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and assessment by spiritual director or psychological counselor. Environment o Environment is not clearly defined. Nursing o "an interpersonal process whereby the professional nurse practitioner assists an individual, family or community to prevent or cope with experience or illness and suffering, and if necessary to find meaning in these experiences. Description of the theory Travelbee believed nursing is accomplished through human-to-human relationships that begin with the original encounter and then progress through stages of emerging identities, developing feelings of empathy, and later feelings of sympathy. The nurse and patient attain a rapport in the final stage. For meeting the goals of nursing it is a prerequisite to achieving a genuine human-to-human relationships. This relationship can only be established by an interaction process. It has five phases. o The inaugural meeting or original encounter o Visibility of personal identities/ emerging identities. o Empathy o Sympathy o Establishing mutual understanding and contact/ rapport Travelbee's ideas have greatly influenced the hospice movement in the west. Conclusion Travelbee's theory has significantly influenced nursing and health care. Travelbee's ideas have greatly influenced the hospice movement in the west.
Health As Expanding Consciousness Margaret Newman = Health is the expansion of consciousness. - Newman, 1983
INTRODUCTION The theory of health as expanding consciousness stems from Rogers' theory of unitary human beings. The theory of health as expanding consciousness was stimulated by concern for those for whom health as the absence of disease or disability is not possible, (Newman, 2010). The theory has progressed to include the health of all persons regardless of the presence or absence of disease, (Newman, 2010). The theory asserts that every person in every situation, no matter how disordered and hopeless it may seem, is part of the universal process of expanding consciousness a process of becoming more of oneself, of finding greater meaning in life, and of reaching new dimensions of connectedness with other people and the world, (Newman, 2010). BACHGROUND OF THE THEORIST Born on October 10, 1933. Bachelors degree - University of Tennessee in 1962
Masters degree - University of California in 1964 Doctorate - New York University in 1971 She has worked in - University of Tennessee, New York University, Pennsylvania State University, University of Minnesotat, University of Minnesota THEORY DEVELOPMENT She was influenced by following theorists: Martha Rogers - Martha Rogers theory of Unitary Human Beings was the main basis of the development of her theory, Health as Expanding Consciousness Itzhak Bentov The concept of evolution of consciousness Arthur Young The Theory of Process David Bohm The Theory of Implicate ASSUMPTIONS 1. Health encompasses conditions heretofore described as illness, or, in medical terms, pathology 2. These pathological conditions can be considered a manifestation of the total pattern of the individual 3. The pattern of the individual that eventually manifests itself as pathology is primary and exists prior to structural or functional changes 4. Removal of the pathology in itself will not change the pattern of the indivdual 5. If becoming ill is the only way an individual's pattern can manifest itself, then that is health for that person 6. Health is an expansion of consciousness. DESCRIPTION OF THE THEORY The theory of health as expanding consciousness (HEC) was stimulated by concern for those for whom health as the absence of disease or disability is not possible. Nurses often relate to such people: people facing the uncertainty, debilitation, loss and eventual death associated with chronic illness. The theory has progressed to include the health of all persons regardless of the presence or absence of disease. The theory asserts that every person in every situation, no matter how disordered and hopeless it may seem, is part of the universal process of expanding consciousness a process of becoming more of oneself, of finding greater meaning in life, and of reaching new dimensions of connectedness with other people and the world (Newman, 2010). Humans are open to the whole energy system of the universe and constantly interacting with the energy. With this process of interaction humans are evolving their individual pattern of whole. According to Newman understanding the pattern is essential. The expanding consciousness is the pattern recognition. The manifestation of disease depends on the pattern of individual so the pathology of the diseases exists before the symptoms appear so removal of disease symptoms does not change the individual structure. Newman also redefines nursing according to her nursing is the process of recognizing the individual in relation to environment and it is the process of understanding of consciousness. The nurse helps to understand people to use the power within to develop the higher level of consciousness. Thus it helps to realize the disease process, its recovery and prevention. Newman also explains the interrelatedness of time, space and movement. Time and space are the temporal pattern of the individual, both have complementary relationship. Humans are constantly changing through time and space and it shows unique pattern of reality. NURSING PARADIGMS Health Health and illness are synthesized as health - the fusion on one state of being (disease) with its opposite (non-disease) results in what can be regarded as health. Nursing Nursing is caring in the human health experience. Nursing is seen as a partnership between the nurse and client, with both grow in the sense of higher levels of consciousness Human The human is unitary, that is cannot be divided into parts, and is inseparable from the larger unitary field Persons as individuals, and human beings as a species are identified by their patterns of consciousness The person does not possess consciousness-the person is consciousness. Persons are centers of consciousness within an overall pattern of expanding consciousness Environment Environment is described as a universe of open systems STRENGTHS AND WEAKNESSES Strengths Can be applied in any setting Generates caring interventions W eaknesses Abstract Multi-dimensional Qualitative Little discussion on environment CRITIQUE Clarity
Semantic clarity is evident in the definitions, descriptions, and dimensions of the concepts of the theory. Simplicity The deeper meaning of the theory of health as expending consciousness is complex. The theory as a whole must be understood, nut just the isolated concepts. Generality The theory has been applied in several different cultures It is applicable across the spectrum of nursing care situations. Empirical Precision Quantitative methods are inadequate in capturing the dynamic, changing nature of this theory. Derivable Consequences Newman's theory provides an evolving guide for all health-related disciplines. CONCLUSION Newman's theory can be conceptualized as A grand theory of nursing Humans cannot be divided into parts Health is central to the theory and is seen and is seen as a process of developing awareness of self and the environment Consciousness is a manifestation of an evolving pattern of person-environment interaction
Health Seeking Behavior (HSBs): Institutional Integrity - the values, financial stability, and wholeness of health care organizations at local, regional, state, and national levels. Best Policies are protocols and procedures developed by an institution for overall use after collecting evidence. DEVELOPMENT OF THE THEORY Kolcaba conducted a concept analysis of comfort that examined literature from several disciplines including nursing, medicine, psychology, psychiatry, ergonomics, and English First, three types of comfort (relief, ease, transcendence) and four contexts of holistic human experience in differing aspects of therapeutic contexts were introduced. (Kolcaba KY & Kolcaba RJ, 1991) A taxonomic structure was developed to guide for assessment, measurement, and evaluation of patient comfort. ( Kolcaba, 1991) Comfort as a product of holistic nursing art. ( Kolcaba K, 1995) A broader theory for comfort was introduced ( Kolcaba KY,(1994). The theory has undergone refinement and tested for its applicability. DESCRIPTION OF THE THEORY Nursing Nursing is described as the process of assessing the patient's comfort needs, developing and implementing appropriate nursing interventions, and evaluating patient comfort following nursing interventions. Intentional assessment of comfort needs, the design of comfort measures to address those needs, and the reassessment of comfort levels after implementation. Assessment may be either objective, such as in the observation of wound healing, or subjective, such as by asking if the patient is comfortable. Health Health is considered to be optimal functioning, as defined by the patient, group, family or community Person/Patient Patients can be considered as individuals, families, institutions, or communities in need of health care. Environment Any aspect of the patient, family, or institutional surroundings that can be manipulated by a nurse(s), or loved one(s) to enhance comfort. CONCLUSION Holistic comfort is defined as the immediate experience of being strengthened through having the needs for relief, ease, and transcendence met in four contexts of experience (physical, psycho spiritual, social, and environmental) (Kolcaba, 2010) The theoretical structure of Kolcaba's comfort theory has real potential to direct the work and thinking of all healthcare providers within one institution. (March A & McCormack D, 2009).
Person
Nursing Skills are carried out to achieve a specific patient-centered purpose rather than completion of the skill itself being the end goal. Skills are made up of a variety of actions, and characterized by harmony of movement, precision, and effective use of self.
Each Person (whether nurse or patient), is endowed with a unique potential to develop self-sustaining resources. People generally tend towards independence and fulfillment of responsibilities. Self-awareness and self-acceptance are essential to personal integrity and self-worth. Whatever an individual does at any given moment represents the best available judgment for that person at the time. KEY ELEMENTS Wiedenbach proposes 4 main elements to clinical nursing. o a philosophy o a purpose o a practice and o the art. The Philosophy The nurses' philosophy is their attitude and belief about life and how that effected reality for them. Wiedenbach believed that there were 3 essential components associated with a nursing philosophy: o Reverence for life o Respect for the dignity, worth, autonomy and individuality of each human being and o resolution to act on personally and professionally held beliefs. The Purpose Nurses purpose is that which the nurse wants to accomplish through what she does. It is all of the activities directed towards the overall good of the patient. The Practice Practice are those observable nursing actions that are affected by beliefs and feelings about meeting the patients need for help. The Art The Art of nursing includes o understanding patients needs and concerns o developing goals and actions intended to enhance patients ability and o directing the activities related to the medical plan to improve the patients condition. The nurses also focuses on prevention of complications related to reoccurrence or development of new concerns. PRESCRIPTIVE THEORY Wiedenbach's prescriptive theory is based on three factors: The central purpose which the practitioner recognizes as essential to the particular discipline. The prescription for the fullfillment of central purpose. The realities in the immediate situation that influence the central purpose. Diagram
CONCLUSION Nursing is the practice of identification of a patients need for help through o observation of presenting behaviors and symptoms o exploration of the meaning of those symptoms with the patient o determining the cause(s) of discomfort, and o determining the patients ability to resolve the discomfort or if the patient has a need for help from the nurse or other healthcare professionals. Nursing primarily consists of identifying a patients need for help.
Has gained prior experience in actual situations to recognize recurring meaningful components Principles, based on experiences, begin to be formulated to guide actions Competent Typically a nurse with 2-3 years experience on the job in the same area or in similar day-to-day situations More aware of long-term goals Gains perspective from planning own actions based on conscious, abstract, and analytical thinking and helps to achieve greater efficiency and organization Proficient Perceives and understands situations as whole parts More holistic understanding improves decision-making Learns from experiences what to expect in certain situations and how to modify plans Expert No longer relies on principles, rules, or guidelines to connect situations and determine actions Much more background of experience Has intuitive grasp of clinical situations Performance is now fluid, flexible, and highly-proficient Different levels of skills reflect changes in 3 aspects of skilled performance: 1. Movement from relying on abstract principles to using past concrete experiences to guide actions 2. Change in learners perception of situations as whole parts rather than in separate pieces 3. Passage from a detached observer to an involved performer, no longer outside the situation but now actively engaged in participation SIGNIFICANCE OF THE THEORY These levels reflect movement from reliance on past abstract principles to the use of past concrete experience as paradigms and change in perception of situation as a complete whole in which certain parts are relevant Each step builds on the previous one as abstract principles are refined and expanded by experience and the learner gains clinical expertise. This theory changed the profession's understanding of what it means to be an expert, placing this designation not on the nurse with the most highly paid or most prestigious position, but on the nurse who provided "the most exquisite nursing care. It recognized that nursing was poorly served by the paradigm that called for all of nursing theory to be developed by researchers and scholars, but rather introduced the revolutionary notion that the practice itself could and should inform theory. CONCLUSION Nursing practice guided by the human becoming theory live the processes of the Parse practice methodology illuminating meaning, synchronizing rhythms, and mobilizing transcendence Research guided by the human becoming theory sheds light on the meaning of universal humanly lived experiences such as hope, taking life day-by-day, grieving, suffering, and time passing
Imogene King's Theory of Goal Attainment Introduction Imogene King was born in 1923. Completed her Bachelor in science of nursing from St. Louis University in 1948 Completed her Master of science in nursing from St. Louis University in 1957 Completed her Doctorate from Teachers college, Columbia University Kings Conceptual Framework It includes: Several basic assumptions Three interacting systems Several concepts relevant for each system Basic assumptions Nursing focus is the care of human being Nursing goal is the health care of individuals & groups Human beings: are open systems interacting constantly with their environment Interacting systems: o personal system o Interpersonal system o Social system Concepts are given for each system Concepts for Personal System Perception Self Growth & development Body image Space Time Concepts for Interpersonal System Interaction Communication Transaction Role Stress Concepts for Social System Organization
Authority Power Status Decision making Major Theses of Kings conceptual framework Each human being perceives the world as a total person in making transactions with individuals and things in environment Transaction represents a life situation in which perceiver & thing perceived are encountered and in which person enters the situation as an active participant and each is changed in the process of these experiences Kings Theory of Goal Attainment Theory of goal attainment was first introduced by Imogene King in the early 1960s. Theory describes a dynamic, interpersonal relationship in which a person grows and develops to attain certain life goals. Factors which affects the attainment of goal are: roles, stress, space & time Propositions of Kings Theory From the theory of goal attainment king developed predictive propositions, which includes: If perceptual interaction accuracy is present in nurse-client interactions, transaction will occur If nurse and client make transaction, goal will be attained If goal are attained, satisfaction will occur If transactions are made in nurse-client interactions, growth & development will be enhanced If role expectations and role performance as perceived by nurse & client are congruent, transaction will occur If role conflict is experienced by nurse or client or both, stress in nurse-client interaction will occur If nurse with special knowledge skill communicate appropriate information to client, mutual goal setting and goal attainment will occur. Nursing Process and Theory of Goal Attainment Nursing process method A system of oriented actions Assessment Planning Implementation Evaluation Nursing process theory A system of oriented concepts Perception, communication and interaction of nurse and client Decision making about the goals Be agree on the means to attain the goals Transaction made Goal attained
ASSUMPTIONS OF THE HEALTH PROMOTION MODEL The HPM is based on the following assumptions, which reflect both nursing and behavioral science perspectives: 1. Individuals seek to actively regulate their own behavior. 2. Individuals in all their biopsychosocial complexity interact with the environment, progressively transforming the environment and being transformed over time. 3. Health professionals constitute a part of the interpersonal environment, which exerts influence on persons throughout their life span. 4. Self-initiated reconfiguration of person-environment interactive patterns is essential to behavior change THEORETICAL PROPOSITIONS OF THE HEALTH PROMOTION MODEL Theoretical statements derived from the model provide a basis for investigative work on health behaviors. The HPM is based on the following theoretical propositions: 1. Prior behavior and inherited and acquired characteristics influence beliefs, affect, and enactment of health-promoting behavior. 2. Persons commit to engaging in behaviors from which they anticipate deriving personally valued benefits. 3. Perceived barriers can constrain commitment to action, a mediator of behavior as well as actual behavior. 4. Perceived competence or self-efficacy to execute a given behavior increases the likelihood of commitment to action and actual performance of the behavior. 5. Greater perceived self-efficacy results in fewer perceived barriers to a specific health behavior. 6. Positive affect toward a behavior results in greater perceived self-efficacy, which can in turn, result in increased positive affect. 7. When positive emotions or affect are associated with a behavior, the probability of commitment and action is increased. 8. Persons are more likely to commit to and engage in health-promoting behaviors when significant others model the behavior, expect the behavior to occur, and provide assistance and support to enable the behavior. 9. Families, peers, and health care providers are important sources of interpersonal influence that can increase or decrease commitment to and engagement in health-promoting behavior. 10. Situational influences in the external environment can increase or decrease commitment to or participation in health-promoting behavior. 11. The greater the commitments to a specific plan of action, the more likely health-promoting behaviors are to be maintained over time. 12. Commitment to a plan of action is less likely to result in the desired behavior when competing demands over which persons have little control require immediate attention. 13. Commitment to a plan of action is less likely to result in the desired behavior when other actions are more attractive and thus preferred over the target behavior. 13. Persons can modify cognitions, affect, and the interpersonal and physical environment to create incentives for health actions.
o o o o
o o
1996- Retired from teaching. Newman's Health as Expanding Consciousness was influenced by Martha Rogers. Newman (2003) writes:
The theory of health as expanding consciousness stems from Rogers' theory of Unitary Human Beings. Rogers' assumptions regarding patterning of persons in interaction with the environment are basic to the view that consciousness is a manifestation of an evolving pattern of person-environment interaction...Consciousness includes not only the cognitive and affective awareness normally associated with consciousness, but also the interconnectedness of the entire libing system, which includes physiochemical maintenance and growth processes as well as the immune system. This pattern of information, which is the consciousness of the system, is part of a larger, undivided pattern of an expanding universe Newmans theory of pattern recognition provides the basis for the process of nurse-client interaction. Newman suggested that the task in intervention is a pattern recognition accomplished by the health professional becoming aware of the pattern of the other person by becoming in touch with their own pattern. Newman suggested that the professional should focus on the pattern of the other person, acting as the reference beam in a hologram. Relationship to the Metaparadigm Concepts Newman has designated caring in the human health experience as the focus of nursing discipline and has specified the focus as the metaparadigm of the discipline. Nursing -to help clients get in touch with the meaning of their lives by the identification of their patterns of relating -Intervention is a form of non intervention whereby the nurses presence assists clients to recognize their own patterns of interacting with the environment. -facilitates pattern recognition in clients by forming relationships with them at critical points n their lives and connecting with them in an authentic way.
-The nurse-client relationship is characterized by a rhythmic coming together and moving apart as clients encounter disruption of their organized predictable state. -Nurses are seen as partners in the process of expanding consciousness. Person -Person as individuals are identified by their individual patterns of consciousness. -Persons are further defined as centers of consciousness within an overall pattern of expanding consciousness -The definition of person has also been expanded to include family and community. Environment -Environment is not explicitly defined but is described as being the larger whole, which is beyond the consciousness of the individual. Health -A fusion of disease and non-disease creates a synthesis that is regarded as health. -Disease and non-disease are each reflections of the larger whole; therefore a new concept pattern of the whole is formed. -Newman has stated that pattern recognition is the essence of the emerging health. Manifest health, encompassing disease and nondisease can be regarded as the explication of the underlying pattern of person-environment.
Based on her view of the person as patient, Hall conceptualized nursing as having three aspects, and delineated the area that is the specific domain of nursing, as well as those areas that are shared with other professions. Hall believed that this model reflected the nature as a professional interpersonal process. She visualized each of the three overlapping circles as an aspect of the nursing process related to the patient, to the supporting sciences, and to the underlying philosophical dynamics. The circles overlap and change in size as the patient progresses through a medical crisis to the rehabilitative phase of the illness. In the acute care phase, the cure is the largest. During the evaluation and follow-up phase, the care circle is predominan
Care This is the part of the model reserved for nurses, and focused on performing that noble task of nurturing the patients, meaning the component of this model is the motherly care provided by nurses, which may include, but is not limited to provision of comfort measures, provision of patient teaching activities and helping the patient meet their needs where help is needed. This aspect provided the opportunity for closeness and required seeing the process as an interpersonal relationship. Hands on care for patients produces an environment of comfort and trust and promotes open communication between nurses and patients. Cure The second aspect of the nursing process is shared with medicine and is labeled as the cure. Hall comments on the two ways that this medical aspect of nursing may be viewed; it may be viewed as the nurse assisting the doctor by assuming medical tasks or functions. The other view of this aspect of nursing is to see the nurse helping the patient through his or her medical, surgical, and rehabilitative care in the role of comforter and nurturer. Core The third are that nursing shares with all of the helping professions is that of using relationships for therapeutic effect the core. This area emphasizes the social, emotional, spiritual, and intellectual needs of the patient in relation to family, institution, community and the world. Knowledge foundational to the core was based on the social sciences and therapeutic use of self. Through the closeness offered by the provision of intimate bodily care, the patient will feel comfortable enough to explore with the nurse who he is, where he is, where he wants to go and will take or refuse help in getting there the patient will make amazingly rapid progress toward recovery and rehabilitation. Hall believed that through this process, the patient would emerge as a whole person.
One of the most important relationship lessons I learned was this: The relationships we have with other people are projections of the relationships we have within ourselves. Our external relationships and our internal relationships are in fact the same relationships. They only seem different because we look at them through different lenses. Lets consider why this is true. Where do all your relationships exist? They exist in your thoughts. Your relationship with another person is whatever you imagine it to be. Whether you love someone or hate someone, youre right. Now the other person may have a completely different relationship to you, but understand that your representation of what someone else thinks of you is also part of your thoughts. So your relationship with someone includes what you think of that person and what you believe s/he thinks of you. You can complicate it further by imagining what the other person thinks you think of him/her, but ultimately those internal representations are all you have. Even if your relationships exist in some objective reality independent of your thoughts, you never have access to the objective viewpoint. Youre always viewing your relationships through the lens of your own consciousness. The closest you can get to being objective is to imagine being objective, but that is in no
way the same thing as true objectivity. Thats because the act of observation requires a conscious observer, which is subjective by its very nature. At first it might seem troublesome that you can never hope to gain a truly accurate, 100% objective understanding of your relationships. You can never escape the subjective lens of your own consciousness. That would be like trying to find the color blue with a red lens permanently taped over your eyes. That doesnt stop people from trying, but such attempts are in vain. If you fall into the trap of trying to think of your relationships as objective entities that are external to you, youll be using an inescapably inaccurate model of reality. Consequently, the likely outcome is that youll frustrate yourself to no end when it comes to human relationships. Youll make relating to other people a lot harder than it needs to be. Intuitively you may know something is off in your approach to relationships, but youll remain stuck until you realize that every relationship you have with another person is really a relationship that exists entirely within yourself. Fortunately, once you embrace the subjective nature of relationships, youll have a much easier time relating to people. Its easier to get where you want to go when you have an accurate map. The subjective view of relationships implies that you can change or improve your relationships with others by working on the internal relationships within yourself. Furthermore, you can improve your internal relationships, such as your self-esteem, by working on your relationships with others. Ultimately its all the same thing. Heres a basic example of how this works. When I first met Erin, I quickly noticed she had an aversion towards orderliness. Having a messy room was a habit since childhood, and being organized was a concept forever alien to her. In Erins filing cabinet, I once found a file labeled Stuff I Dont Need. Chew on that for a while. On the other hand, I grew up in a house that was always and I do meanalways neat and tidy. Even as a child, I took pride in keeping my room clean and well organized. So it probably comes as no surprise that I often push Erin to be neater and more organized. If we try to look at this situation objectively, you might suggest solutions like me working on becoming more tolerant of disorder, Erin working on being neater, or a mixture of both. Or you might conclude were incompatible in this area and that we should try to find ways to reduce the level of conflict. Basically the solution will be some kind of compromise that seeks to mitigate the symptoms, but the core issue remains unresolved. Lets see what the subjective lens has to say now. This model says that my relationship with Erin is purely within my own consciousness. So my conflict with Erin is just the projection of an internal conflict. Supposedly my desire for Erin to be neater and more organized means that I really want to improve in this area myself. Is that true? Yes, I have to admit that it is. When I criticize Erin for not being neat enough, Im voicing my own desire to become even more organized. This is an entirely different definition of the problem, one that suggests a new solution. In this case the solution is for me to work on improving my own standards for neatness and order. Thats a very different solution than what we get with the objective model. To implement this solution, Erin neednt even be involved. From the standpoint of the objective model, this subjective solution seems rather foolish. If anything it will only backfire. Wouldnt my working on becoming neater just increase the conflict between me and Erin? Now heres the really fascinating part. When I actually tried the subjective solution by going to work on myself, Erin suddenly began taking a keen interest in becoming more organized herself. She bought new home office furniture and assigned new homes to objects that were previously cluttering her workspace. She hired a cleaning service to clean the house and did more decluttering before they came over. She bought new bedroom furniture for our children. She did a lot of purging and donated many old
items to charity. She began looking for a housekeeper and wrote up a list of cleaning tasks to be outsourced. And I really wasnt pushing her to do this. If anything she started pushing me a bit. Somehow when I worked on myself (recognizing that this is an internal issue, not an external one), Erin came along for the ride. Ive tested this pattern in other ways, and it continues to play out. My external relationships keep changing to keep pace with my internal relationships. Ive seen this effect with other people too, but its been most obvious with Erin and my kids, since theyre the people I spend the most time with. Its rather spooky at times how strong and immediate the effect is. However, the subjective model suggests that this is exactly how reality works, so Im glad to have a paradigm that fits the results. I encourage you to experiment to see how your external relationships reflect your internal ones. Try this simple exercise: Make a list of all the things that bother you about other people. Now re-read that list as if it applies to you. If youre honest youll have to admit that all of your complaints about others are really complaints about yourself. For example, if you dislike George Bush because you think hes a poor leader, could this be because your own leadership skills are sub par? Then go to work on your own leadership skills, or work on becoming more accepting of your current skill level, and notice how George Bush suddenly seems to be making dramatic improvements in this area. It can be hard to admit that your complaints about others are really complaints about yourself, but the upside is that your relationship issues reveal where you still need to grow. Consequently, a fantastic way to accelerate your personal growth is to build relationships with others. The more you interact with others, the more you learn about yourself. I believe the true value of human relationships is that they serve as pointers to unconditional love. According to the subjective model, when you forgive, accept, and love all parts of yourself, you will forgive, accept, and love all other human beings as they are. The more you improve your internal relationships between your thoughts, beliefs, and intentions, the more loving and harmonious your human relationships will become. Hold unconditional love in your consciousness, and youll see it reflected in your reality.
REFERRENCE; http://www.stevepavlina.com/blog/2007/01/understanding-human-relationships/
From Novice to Expert to Mentor: Shaping the Future By Kathleen Dracup, RN, DNSc and Christopher W. Bryan-Brown, MD From the School of Nursing, University of California, San Francisco, San Francisco, Calif (KD), and the Department of Anesthesiology, Albert Einstein College of Medicine, Bronx, NY (CWB-B). The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires. William Arthur Ward Many of us can relate to the story that Jon Carroll, 1 a columnist for the San Francisco Chronicle, tells about his first public singing recital. He had taken a series of singing lessons and then found himself standing on a stage about to sing his first solo in front of a large audience. It took him 4 attempts to find the opening note while he also battled an uncontrollable head bob. Scanning the audiences faces while he was singing, Carroll said he had the "unshakable perception that cyanide gas had been released in the room and that the face of every person . . . was set in the final rictus of death." The conclusion of the song was followed by polite applause (the same sort of applause, he wrote, that might occur at the end of a particularly painful 2-hour kettledrum solo). But, to his surprise, his singing teacher walked over to him with tears running down her face and put her arm around him, saying proudly to the audience, "I just want to say that when this man came to me. . .he couldnt even sing Happy Birthday." The audience applauded wildly. Carroll was stunned at the teachers remarks and the audiences reaction. Clearly, this was more than a teacher. She was a mentor. She inspired.
dissatisfaction with the hospital work environment of the 1990s. While fewer people have been seeking nursing careers, the demand for nurses has never been greater (with a projected need for 1 million more nurses by 2010). 2 The aging of the baby boomers has created a population growth of elderly or soon-to-be-elderly patients, and advances in healthcare (particularly in our critical care specialty) have led to increasingly complex care. It appears, however, that the worst of the shortage may now be over, perhaps fueled by a depressed job market and a shortage of places for professional employment. The American Association of Colleges of Nursing reported that nursing school enrollments had risen more than 16% in 2003 compared with the previous year. 2 In addition to experiencing an influx of new applicants, nursing schools have adapted their curricula to incorporate accelerated programs and programs for people with baccalaureate degrees in other professions who wish to return to school to study nursing. Although these programs help produce more nurses quickly, they decrease the time devoted to gaining clinical experience. The influx of a substantial number of new nurses into the profession, many of whom may be relatively uninformed about the realities of todays healthcare system, and the growth of accelerated programs present the next challenge for the critical care team in terms of assimilating these nurses into practice.
situation and give new nurses confidence while carefully monitoring their actions. Being a learner in the challenging environment of an ICU can be difficult, and novice nurses may feel an incredible sense of failure or shame when they make a mistake.
Mentors Wanted
The anticipated influx of new nurses will most likely put demands on current clinical nurse experts and require that they step up into a mentor role for this next generation of nurses. Mentorship has its earliest roots in Homers Odysseywritten almost 3000 years ago.5 As the story goes, the goddess Athena assumed the role of a nobleman named Mentor in order to teach Telemachus, Odysseuss son, and to guide him through lifes challenges. Robert Fitzgerald 5 correctly refers to Athenas cognomen in the first book of the Odyssey as "Mentes." We need talented mentors to guide the next generation of nurses. If the only nurse mentors who apply for the job are those who are long on experience but short on knowledge and skill, we will scare off the next generation! The concept of a mentor is familiar in the world of business, but more foreign to nursing. Mentors do more than teach skills; they facilitate new learning experiences, help new nurses make career decisions, and introduce them to networks of colleagues who can provide new professional challenges and opportunities. Mentors are interactive sounding boards who help others make decisions. We like the 5 core competencies of leaders and mentors developed for the Robert Wood Johnson Nurse Fellows Program.6 The first competency is self-knowledgethe ability to understand and develop yourself in the context of organizational challenges, interpersonal demands, and individual motivation. Mentors are aware of their individual leadership strengths and have the ability to understand how others see them. Mentors are also aware of their personal learning styles and are able to work with the different styles of other people. The second competency is strategic visionthe ability to connect broad social, economic, and political changes to the strategic direction of institutions and organizations. With strategic vision, mentors have the ability to identify key trends in the external environment (eg, reimbursement policies for hospitals, changing roles for men and women, changing patient demographics) and understand the broader impact of the environment on healthcare. With this competency, leaders are able to focus on goals and advise wisely. The third competency is risk-taking and creativitymentors have the ability to be successful by moving outside the traditional and patterned ways of success. They are able to identify creative responses to organizational challenges and can tolerate ambiguity and chaos. The mentor is one who develops and sustains creativity and entrepreneurship, encouraging others to take risks and turn mistakes into opportunities for growth. The fourth competency is interpersonal and communication effectiveness. Great mentors have the ability to nurture a partnership that is mutual and equal, not patriarchal or matriarchal. This skill set requires that mentors be able to give the people they guide a feeling of being included and involved in the relationship. Mentors are great communicators and also great active listeners. They avoid power struggles and dependent relationships and are respectful of the people they guide. They nurture team performance and accountability and give the lifelong gift of confidence. The fifth competency is inspiration. Mentors are ultimately change-agents who create personal as well as organizational changes. Change is always difficult, and mentors understand and address resistance to change and build teams that can move from planning to action. Mentors encourage change by making others feel hopeful and optimistic about the future. They are able to set a positive and constructive tone and are committed to facilitating growth and career opportunities for others.
REFERENCES
1. 2. 3. Carroll J. San Francisco Chronicle. February 20, 2004:D4. American Association of Colleges of Nursing. Nursing Shortage Fact Sheet. Available at:http://www.aacn.nche.edu/media/backgrounders/shortagefacts.htm. Accessed September 27, 2004. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, Calif: Addison-Wesley; 1984.
4.
5. 6.
Dreyfus SE, Dreyfus HL. A five-stage model of the mental activities involved in directed skill acquisition. University of California, Berkeley; 1980. Unpublished report supported by the Air Force Office of Scientific Research, USAF (contract F49620-79-C0063). Homer. The Odyssey. Fitzgerald R, transed. New York, NY: Farrar, Straus, Giroux; 1998. Robert Wood Johnson Nurse Fellows Program. Available at:http://www.futurehealth.ucsf.edu/rwj/. Accessed September 27, 2004.
Care of the Congestive Heart Failure Patient: The Care, Cure, and Core Model Mary L. McCoy RN BSN(c), Case Management, Plymouth, Indiana
Introduction
Congestive heart failure patients have decreased physical endurance and emotional concerns resulting from significant changes in their quality of life. Congestive heart failure patients perception of quality of life depends on individual health status and limitations in caring for themselves. Programs with a focus on patient education and disease management can improve quality of life and decrease hospital readmission rates for congestive heart failure patients (Chelho, Ramos, Prata, Bettercourt, Ferreira & Cerqueira-Gomes, 2005). Congestive heart failure is a chronic disease that progressively decreases patients abilities of self-care due to significant weakness that is experienced as a result of compromised cardiac and respiratory systems. This disease is present in 10% of elderly over the age of 70. Congestive heart failure patients readmission rate to hospitals due to poor disease management is an ongoing problem. The cost of congestive heart failure admissions to the hospital ranges from 8 to 15 billion dollars a year (Quaglletti, Atwood, Ackerman, & Froelicher, 2000). Current patient care models focus on the physical, social, emotional, and educational needs of patients. Congestive heart failure patients may have physical, social, emotional and/or education needs depending on the severity and stage of their disease process, knowledge of the disease, and current social support systems. It is imperative to evaluate and analyze various patient care models, and to choose one that best meets the particular patients needs because care plans are the essential framework through which nurses
work to provide the care a patient needs (Anderson & McFarlane, 2004). Lydia Halls Care, Cure, and Core Model (Figure A) refers to patients as having three needs of care: the physical, the medical, and the social needs. Nurses can easily provide the Care, Core and Cure model of nursing to meet the needs of patients with chronic disease (Touhy & Birnbach, 2001). Nurses using Lydia Halls model, assist with education, medical management, and provide physical, emotional, or social support for congestive heart failure patients. The medical management and education offered by nurses increases patients knowledge and ability to manage their disease and prevent exacerbations and reduce hospital readmissions (Quaglietti et al., 2000). Development of the nurse and patient relationship is critical in problem solving and providing care and education to promote effective health management for the congestive heart failure patient. Open communication and trust is necessary to facilitate care, provide education, and arrange discharge planning (Touhy & Birnbach, 2001).
Framework
Lydia Halls model for nursing provides a framework to encourage open communication between patients and nurses. The model has three interrelated circles that represent medical and clinical management nurses give to patients. The care circle is the intimate care nurses provide to patients to assist in bathing, dressing and assistance with daily activities. The disease management and treatment of the patient is addressed in the cure circle of the framework. The core circle symbolizes the emotional and social structure of the patient. The model is not static, but rather the patient can be in an individual circle or the circles can overlap depending on the needs of the patient during management of their disease. Patients who have their care, cure, and core needs met have improved self-esteem and awareness of the importance of disease management and improved quality of life. The care, cure, core model provides an opportunity for Patients to develop trust and communicate their fears and concerns in relation to disease management (Touhy & Birnbach, 2001). The care model (Figure B) dominates when Nurses provide hands on care to congestive heart failure patients. Hands on care for patients produces an environment of comfort and trust and promotes open communication between nurses and patients. Open communication encourages expressions of thoughts and fears and decreases anxiety. Patients develop feelings of security and verbalize concerns of disease management, emotional, and/or social issues in relation to the lifestyle changes they are experiencing secondary to congestive heart failure (Touhy & Birnbach, 2001). Patient education and discharge planning begins in the care model. During this phase, nurses have the primary role of answering questions and address concerns in relation to disease process, disease management. Congestive heart failure patients needs are addressed as nurses and patients develop both interpersonal and professional working relationships (Touhy & Birnbach, 2001). The cure model (Figure C) dominates when nurses perform physical assessments and care management plans for congestive heart failure patients. During this phase, nurses assess patients ability to perform activities of daily living based on physical changes that occur during walking, talking or bathing (Touhy & Birnbach, 2001). Nurses monitor patients fatigue level, respiratory status, blood pressure and oxygen saturation to determine patients tolerance level and need for supplemental oxygen. Lung sounds are osculated for diminished breath sounds or crackles for signs of fluid congestion. Congestive heart failure patients pulse strength, edema, and temperature are assessed to monitor circulation status secondary to decrease cardiac output and potential of pooling of fluid in the lower extremities (LeMone & Burke, 2004). Education to congestive heart failure patients is essential to increase their understanding of their disease process and to improve medication compliance. It is important that nurses review medications and stress the importance of compliance to medication schedules. Improved compliance can improve the quality of life for the congestive heart failure patient and result in decreased hospital readmissions (Coelho et al., 2005). Diet compliance also improves the status of congestive heart failure patients. Patients who understand their ordered diet understand the importance of compliance to prevent weight gain due to fluid overload. Patients who recognize the symptoms that accompany their disease understand when to notify the physician of weight gain, increased shortness of breath, fatigue, or dizziness (LeMone & Burke, 2004). The core model (Figure D) of the framework dominates when nurses and patients are able to discuss emotional concerns and distress to physical and mental changes due to patients disease process. Patients address emotional concerns and distress due to their perceived ability or inability to manage their disease, living alone, and general fear of their disease process. These emotions and concerns effect compliance to the medical plan and quality of life (Touhy & Birnbach, 2001). An essential role of nurses in the healthcare plan is to assist with management of congestive heart failure patients by providing medical, physical, and social care. The framework of Lydia Hall is used in the following care plan to assist in meeting the personal, medical, and social needs of congestive heart failure patients (Touhy & Birnbach, 2001).
Conclusion
Nurses work with the medical team to assist in evaluating congestive heart failure patients understanding of symptoms of their disease, compliance to diet and medication regimens, and the importance of informed follow up with their physician or nurses. Nurses can promote trust and facilitate open communication with patients when providing hands on care (Touhy & Brinbach, 2001).
Licensed Practical Nurses have an important role in management of congestive heart failure patients assessment and education. Lydia Halls Framework of Care, Cure, and Core provide a model for nurses to follow when evaluating congestive heart failure patients physical, medical, and social needs (Figure E). The individualized care offered by nurses promotes improved quality of life and decreased hospital readmissions for congestive heart failure patients (Touhy & Birnbach, 2001).
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