ⚫Transactions ⚫Role ⚫Stress
  88. 88. Social System Concepts ⚫ Organization ⚫formal or informal structure that orders positions and activities ⚫ made up of persons with roles and positions to meet goals ⚫ Authority ⚫ regularity, direction and responsibility for actions ⚫ Power ⚫ energy necessary to avoid chaos in a society ⚫ Status ⚫ relationship of one’s place in a group to others ⚫ Decision Making ⚫ changing and orderly process wherein choices are made in relation to goals
  89. 89. THEORY OF GOAL ATTAINMENT ⚫ …elements are seen in the interpersonal systems in which two people, who are usually strangers, come together in a health care organization to help and be helped to maintain a state of health that permits functioning of roles. ⚫ …reflects King’s belief that the practice of nursing is differentiated from other healthcare professions by what nurses do with and for individuals ⚫ nurse and client communicate information, set goal mutually and then act to attain those goals
  90. 90. MAJOR CONCEPTS OF THE THEORY ⚫Interaction ⚫process of perception and communication between person and environment and between person and person ⚫represented by verbal or non-verbal behaviors that seek to reach goals
  91. 91. Feedback KING’S DIAGRAM OF INTERACTION Feedback
  92. 92. MAJOR CONCEPTS OF THE THEORY ⚫Perception ⚫reality as seen by an individual ⚫organizing, interpreting, and transforming information from sensory to memory
  93. 93. MAJOR CONCEPTS OF THE THEORY ⚫Communication ⚫exchange of information between people (face-to- face, electronic media, written) ⚫may be intrapersonal / interpersonal
  94. 94. MAJOR CONCEPTS OF THE THEORY ⚫Transaction ⚫process of interactions in which human beings communicate with the environment to achieve goals that are valued ⚫goal-directed human behaviors ⚫mutual goal setting
  95. 95. MAJOR CONCEPTS OF THE THEORY ⚫Role ⚫set of expected behaviors ⚫ Position ⚫ Rights and responsibilities ⚫ Relationship between individuals
  96. 96. MAJOR CONCEPTS OF THE THEORY ⚫Stress ⚫ever changing condition where an individual interacts with the environment to maintain balance for growth, development, and performance ⚫it is the exchange of information between human and environment for regulation and control of stressors
  97. 97. MAJOR CONCEPTS OF THE THEORY ⚫Growth and Development ⚫ever occurring changes in behavior and at the cellular and molecular level of an individual ⚫Moves a person from potential to achievement
  98. 98. MAJOR CONCEPTS OF THE THEORY ⚫Time ⚫an interval between two events that is experienced differently by each person
  99. 99. MAJOR CONCEPTS OF THE THEORY ⚫Space ⚫exists in every direction and is the same in all directions ⚫includes that physical area named territory ⚫defined by the behaviors of a person
  100. 100. THEORETICAL ASSERTIONS ⚫If perceptual accuracy (PA) is present in nurse- client (I) interactions, transactions (T) will occur. PA (I) =T
  101. 101. PERCEPTION What is the patient’s perception of the situation? Patient says ” I have undergone surgery for hernia”. “ The wound is getting healed, I have no other problem” “I have pain in the area of surgery when moving” “I’m taking medicines for hypertension for the last 7 years from here” “I have vision problem to my left eye. I had undergone a surgery for my right eye about 10 years back”. What are my perceptions of the situation? •Patient underwent herniorraphy operation on 30th March for indirect inguinal hernia which he kept untreated for 35 years. • Patient has health maintenance related problems. • Patient is at risk of developing infection. • Patient has pain related to surgical incision. •Patient may develop hypertension related complications in future.
  102. 102. THEORETICAL ASSERTIONS ⚫If nurse and client make transactions (T), goals will be attained (GA).
  103. 103. THEORETICAL ASSERTIONS ⚫If goals are attained (GA), satisfactions (S) will occur.
  104. 104. THEORETICAL ASSERTIONS ⚫If goals are attained (GA), effective nursing care (NCe) will occur.
  105. 105. THEORETICAL ASSERTIONS ⚫If transactions (T) are made in nurse-client interactions (I), growth and development (GD) will be enhanced.
  106. 106. THEORETICAL ASSERTIONS ⚫If role expectations and role performance as perceived by nurse and client are congruent (RCN), transactions (T) will occur.
  107. 107. THEORETICAL ASSERTIONS ⚫If role conflict (RC) is experienced by nurse and client or both, stress (ST) in nurse-client interactions (I) will occur.
  108. 108. THEORETICAL ASSERTIONS ⚫If nurses with special knowledge and skills communicate (CM) appropriate information to clients, mutual goal setting (T) and goal attainment (GA) will occur. [Mutual goal setting is a step in transaction and thus has been programmed as transaction.]
  111. 111. Nursing process method Nursing process theory (King) A system of oriented actions A system of oriented concepts Assessment Perception, communication and interaction of nurse and client Planning Decision making about the goals Agree on the means to attain the goals Implementation Transaction made Evaluation Goal attained
  112. 112. KING’S THEORY APPLIED ⚫Mr. Sy is 74yrs old, married, got admitted in L3 ward of ...Hospital on 03/27/08 with a diagnosis of indirect inguinal hernia, underwent herniorraphy with prolene mesh done on 03/30/08.
  113. 113. ASSESSMENT What other information do I need to assist this patient to achieve health? History Identification details Present History of Illness Past health history Family History Socioeconomic Status Life Style Physical examination Review of Systems Laboratory Investigations Other investigations What does this information mean to this situation? Patient neglected a health problem for 35 years Patient has acute pain at the site of surgical wound Patient has family history of inguinal hernia and risk for recurrence Patient has a risk for recurrence due to constipation. Patient has risk for infection due to inadequate knowledge and age. Patient is at risk of developing complications of hypertension Patient requires education regarding health maintenance
  114. 114. PERCEPTION What is the patient’s perception of the situation? Patient says ” I have undergone surgery for hernia”. “ The wound is getting healed, I have no other problem” “I have pain in the area of surgery when moving” “I’m taking medicines for hypertension for the last 7 years from here” “I have vision problem to my left eye. I had undergone a surgery for my right eye about 10 years back”. What are my perceptions of the situation? •Patient underwent herniorraphy operation on 30th March for indirect inguinal hernia which he kept untreated for 35 years. • Patient has health maintenance related problems. • Patient is at risk of developing infection. • Patient has pain related to surgical incision. •Patient may develop hypertension related complications in future.
  115. 115. JUDGMENT What conclusion (judgment) does this patient make? •Patient requires management for his pain •Patient understands the need for taking care of health risks and agrees to work on these aspects What conclusions Based on the assessment following nursing diagnoses were (judgment) do I formulated, i.e. the clinical judgment about the patient’s make? actual and potential problems. Nursing diagnosis 2.Acute pain related to surgical incision ·The data collected by 3.Risk for infection related to surgical incision assessment are used 4.Risk for constipation related to bed rest, pain medication to make nursing and NPO or soft diet diagnosis in nursing 5.Deficient knowledge regarding the treatment and home process. Acc. to King care in process of attaining 6.Ineffective health maintenance goal, the nurse identifies the problems, concerns and disturbances about which person seek help.
  116. 116. GOALS What goals do I think will serve the patient’s best interest? What are the patient’s goals? 1. The client will experience improved comfort, as evidenced by:  a decrease in the rating of the pain,  the ability to rest and sleep comfortably 4. The client will be free of infection as evidenced by normal temperature, normal vital signs. 5. The client will have improved bowel elimination, as evidenced by:  Elimination of stool without straining 7. Client will acquire adequate knowledge regarding the treatment and home care. P 8a . t C ie lin et n ’s t w go ila l l a stt a e rn ed : to health problems promptly Freedom from pain Rapid healing Adequate bowel movement Acquiring adequate knowledge regarding his health problems Are the patient’s goals and professional goals are congruent? Yes What does the patient perceives as the best way to achieve goals? Working with the health professionals Gaining knowledge Disclosing adequate information regarding health problems Is the patient willing to work towards the goals? Yes
  117. 117. IMPLEMENTATION Am I doing what the patient and I have agreed upon? Yes How am I carrying out the actions? On a mutually acceptable manner in accordance with the goals set. When do I carry out the action? According to priority, a few interventions require immediate attention. Other interventions are carried out during the period of hospitalization till 5th April. Why am I carrying out the action? Patient’s condition demands nursing care. Is it reasonable to think that the identified goals will be reached by carrying out the action? Yes
  118. 118. EVALUATION Are my actions helping the patient achieve mutually defined goals? Yes How well are goals being met? Short-term goals are met before discharge from hospital Long-term goals are expected to be met, because the patient is motivated to continue home care. What actions are not working? What is patient’s response to my actions? Patient is satisfied with my actions Are other factors hindering goal achievement? Patient’s age is a hindering factor in goal achievement regarding health maintenance. How should the plan be changed to achieve goals? Health teaching can be modified according to developmental stage. Involvement of family member in care of the patient.
  119. 119. Usefulness of Theory: RESEARCH ⚫Basis for development of middle-range nursing theories ⚫Model for Multicultural Nursing Practice (Rooda, 1992) ⚫Theory of Personal System Empathy (Alligood & May, 2000) ⚫Theory of Family Health (Doornbos, 2000)
  120. 120. Usefulness of Theory: EDUCATION ⚫Framework for the baccalaureate program (Ohio State University School of Nursing) ⚫Educational reform resulting in nursing education (Sweden)
  121. 121. Usefulness of Theory: PRACTICE ⚫A model for bedside nursing practice in the hospital setting (Coker & Schreiber, 1990) ⚫Managed care program in hospital settings (Hampton, 1994) ⚫Goal-Oriented Nursing Record system for documentation ⚫Structure of Quality Assurance Program
  122. 122. Theory Analysis ⚫SIMPLICITY ⚫Easily understood ⚫CLARITY ⚫Clear and conceptually defined from research literature at the time the theory was developed ⚫GENERALITY ⚫Others have critiqued it to have limited application to nursing esp. in patients who are unable to competently interact with the nurse
  123. 123. King’s Response to Critique: ⚫70% of communication is non-verbal ⚫It is impossible for a theory to address every person, event and situation ⚫Even Einstein’s Theory of Relativity could not be tested until space travel made testing possible
  124. 124. Theory Analysis ⚫Empirical Precision ⚫From a study of 17 patients, goals were attained in 12 cases (70%). ⚫King believes that if nursing students are taught the theory of goal attainment and it is used in nursing practice, goal attainment can be measured and the effectiveness of nursing care can be demonstrated. ⚫ Promoting health behaviors of adolescents (Hanna) ⚫ Interaction analysis between nurses and patients (Kameoka)
  125. 125. REFERENCES: George, J.B. (Ed.) (2008). Nursing theories: the base for professional nursing practice. Upper Saddle River, N.J. : Prentice Hall. Marriner-Tomey, A. & Alligood, M. (2006). Nursing theorists and their work. St. Louis, Mo. : Mosby. McEwen, M. & Willis, E. (2002). Theoretical basis for nursing. Philadelphia: Lippincott Williams & Wilkins. Nursing theories. (2008). Retrieved July 29, 2009 from Parker, M.E. (Ed.) (1990). Nursing theories in practice. New York: Northeastern Press.