1. Faculty of Nursing & Allied Health Sciences NMNM5103 Nursing Model and Development

2. Faculty of Nursing & Allied Health Sciences Topic 2: Learning Outcomes 1.Differentiate the models of nursing related to concept of nursing client : Johnsons`,Roys` & Neuman 1.Analyse nursing theories on human being- interaction: Rogers`, Nightingales, `Watson & Benners` 1.Differentiate the models of nursing related to concept of nursing client : Johnsons`,Roys` & Neuman 1.Analyse nursing theories on human being- interaction: Rogers`, Nightingales, `Watson & Benners` By the end of this session, student will be able to:

3. Faculty of Nursing & Allied Health Sciences  The Neuman System model provides a comprehensive, flexible, holistic and systems-based perspective.  Focuses attention on the response of the client system to actual or potential environmental stressor.  Use of primary, secondary and tertiary nursing prevention, intervention for retention, attainment and maintenance of optimal, client system wellness - Betty Neuman (1996) - Betty Neuman (1996)  The Neuman System model provides a comprehensive, flexible, holistic and systems-based perspective.  Focuses attention on the response of the client system to actual or potential environmental stressor.  Use of primary, secondary and tertiary nursing prevention, intervention for retention, attainment and maintenance of optimal, client system wellness - Betty Neuman (1996) - Betty Neuman (1996) Neuman System model

4. Faculty of Nursing & Allied Health Sciences Client-Client system 5 variables -Physiological – bodily structure and function -Psychological - mental processes and relationships -Sociocultural – combined social and cultural processes -Developmental – life developmental processes -Spiritual – spiritual belief influence

5. Faculty of Nursing & Allied Health Sciences Environment “ All Internal & external factors or influences surrounding the identified client or client system” Neuman 1995.

6. Faculty of Nursing & Allied Health Sciences Nursing Nursing`s major concern is to keep the client system stable by (i) accurately assessing the effects and possible effects of environmental stressors, and (2) assisting client adjustments required for optimal wellness.

7. Faculty of Nursing & Allied Health Sciences Roys` Adaptation model Has been in use for approximately 35 years Providing direction for nursing practice, education, administration and research Focuses on enhancing the basic life processes of the individual and group Cognitive processes: input processes (arousal and attention, sensation and perception), central processes (coding concept formation,memory, language) output processes (planning and motor responses) and emotion. Through these cognitive processes, adaptive responses occur.

8. Faculty of Nursing & Allied Health Sciences Theoretical system of knowledge viewing client as biopsychosocial being (ill or potentially so) who adapts to changing environment (nurse act through nursing process to promote adaptation)Theoretical system of knowledge viewing client as biopsychosocial being (ill or potentially so) who adapts to changing environment (nurse act through nursing process to promote adaptation) Goals of nursing: promote persons` adaptation in physiologic needs, self- concepts, role function, and interdependence.Goals of nursing: promote persons` adaptation in physiologic needs, self- concepts, role function, and interdependence. Theoretical system of knowledge viewing client as biopsychosocial being (ill or potentially so) who adapts to changing environment (nurse act through nursing process to promote adaptation)Theoretical system of knowledge viewing client as biopsychosocial being (ill or potentially so) who adapts to changing environment (nurse act through nursing process to promote adaptation) Goals of nursing: promote persons` adaptation in physiologic needs, self- concepts, role function, and interdependence.Goals of nursing: promote persons` adaptation in physiologic needs, self- concepts, role function, and interdependence. Roys` Adaptation model

9. Faculty of Nursing & Allied Health Sciences Dorothy Johnson

10. Faculty of Nursing & Allied Health Sciences -The BSM of nursing was first proposed in 1968 -It advocates the fostering of efficient and effective behavioral functioning of the patient to prevent illness. -The patient is defined as a behavioral system composed of seven behavioral subsystems. -Each subsystem is comprised of four structural characteristics. -. An imbalance is each results in disequalibrium -The nurse role s to help the patient maintain his/her equalibrium -The BSM of nursing was first proposed in 1968 -It advocates the fostering of efficient and effective behavioral functioning of the patient to prevent illness. -The patient is defined as a behavioral system composed of seven behavioral subsystems. -Each subsystem is comprised of four structural characteristics. -. An imbalance is each results in disequalibrium -The nurse role s to help the patient maintain his/her equalibrium The Theory

11. Faculty of Nursing & Allied Health Sciences Major Concept of the model The client is seen as a collection of behavioral systems that interrelate to form the behavioral system Each individual has patterned, purposeful, repetitive ways of acting that comprise a behavioral system specific to that individual

12. Faculty of Nursing & Allied Health Sciences The four major concepts Human being: having 2 major systems, the biological system and behavioral system, nursing is focus on behavioral system Society: relates to environment, an individual’s behavior influenced by the events in environment Health: is a purposeful adaptive response, physically, mentally, emotionally and socially to internal and external stimuli in order to maintain stability and comfort Nursing: primary goal is to foster equilibrium within the individual, maintaining balance in the behavior system when illness occurs in an individual.

13. Faculty of Nursing & Allied Health Sciences -To assist the patient whose behavior is proportional to social demands -To assist the patient who is able to modify his behavior in ways that it supports biological imperatives. -To assist the patient who is able to benefit to the fullest extent during illness from the physicians knowledge and skills -To assist the patient whose behavior does not give evidence of unnecessary trauma as a consequence of illness. - -To assist the patient whose behavior is proportional to social demands -To assist the patient who is able to modify his behavior in ways that it supports biological imperatives. -To assist the patient who is able to benefit to the fullest extent during illness from the physicians knowledge and skills -To assist the patient whose behavior does not give evidence of unnecessary trauma as a consequence of illness. - Goals of Nsg according to BSM

14. Faculty of Nursing & Allied Health Sciences Johnson Nursing specific objective is to maintain or restore the person`s behavioral system balance and stability, or to help the person achieve a more optimum level of functioning

15. Faculty of Nursing & Allied Health Sciences The Subsystems of behavior

16. Faculty of Nursing & Allied Health Sciences -Individual made up of 7 subsystems -Interrelated parts function together to form a whole -Interact with each other -Interrelated and interconnected -Environment constantly acting on subsystems. -Individual made up of 7 subsystems -Interrelated parts function together to form a whole -Interact with each other -Interrelated and interconnected -Environment constantly acting on subsystems. SubsystemsSubsystems

17. Faculty of Nursing & Allied Health Sciences -Behavioral associated with the development and maintenance of interpersonal relationships with parents, peers, authority figures. -Establish a sense of relatedness and belonging with others including attachment behavior, interpersonal relationships and communication skills. -Goal attainment -Behavioral associated with the development and maintenance of interpersonal relationships with parents, peers, authority figures. -Establish a sense of relatedness and belonging with others including attachment behavior, interpersonal relationships and communication skills. -Goal attainment Affiliative or attachment subsystems

18. Faculty of Nursing & Allied Health Sciences -Behavior associated with obtaining assistance from others in the environment for completing tasks and/or emotional support -Includes seeking of attention, approval, recognition, basic self care skills and emotional -Behavior associated with obtaining assistance from others in the environment for completing tasks and/or emotional support -Includes seeking of attention, approval, recognition, basic self care skills and emotional Dependency Subsystem

19. Faculty of Nursing & Allied Health Sciences -Behaviors associated with the intake of needed resources from the external environments, including food, fluid, information, knowledge and objects for the propose of establishing an effective relationship with the environment. Ingestive subsystem

20. Faculty of Nursing & Allied Health Sciences -Behavior associated with the release of physical waste products from the body. -Express feelings. -Behavior associated with the release of physical waste products from the body. -Express feelings. Eliminative Subsystem

21. Faculty of Nursing & Allied Health Sciences -Behavior associated with a specific gender based identity for the purpose of ensuring pleasure/procreation, and knowledge and behavior being congruent with biological Sexual Subsystem

22. Faculty of Nursing & Allied Health Sciences -Behavior associated with real or potential threat in the environment for the purpose of ensuring survival. -Protection of self through direct or indirect acts. -Identification of potential danger. -Behavior associated with real or potential threat in the environment for the purpose of ensuring survival. -Protection of self through direct or indirect acts. -Identification of potential danger. Aggressive Protective Subsystem

23. Faculty of Nursing & Allied Health Sciences -Behavior associated with mastery of oneself and one’s environment for the purpose of producing a desired effect. -Includes problem solving activity -Knowledge of personal strengths and weaknesses. -Behavior associated with mastery of oneself and one’s environment for the purpose of producing a desired effect. -Includes problem solving activity -Knowledge of personal strengths and weaknesses. Achievement Subsystem

24. Faculty of Nursing & Allied Health Sciences -Behavior associated with maintaining and restoring energy equilibrium, e.g relief from fatigue, recovery from illness, sleep behavior, leisure/recreational interests and sick role behavior. RestorativeRestorative

25. Faculty of Nursing & Allied Health Sciences -Nurse creates a balance between client and environment to achieve an optimal level of functioning Purpose of the Systems Theory

26. Faculty of Nursing & Allied Health Sciences Subsystems Individual made up of 7 subsystems Interrelated parts function together to form a whole Interact with each other Interrelated and interconnected Environment constantly acting on subsystems.

27. Faculty of Nursing & Allied Health Sciences Five Core Principals Wholeness and Order Stabilization Reorganization Hierarchic Interaction Dialectical Contradiction

28. Faculty of Nursing & Allied Health Sciences Wholeness and Order Developmental analogy of wholeness and order is continuity and identity. Continuity and change can exist across the life span Continuity is in the relationship of the parts rather than in their individuality.

29. Faculty of Nursing & Allied Health Sciences Stabilization Dynamic systems respond to contextual changes. Set point maintained by altering internal conditions to compensate for changes in external conditions. Nurses act as external regulators Monitor patient response, looking for successful adaptation to occur. Nurses intervene help patient restore behavioral system balance

30. Faculty of Nursing & Allied Health Sciences Reorganization Occurs when the behavioral system encounters new experiences in the environment that cannot be balanced by existing system mechanisms. Nurses acts to provide conditions or resources essential to help the accommodation process.

31. Faculty of Nursing & Allied Health Sciences Hierarchic Interaction Hierarchies, or a pattern of relying on particular subsystems, lead to a degree of stability.

32. Faculty of Nursing & Allied Health Sciences -Motivational force for behavioral change -Environmental domains that the person is responding include the biological, psychological, cultural, familial, social and physical setting -Nursing intervention: focus on restoring behavioral system balance leading to a new level of development. -Motivational force for behavioral change -Environmental domains that the person is responding include the biological, psychological, cultural, familial, social and physical setting -Nursing intervention: focus on restoring behavioral system balance leading to a new level of development. Dialectical Contradiction

33. Faculty of Nursing & Allied Health Sciences The Johnson Model Proposes For behavior to be maintained, it must be protected, nurtured and stimulated –Protected from noxious stimuli that threaten the survival of the behavioral system –Nurturance, which provides adequate input to sustain behavior –Stimulation to continue growth of the behavior and counteracts stagnation

34. Faculty of Nursing & Allied Health Sciences Limitation Very individualistic Family of the client is only considered as environment Focused on the nursing care of the hospitalised and ill Does not focus on health promotion, primary prevention Limited literature on the use of BSM in clinical practice to provide framework for nursing research

35. Faculty of Nursing & Allied Health Sciences Definition of nursing Johnson vs Roy J: External regulatory force acting to preserve the organization and integration of patient`s behavior at an optimal level when behavior is a threat to social, physical health or illness R: Theoretical system of knowledge viewing client as biopsychosocial being ill or potentially so who adapts to changing environment. Nurses act through nursing process to promote adaptation

36. Faculty of Nursing & Allied Health Sciences Focus of Nursing Johnson vs Roy J: Man as behavioral system with subsystems, each having structure, a function and functional imperatives (drive, set, behavior) and each requiring protection, stimulation and nurturance. R: Focal, contextual and residual stimuli and their effect on the cognator and regulator mechanisms, in turn effecting four adaptive modes: physiologic, self-concept, role function and interdependence

37. Faculty of Nursing & Allied Health Sciences Goals of Nursing Johnson vs Roy J: Behavioral system balance, subsystems that function efficiently and effectively R: Promote person`s adaptation in physiologic needs; self-concept, role function, and interdependence.

38. Faculty of Nursing & Allied Health Sciences Nursing Problems Johnson vs Roy Nursing Problems Johnson vs Roy J: Structural functional stress in one subsystem (insufficiency, discrepancy) and between subsystems (incompatibility, dominance) R: Ineffective coping mechanisms causing ineffective responses that disrupt the integrity of the person

39. Faculty of Nursing & Allied Health Sciences Nursing Therapeutic Johnson vs Roy J: Inhibition, constriction,supplementation,protection, nurturing (supportive/maintenance, teaching, counseling and behavior modification) R: Manipulation of focal, and contextual stimuli with patient`s zone of positive coping

40. Faculty of Nursing & Allied Health Sciences Roles and Images of Nurses in Outcomes theories (J n R) They provide an image of the nurse as goal setter, a futurist, environmentalist, who has extrasensory and energy preservation powers.

41. Faculty of Nursing & Allied Health Sciences Jean Watson`s theory Dr. Jean Watson, PhD, RN, AHN- BC, FAAN Watson Caring Science Institute

42. Faculty of Nursing & Allied Health Sciences Caring –healing consciousness and intentionally to care and promote healing as energy within the human environment field of a caring moment - 10 carative factors. Caratas (greek) meaning “to cherish and appreciate, giving special attention to, or loving” Caring –healing consciousness and intentionally to care and promote healing as energy within the human environment field of a caring moment - 10 carative factors. Caratas (greek) meaning “to cherish and appreciate, giving special attention to, or loving” Watsons` Philosophy in nursing practice

43. Faculty of Nursing & Allied Health Sciences Watson`s (2001) translation of the carative factors into clinical caritas processes Practice of loving kindness and equanimity within context of caring consciousness Being authentically present, and enabling and sustaining the deep belief system and subjective life world of self and the one-being-cared-for Cultivation of one`s own spiritual practices and transpersonal self, going beyond ego self, opening to others with sensitivity and compassion

44. Faculty of Nursing & Allied Health Sciences Watson`s (2001) translation of the carative factors into clinical caritas processes Developing and sustaining a helping-trusting, authentic caring relationship Being present to, and supportive of, the expression of positive and negative feelings as a connection with deeper spirit of self and the one-being-cared-for

45. Faculty of Nursing & Allied Health Sciences Theories and Education Benner`s application of the Dreyfus model; learning needs at the early stages of clinical knowledge development are different from those required at later stages. These differences need to be acknowledged and valued to develop nursing education programs appropriate for the background experience of the student.

46. Faculty of Nursing & Allied Health Sciences Domains of Nursing Practice The Helping Role The teaching-coaching function The diagnostic and patient-monitoring function Effective management of rapidly changing situations Administering and monitoring therapeutic intervention and regimens Monitoring and ensuring the quality of health care practices Organizational and work-role competencies Benners 2007

47. Faculty of Nursing & Allied Health Sciences Contribution of Nursing Theories to practice Benner`s : (interpretive phenomenological approach) aid in the development of clinical promotion ladders, new graduates orientation programme and clinical knowledge development seminar. Jelsma(1990) applied Benners findings in developing cross-training programme to address staff imbalances Benner : nursing practice concerns and the role of caring in practice - error recognition and enhancement of the safety or nursing practice (Benner & Malloch,2010).

48. Faculty of Nursing & Allied Health Sciences Dreyfus model applied to nursing Novice: had no experience of the situations in which they are expected to perform Must be given rules to guide their performance, however, rules cannot tell them the most relevant tasks to perform in actual situation

49. Faculty of Nursing & Allied Health Sciences Dreyfus model applied to nursing Advanced Beginner: ones who can demonstrate marginally accepted performance, who have coped with enough real situations to note. Eg: assessing patient`s readiness to learn depends on experience with previous patients with similar teaching-learning needs.

50. Faculty of Nursing & Allied Health Sciences Dreyfus model applied to nursing Competent: typified by the nurse who has been on the job in the same situation for two or three years. The plan dictates which attributes and aspects of the current and contemplated future situation.

51. Faculty of Nursing & Allied Health Sciences Dreyfus model applied to nursing Proficient performers are best taught by use case studies where their ability to grasp the situation is solicited and taxed. Proficient nurses understand a situation as a whole because they perceive its meaning in terms of long-term goals.

52. Faculty of Nursing & Allied Health Sciences Dreyfus model applied to nursing Expert: The expert nurse is able to identify changes and immediate action to overcome the problem if the endotracheal tube of the ventilated is block due to thick secretion, by looking at the changes in vital signs and patient condition, the expert nurse will just do the suction immediately and proceed to reintubate the patient when needed.

53. Faculty of Nursing & Allied Health Sciences Discussion Application of Benner`s theory in education and research

54. Faculty of Nursing & Allied Health Sciences Thank you