A comparison of three models of nursing

of three models of nursing

A comparison Judith M Chavasse

Models of nursing need to be understood and also assessed for contextual relevance. An attempt to understand three models in a practical way is described, using two case studies to illustrate them. Questions about their suitability in the context of Irish nursing at this time are discussed.

stimuli.

A COMPARISON OF THREE MODELS OF NURSING One

ing Studies lecturers clinical over

in University

should expertise.

the

stimuli

beliefs of the Department

of the

years

1986

the

study

models

College

and

in the

summer

decided

of nursing

of Nurs-

Dublin

try to maintain How this is done

author

that

is that

of

which

to

ities

(Orem

this

article

models of nursing consideration: those described Tierney,

Sr.

Orem.

The

which

comprises

venting,

first

Callista is based

were chosen for by Roper, Logan

components ation model

and

modes: role

cept, dependence the ROY, affected experiences

and

Dorothea

on a model of Living seeking

of living with

in health physiological

function (Riehl person

and

and & Roy as an

by the world this world

illness

needs,

and

effects

which

&

Roy

maintain to

though

the using McFarlane

1986).

Orem’s individual

called

explore

analysis

model

three

suggested

activ-

The

the

in

models

in

in Table

1,

by

1980). using

of

activities

will be made

tabulated

(McFarlane

person unclear

Self Care

the

are

is described

are

round

to

stimuli

the

time

No attempt

they

a framework

Residual

this

health,

1980).

contribute

be affecting

at

im-

Elizabeth care

three

of two

models

as

for the descriptions.

pre-

in four self con-

of

inter-

1980). According adaptive system

through

may

most

contextual

(dependant)

relations

within

person;

stimuli

is organised

patients

(Roper et al 1980). Roy’s Adaptdescribes the goal of nursing as the

adaptation

adaptive

Roy

Activities

comforting

person’s

(Andrews

detail,

Three

which

whose

needed

caring

is that

the

of the focal stimulus.

vacation

for patients.

and

the effect

nursing

actually

stimulus

are all other

are factors but

focal

confronting

a level of has varied

she

while

The

mediately

without,

various

types

J M Chavasse BA RGN RNT Director, Department of Nursing Studies, Universii College Dublin Manuscript accepted November 1996

to is and of

Case 1 This

patient

had

initially

because

was

she had

loss, shortness leg.

an

been

a poor

of breath

Eventually,

caecum

with By

patient

was severely

but cared

the

in no pain. speak

for

appetite, and

the

for in a ward

some

and

alert

of

met

was

her

the

and

quite

weak,

and

could

hear,

difficulty. which

weight

of the left

anaemia

author

jaundiced

She was without

who care

of carcinoma

metastases

time

woman medical

swelling

a diagnosis liver

made.

see and

80-year-old

admitted

uses

She was being team

nursing, 177

178

NURSE

EDUCATION

TODAY

Table 1 Analysis of three models of nursing

Orem

ROY

Type of Model

Roper

Systems: adaptation

Systems: self-care

Systems: activities of living

Goal-content

Assisting man toward health by promoting and supporting his adaptive abilities

Assist man to achieve health and develop an optimal level of self-care agency

Maintaining activities of living (ALs); preventing, comforting, minimising dependency

Prescriptions

Manipulation of focal, contextual and residual stimuli

Acting for or doing for, guiding, supporting, providing a developmental environment, teaching

Goals negotiated between nurse and patient

Survey list Agency (action)

Nurse-patient Patient: adaptive system; it is the patient who must do the adapting Nurse: the supporter and promotor of adaptation

Nurse-patient Nurse: designer and controller of the system; possible substitute self-care agent Patient: assumption of self-care always stressed

Nurse-patient Nurse may observe and record, act for, work with, teach, help to adjust to (considerable emphasis on recording data)

Procedure

Nursing process Assessment, planning, intervention and reassessment

Nursing process Assessment, planning, intervention, evaluation

Dynamics

Patient: adaptive mechanisms Nurse: problem solving ability

Nursing process Determination of need for nursing, design system and plan for implementation and initiating, conducting, and controlling the system Nurse: knowledge of science and technologies Patient: abilities, interest and motivation

Patients

Man: a biopsychosocial being in constant interaction with his environment; on a particular point on healthillness continuum

Man with therapeutic self-care demands that cannot be met by his own self-care agency

Framework

Any setting, any time, with man in relation to situations of health and illness

Wherever the goal of nursing activity can be realised

Wherever an individual is unable to carry out ALs for himself

Terminus

When the patient adapts to stimuli placing unusual demands on him

Patient’s achievement of his optimal level of self-care agency

Whether or not the goals set by patient and nurse have been reached

following Tierney

a modification model (hereafter

of the Roper, referred

Logan,

to as Roper’s

identified. her

long

The hair

Nurse: information from physiological, psychological, and nursing science Patient: key behaviours observable in all human beings Man and his activities of living (ALs); he may or may not be able to carry these out for himself

patient plaited

edentulous

observed

living with the exception

using the other two moelds for comparison

sexuality

as a learning

planned,

Roy’s

using

Roper’s

model.

Activities

of

She was

also assessed and a nursing care plan drawn up

which was not assessed. Table 2 shows the nursing problems identified and intervention living, such as personal cleansing and dressing, are not recorded unless problems have been

and moisture.

daily, mouth

model). Figure 1 shows the extent of her dependence in relation to all the activities of of expressing

for cleanliness

was bed bathed and

and

exercise.

adaptation

model

Ptpsiological modes ~ the problems, goals and planned action - were very similar to those

daily

Apply zinc and castor oil after washing daily or more often if needed Encourage patient to walk across ward and to sit up for as long as she is willing Use Polycore mattress

Alleviate discomfort Protect skin Encourage healing Maintain mobility Prevent pressure sores

Monitor development

Incontinent of faeces with diarrhoea, skin on thighs and vulva excoriated Weak and lethargic

Jaundice

Observe and record colour Avoid mirrors

daily

Give Milpar 1Oml if BNO 2 G.S. if BNOx3/7 If patient has diarrhoea, keep clean and dry

One bowel motion/day

Bowels alternate between constipation and diarrhoea

daily

daily

17/7/86

Serve small helpings; offer savoury foods, incl. potatoes (patient likes these) Pour out iced water and keep within reach Supplement above with egg flips, ‘Build-up’ etc.

Eat something at every meal Fluid intake, 1500 ml/day minimum Maintain nutrition

Poor appetite

Review date

Action

Goal

Problem

Table 2 Nursing care plan for Patient 1 using Roper’s model

Signature

Evaluation

NURSE EDUCATION ‘I‘ODAY

180

Life-span

Activities of living

Conception

preventing comforting seeking Maintaining a safe environment Communicating Breathing Eating and drinking Eliminating Personal cleansing and dressing Controlling body temperature Mobilising Working and playing Expressing sexuality Sleeping Dying

already

identified,

level assessment

though

x X X X X X )f -* x

x

ations for problems

the attempt

clarified

already

Continuum Totally independen

Totally dependent

Fig. 1. Patient l’s levels of dependence

second

(Roper, Logan, Tierney)

to do a

some explan-

1980): 1. Acting or doing for another.

noted.

2. Guiding. 3. Supporting

Self--concept

modes were

ment in that verbal

cues

ation

and

served

inaccessible

the patient

behaviour

but

In

general

she was

did not seem enquiry

4. Providing

and

reIt

did not see this as

by a nurse or the writer

The

difference

self-care mined

of her generation are not accustomed to talking about their inner feelings. This point applies to

needed.

ation

from

the patient’s

to the nurses

family.

Several

fied and intervention The

and

issue that

behaviour

interaction

potential

problems

weakness

with

her

were identi-

apparent

model was that of personal physical

in rel-

planned.

became

choice.

and dependency

using

this

In spite of the patient

had the opportunity to make choices about her life. Contact with family and friends was frequent, ward

in line with policy,

cultural

although

this

been specified in the original

Orem’s Orem

self care model identified

expectations

and

contact

not

five helping

had

care plan.

(Table

promotes

between

and the

her amount

Most

the patient’s

need for

to provide

it drter-

ability and

method

of the nursing

for the patient,

although

of

nursing

involved

‘doing’

we also endeavoured

to provide physical and psychological support. Such an environment was created by the hos-

and Interdependency were assessed on

Role function evidence

model also.

that

development.

5. Teaching.

did not know her well enough or simply people

thr grssessment of Orem’s

and

an environment

personal

convers-

quiet

(physically

psychologically)

assess-

to be depressed.

seems that either the patient a legitimate

for

did not pick up any

or prompts.

b Deatl h

?:

l

Care

Requirements

same as the problems model;

identified

the

using Roper’s

between

solitude

allowed us to recognise

that thr

patient

her own solitude

created

into

whom

the balance’

Self

and interaction ing

assessing

The universal

were seen to be much

herself,

choosing

she interacted.

The

by withdraw-

the

people

patient

showed

with no

awareness of approaching death and neither picked up the nurses’ openings nor gave cu(‘s which allowed the introduction of the xubj~t. She

received

Holy

Communion

and

kept

hvr

Rosary beads at hand, but for her this \\;15 as much part of living as preparation for tl+t~g. picked up the nurses’ openings nor ~;I\Y (‘I,<‘5 Orem’s model illustrated the extent to which the patient’s care was self-motivated. Although

4)

methods

pital and ward atmosphere.

(Orem

she was weak and dependent,

the only self care

*Stimulus: focal (F); contextual (C); residual (R)

Loneliness

Shares feelings with son and daughterin-law indirectly: food and new clothing given and accepted Probably very little verbal exchange (R)

Accepts help calmly Still very much her own person in making the choices open to her

Interdependency

Encourage and allow all possible choices e.g. diet, how long she will stay up, what she will wear, etc.

Encourage and allow contact with family and friends

Maintain adaptation

Sense of failure

Now in a dependent relationship (F) but supported by a loving family (C) O.K. in cultural context?

Obviously a much loved mother and grandmother

Be available to listen if she chooses to talk Develop supportive relationship

Maintain adaptation

Anxiety Powerlessness Social disengagement

Role function

Intervention

Goal

Problem (P)

Reserved (C or R)? Does not see this as legitimate enquiry by nurse (R) Denial ? Acceptance?

Second level assessment*

Impossible to assess Not apparently aware that she is dying, but often says ‘I’m 80

First level assessment

Self-concept

Mode

Table 3 Nursing assessment care plan for Patient 1 using Roy’s model (Physiological mode omitted)

Avoid over-tiredness Maintain mobility within limit of her willingness Maintain privacy and dignity Keep good communications with family

Poor appetite Prefers savoury food, esp. potatoes

Alternates between constipation and diarrhoea Incontinent of faeces with diarrhoea; skin excoriated

Weak and lethargic Willing to get up for & hr and walk with help for 5 mins

Appears content but does not talk much to nurses or patients Talks to famity and looks happiest when they’re there General condition deteriorating Pressure sores (P)

All systems slowing down Distressing realisation that she is dying (P)

Jaundice

Maintaining sufficient intake of food

Provision of care for eliminative purposes

Maintaining balance between activity and rest

Maintaining balance between solitude and interaction

Promotion of normalcy Development requisite

Health deviation requisite

Prevention of hazards

Fluid intake: 1500 ml/day minimum

Cannot pour out water; likes iced water best Dehydration (P)

Maintaining sufficient intake of water

Monitor development

Prevent complications Allow ignorance or support towards positive acceptance of impending death

Maintain comfort Prevent pressure sores

1 bowel motion/day Alleviate discomfort. Protect skin; promote healing.

Eat something at every meal

Ensure adequate ventilation Prevent pneumonia

Mild dyspnoea Hypostatic pneumonia (P)

Goal

model

Maintaining sufficient intake of air

problem)

1 using Orem’s

Assessment (P=Potential

and care plan for Patient

Universal self-care requisites

Table 4 Nursing assessment

Observe and record colour Avoid mirrors

General observation Listen to what she does and does not say

Polycore mattress Turn 4 hourly when in bed

Ensure privacy during toilet Allow free visiting

Assist and encourage Katy to walk across ward and to sit up for as long as she will

Give Milpar 1Oml if BNO 2 G.S. if BNOx3/7 Keep clean and dry. Apply Zinc and Castor Oil after washing daily or oftener if sore

Serve small helpings, esp. of first course Supplement with egg flips (NB not too sweet), ‘Build up’, etc.

Pour out her iced water and leave within reach

Assist to sit up Assist to get up and walk

Plan

Jaundice is deeper; no skin irritation

N.A.D. Appears to be unaware and peacef u I

Says she is comfortable Skin intact

Continues quiet and withdrawn but alert with family

Gets up for $ hr every a.m. and most p.m.‘s

B.O. x 1 on 15th and 16th Skin still inflamed; less tender

Usually eats a little Needs coaxing but dislikes actual help

Adequate hydration

Breathes fairly comfortably Chest clear

Evaluation on 17/7/86

TODAY

183

(see listing

of Orem’s

five

it

plain

the

NURSE

requirement

for

compensatory

was the prevention

- for

which

elimination

nursing

and

was

wholly

activity,

care

was

largely compensatory - for water,

food, solitude,

interaction,

care

was partly compensatory - for air and

rest,

care

was self care,

vided the environment This we found rather appeared

pro-

was right.

surprising

factor

as the patient

son & Vaughan

influencing

1984)

knowledge

of conditions

promoting

was probably

limited

then appropriate

(Pear-

the patient’s

well-being

health

and

and it was not

to start teaching

helping patient care,

model

methods), could

carry

although

was dependent nurses from

her.

on medical

ation

recurring, living

by

about

patient

was

very

different

-

a

widow of 58 with no family who lived alone in the country. tigation

She had been admitted

of abdominal

pain,

sional bouts of vomiting. (actually

chronic

nausea

She had had ‘asthma’

obstructive and

for invesand occa-

airways

for several

years

previously.

She

and rather

tense; she was willing,

prompting,

to speak

disease)

a mastectomy

appeared

dignified,

freely

and

15 years intelligent

with a little clearly

about

her health and way of life. The

patient

as Activities

was largely of Living

independent

were

so far

concerned;

even

her appetite was quite good most of the time. The only problems identified using Roper’s model

were

her

which

were

relieved

pain

and

nausea

(both

pharmacologically

necessary)

and

alleviated

by encouraging

anxiety.

The

latter

her

anxieties. Table 5 is an abbreviated

of

anxiety

became

apparent

of teaching

cussing her home situation could be introduced.

and

Assessment

the

nurses’ praise and admirwere supportive,

she

house

could

needed

liver function

the need

to reduce the

tests how

ation exercises.

ring

help

a

a lot of teaching:

and liver tests and about medication were and

them,

was able to relax,

at least while

abnormal.

started

She

also

the limits

to learn

and noticed

pain or nausea

sometimes

relieved

vironment

made

availability

of a nurse who could

completely. all

was unusual.

of

relax-

when

this

the

that if she present ward

en-

possible,

but

the

teach

the patient

nurses

were

she was discharged

tedly, to complete date.

her tests in another Her

were

The

Although

to go home,

at a later

in

in an

She was keen about these as she

had read about

frustrated

a sy-

a bell

needed

quite

and

organised

to live within

her breathlessness

pleased

as was

and of loneliness

if she

some

ation

but

more reconciled

teaching

relaxwas rather

unexpechospital

was incomplete

and it was felt that more could have been done for her.

was to be

to express

relaxation

became

She had already

reconsidered

to do

dependency

to talk about her fear of cancer

which

of

Apart

the nurses

when her

DISCUSSION

and

These brief studies raise a number

Care Plan using Roy’s model (Rambo 1984). As can be seen, some of the reasons behind her interventions

need

of the future,

alone.

and the

anti-emetics.

She feared

The

the opportunity

prescription

and

of her abilities

emergency. The patient

second

she

this she did not

neighbour’s

The

self

she was in hospital

for analgesics for her.

that

out her own physical

after some counselling

stem

Case 2

became

while

to the situation.

self care

was that

self care model this

anything

so very weak and dependent.

A cultural

Orem’s Using

of hazards.

EDUCATION

additional and

dis-

and neighbourhood

both

patients,

very

satisfactory

Roper’s way

model

of issues. For

seemed

of identifying

to be a physical

nursing problems and goals and planning the relevant care. Roper’s deliberate decision to base her model on observable behaviours (Roper et al 1980) leaves us with a material or

focal (F); contextual

(C); residual (R)

Widow Good neighbour

Role functions

Stimulus:

No immediate family but has good friends nearby

Interdependence

Personal self

Physical self

Worry that cancer will recur Worry about liver function tests Worry about future

(C)

Depends on neighbours for gardening and maintenance (C) Can give them help with book-keeping

Associated with mastectomy (C) Tentative medical diagnosis (F) Fear that ‘asthma’ will make her unable to cope alone, esp. with house and garden (C) Feels that she is a drag on neighbours

Fear of future Fear of increasing dependency

Anxiety

or

Help her to recognise that there is a fair exchangeand so adapt to situation

Mrs R. will appear more relaxed Mrs R. will sleep better Mrs R. will sleep better

Alleviate

Pain

Self concept

pain

Abdominal

Regulation

Relieve completely alleviate

Nausea and occasional vomiting

I, impaired liver function? 2.Tension 1. Impaired liver function?

Nausea

exertion

Live within limits

D.O.E.

C.0.A.D

D.O.E.

Physiological Oxygen and circulation Nutrition

Goal

Problem

Second level assessment

First level assessment

Mode

2 using Roy’s model

and care plan for Patient

Table 5 Nursing assessment

exercise

Discuss

Verbalise anxieties

Teach about liver tests

Relaxation

1. Find out what helps (apart from drugs) 2. Teach relaxation 1, Find out what helps 2. Teach relaxation

Teach and help to plan

Intervention

NURSE

physical

definition

her writings

of man (see Table

do acknowledge

social needs (Maslow ation and Orem’s

1) though

Maslow’s

1970).

‘higher’

Both Roy’s Adapt-

self care models include

these

her needs

EDUCATION

as fully as the writer

had

a

clearer

factorial

kind

ing the nursing she needed.

functions

and

what

nursing

human

should

attributes

address.

The

writer’s

own belief is that any model of nursing include

acknowledgement

the transpersonal nature,

On ‘a more

provided

practical

dying,

of

model

but

note,

care which

by student

The

as no problem

model

applied.

for.

or

When

potential

in

way

model

‘AL’

of no

it is dif-

it

was

being

was used, several

problems

but socio-cultural

ment difficult.

chiefly

this was a limitation

the

Roy’s

the

In retrospect,

psycho-social

identified

model

who needed

was recognised,

to be sure whether

the

Roper’s

for

were

also

factors made assess-

The issue of personal

choice was

manifested. model illustrated

of self-care

dependent

even

patient.

In

a surprising

by a very weak addition

Three

issues related

rent.

Aggleton

to

and

physical

are

relevance;

sible need dying

Requisite

to modify

though,

again,

very sensitive situation Our picture

of a Developclarified

her

her self-concept complete

towards

assessment

In

practice,

with a

a

loving

provided

factors and potential

use of Roper’s

socio-cultural

physical

nursing,

model

milieu

family and an a framework

individualised care. Since the second

of a

was expanded

use of the two latter models which alerted some additional

pos-

was difftcult.

of this patient

which

by us to

suitable

cally

or mentally

contextual The

had

than

and

model, Even

begin model,

stand

levels a clear

on a complete towards

goals

nurses

for

inadequate. Although the student nurses had neither the time nor the experience to explore

in Ireland: most

nearer

than

so recently

to under-

of any model

a second of man,

aban-

consideration. model,

centred

is important

in

of care, if that model points likely

and

there

reserved

be

is not

to become

cultural

to

represents

unlikely

list of

for the patients

for which

has

home,

into a check

and relevant

are

frustrated. The social also

are

in

Roy’s

are fairly obscure.

all the facets

vision

time,

was

syllabuses

Nurses need the opportunity

Although

nurs-

understand

we have

and include

adopted. Stalling

tients

where

developed

is little better

lists of tasks

Other

the appropriate-

nursing to

can very easily degenerate the

physi-

Very few nurses who

and parts of Orem’s Roper’s

their

as being

people.

knowledge

using the present could

in

model

are also relevant.

ness of the model chosen. trained

that models

for severely

will influence

problems.

less need

Orem’s

appasuggest

specific

Roy’s

level of nursing

ing is practiced

combined

model

to recognise

considerations

priorities

included

became (1986)

handicapped

selecting

attentive chaplain, for well planned

Roper’s

content

Chalmers

contextually

more

probably patient

for understand-

The actual

to context

they instance

doned.

Consideration

and

that nurses will come of nursing

and

Self-Care

Use

methods

CONTEXT OF THE NURSING SITUATION

ALs which

interaction.

multi-

of assessment, care plan, intervention evaluation was very similar in both cases.

care, our attention was also focused on the first patient’s need for a balance between solitude mental

of helping

a useful classification

Ireland

Use of Orem’s degree

provided

live categories

the

to,

aspects

was being

allow

of

and tension.

of human

nurses of 18 or 19 years of

does

was planned

ficult

aspect

for the first patient,

a lot of physical

care

of, and attention

or spiritual

by Roy and Orem.

was adequate

age.

should

as well as the bio-psycho-social

developed

or

did, if Roy’s

understanding

causes of her anxiety

of Orem’s

be,

I II.5

model could have been used, they would have

needs, though they are expressed differently in each. It comes back to what we believe manto

TODAY

context

of the pa-

considered.

Patient

the vast majority about

to consider

their that

enough

extremely

1

of people

feelings nurses

and

should

enquire about their social circumstances unless these have a direct bearing on their medical

186

NUKSE

diagnosis.

EDUCATION

When

TODAY

upset,

they value

ear; when calm they protect a change Patient ing

of topic or a joke. 2 represents

to see health

context.

Although

On the other hand,

a minority and

illness

such

people

much in a minority,

a listening

their feelings with who are learnin

a wholistic

are

their number

still

very

is increasing

and nurses need to be aware of, and prepare

to

serve, them too. This exercise

to

understand practical

in the

achieved;

questions models

undertaken

about became

abstract.

in addition

need

and

practice;

to be critical

choosing

This certain

the appropriateness apparent.

the need for conceptual thinking

in

order

in a more

way than is possible by merely reflect-

ing on them partly

was

three models of nursing

and

This models it

does

goal

of different

is not to decry to guide illustrate

seek relevance

a model for practice.

was

important

our the when

References Andrew H A, Roy C 1986 Essentials of the Roy Adaptation Model. Appleton-Century-Crofts. Connecticut McFarlane E A 1980 Nursing theory: the comparison of four theoretical proposals. Journal of Advanced Nursing 5: 3-19 Maslow A E 1970 Motivation and personality 2nd cdn. Harper & Row, New York Orem D E 1980 Nursing concepts of practice. McGraw-Hill, New York Pearson A, Vaughan B 1984 A systematic approach to nursing care. Open University Press, Milton Keynes, p 553 Rambo B J 1984 Adaptation nursing: assessment and intervention. W B Saunders, Philadelphia Rich1 J P, Roy C 1980 Conceptual models for practice Appleton-Century-Crofts, New York Roprr N, Logan W, Tierney A 1980 The elements of nursing. Churchill Livingstone, Edinburgh