Journal of Gerontological Nursing

Assessing Delivery of Nursing Care

Carolyn C Hoch, PhD, RN, CS

Abstract

This article grew out of a search to find appropriate models around which to organize geriatric nursing practice. The need for conceptual models for nursing practice was well articulated over a decade ago by Riehl and Roy: "The conceptual framework of models, and particularly their applications into practice, has not yet evolved into an articulate, well-defined, and integrated discipline of study. " ' By definition, "A model for nursing practice is a systematically constructed, scientifically based, and logically related set of concepts which identify the essential components of nursing practice together with the theoretical bases for these concepts and the values required in their use by the practitioner."2 In essence, models show the component parts of nursing and their relationship, thereby facilitating a cohesive and systematic approach to patient care.

Although numerous nursing models have appeared in recent literature, there is a paucity of studies that actually apply nursing models as organizing frameworks for practice. For nursing to develop further as a discipline with scientifically grounded practice, it is essential to test the efficacy and usefulness of existing models through controlled research. The degree to which the practitioner is able to control, alter, or manipulate the major independent variables and conditions as specified by the model, in order to realize some desired outcome, determines the usefulness of any given nursing model.

This article compares two nursing models - the Roy Adaptation Model and the Neuman Health-Care Systems Model - with respect to effectiveness in decreasing depression and increasing life satisfaction in retired individuals. The dependent variables were depression and life satisfaction scores; the independent variables were the treatment protocols developed from the two nursing models.

I ndividuals react to stimuli either adaptively or maladaptively.

Theoretical Background

The Roy Model - This model for nursing practice is based on the concept of adaptation, defined as a positive response to a changing environment. Patients are viewed as biopsychosocial beings in constant interaction with a changing environment. Both innate and acquired mechanisms (biological, psychological, and social) assist them in coping, more or less effectively, with the changing environment. The Roy model also views health and illness as a continuum. At any given point along this continuum, humans are exposed to a variety of stimuli, termed "focal," "contextual," and "residual." Focal stimuli immediately confront the person; eg, a specific or central environmental change, such as retirement. Contextual stimuli are all other, more or less peripheral, stimuli that influence the situation and are measurable or are reported by the individual; eg, the extent of financial or interpersonal resources. Residual stimuli refer to characteristics of an individual and his or her life situation that are present and relevant, but elusive or difficult to measure objectively; eg, character traits.3,4.

Individuals react to stimuli either adaptively or maladaptively. An adaptive response is behavior that maintains the integrity of the individual; integrity involves soundness, completeness, and unity. According to the Roy model, the main goal of nursing is to promote and support adaptation in each of four modes (physiological, self-concept, role function, and interdependence) in situations along the health -illness continuum. Problems in adaptation arise when responses are inadequate to meet needs. These problems are the specific concern of nursing; namely, to help the individual solve problems and bring about adaptation, thereby freeing the individual to respond to other stimuli.3,4

The Roy model was selected for this study because the four modes of adaptation identified by the model are especially pertinent to the elderly population. Physiological needs arise as a normal pan of the aging process, particularly as a reflection of diminished physiological reserves. Problems in self-concept may arise…

This article grew out of a search to find appropriate models around which to organize geriatric nursing practice. The need for conceptual models for nursing practice was well articulated over a decade ago by Riehl and Roy: "The conceptual framework of models, and particularly their applications into practice, has not yet evolved into an articulate, well-defined, and integrated discipline of study. " ' By definition, "A model for nursing practice is a systematically constructed, scientifically based, and logically related set of concepts which identify the essential components of nursing practice together with the theoretical bases for these concepts and the values required in their use by the practitioner."2 In essence, models show the component parts of nursing and their relationship, thereby facilitating a cohesive and systematic approach to patient care.

Although numerous nursing models have appeared in recent literature, there is a paucity of studies that actually apply nursing models as organizing frameworks for practice. For nursing to develop further as a discipline with scientifically grounded practice, it is essential to test the efficacy and usefulness of existing models through controlled research. The degree to which the practitioner is able to control, alter, or manipulate the major independent variables and conditions as specified by the model, in order to realize some desired outcome, determines the usefulness of any given nursing model.

This article compares two nursing models - the Roy Adaptation Model and the Neuman Health-Care Systems Model - with respect to effectiveness in decreasing depression and increasing life satisfaction in retired individuals. The dependent variables were depression and life satisfaction scores; the independent variables were the treatment protocols developed from the two nursing models.

I ndividuals react to stimuli either adaptively or maladaptively.

Theoretical Background

The Roy Model - This model for nursing practice is based on the concept of adaptation, defined as a positive response to a changing environment. Patients are viewed as biopsychosocial beings in constant interaction with a changing environment. Both innate and acquired mechanisms (biological, psychological, and social) assist them in coping, more or less effectively, with the changing environment. The Roy model also views health and illness as a continuum. At any given point along this continuum, humans are exposed to a variety of stimuli, termed "focal," "contextual," and "residual." Focal stimuli immediately confront the person; eg, a specific or central environmental change, such as retirement. Contextual stimuli are all other, more or less peripheral, stimuli that influence the situation and are measurable or are reported by the individual; eg, the extent of financial or interpersonal resources. Residual stimuli refer to characteristics of an individual and his or her life situation that are present and relevant, but elusive or difficult to measure objectively; eg, character traits.3,4.

Individuals react to stimuli either adaptively or maladaptively. An adaptive response is behavior that maintains the integrity of the individual; integrity involves soundness, completeness, and unity. According to the Roy model, the main goal of nursing is to promote and support adaptation in each of four modes (physiological, self-concept, role function, and interdependence) in situations along the health -illness continuum. Problems in adaptation arise when responses are inadequate to meet needs. These problems are the specific concern of nursing; namely, to help the individual solve problems and bring about adaptation, thereby freeing the individual to respond to other stimuli.3,4

The Roy model was selected for this study because the four modes of adaptation identified by the model are especially pertinent to the elderly population. Physiological needs arise as a normal pan of the aging process, particularly as a reflection of diminished physiological reserves. Problems in self-concept may arise from losses and developmental transitions faced by the elderly person, particularly retirement and its attendant alteration in role identification and functions. The conflict between dependence and independence is also intensified by aging. Numerous physical, mental, social, and economic factors confront the elderly with the realities of dependency, even though the individual may have a strong desire to remain independent. Motivation for independence may be adaptive (ie, provides self-sufficiency and the desire not to burden others) or maladaptive (ie, results from mistrust of and withdrawal from others).

Table

TABLE 1DEMOGRAPHIC AND WORK-RELATED CHARACTERISTICS OF THE SAMPLE

TABLE 1

DEMOGRAPHIC AND WORK-RELATED CHARACTERISTICS OF THE SAMPLE

The Neuman Model - Neuman identified the Health-Care Systems model as a total person approach to patient problems. The central focus of this model is an individual's relationship to stress and reaction to Stressors, and factors of reconstitution. This is a systems model that provides a framework to facilitate attainment and maintenance of the highest possible level of health. Interventions focus on the reduction of stress factors and adverse conditions, which either affect or have the potential for affecting optimal functioning in a given situation.5

The major component parts of the Neuman model are stress and reaction to stress. An individual is viewed as an open system in constant interaction with the environment. Successful transactions with the environment reflect the individual's adjustment to the environment or vice versa. This process of interaction and adjustment relies on lines of defense, which are variables of physiological, psychological, sociocultural, and developmental nature. Stressors, or tension-producing stimuli, impinge upon an individual's current state of well-being or flexible line of defense. If the Stressor breaks through the normal line of defense, equilibrium is disturbed and a range of responses automatically ensues. In addition, internal resistance factors (lines of resistance) are activated to provide stability and a return to normal functioning.

Stressors not only evoke reactions within an individual, but also may create interpersonal forces or strong emotional fields between individuals or between the individual and other extrapersonal forces. Nursing intervention can begin at any point where a Stressor is suspected or identified and can be introduced at the primary, secondary, or tertiary levels of prevention . At the level of primary prevention, a nurse can intervene before a reaction has occurred, whether a known risk or hazard is present or suspected. General knowledge is applied to identify and allay the potential risk factors associated with Stressors. The goal of primary prevention is to prevent or minimize penetration of the normal, healthy line of defense or to strengthen the flexible line of defense to decrease the effects of the Stressors. Secondary prevention can occur after a Stressor causes a reaction within an individual; it is aimed at treatment of symptoms and reconstitution. Intervention can begin at any point following the occurrence of symptoms. Tertiary prevention follows active treatment; emphasis is on maintaining a reasonable degree of adaptation.5

Table

TABLE 2ROY ADAPTATION MODEL NURSING ASSESSMENT GUIDE SAMPLE ASSESSMENT QUESTIONS

TABLE 2

ROY ADAPTATION MODEL NURSING ASSESSMENT GUIDE SAMPLE ASSESSMENT QUESTIONS

Table

TABLES 3NEUMAN MODEL NURSING ASSESSMENT GUIDE

TABLES 3

NEUMAN MODEL NURSING ASSESSMENT GUIDE

The Neuman model was selected for this study because its components seemed appropriate for use with retired individuals. Older adults are exposed to numerous tension-producing stimuli or Stressors - the decreased physiological function that results from the aging process, loss of work identity, change in activity focus , alteration of roles - all of which afford opportunity for multilevel intervention.

Summary - Because retired individuals face multiple biopsychosocial Stressors and have attendant needs for adaptation, they represent an ideal population for testing the Roy and Neuman nursing models. Moreover, the impact of aging and retirement can result in depression and decreased life satisfaction.6·7 Thus, it may be argued that nursing has the responsibility to help retired individuals attain and maintain the highest possible degree of health and to help prevent despair.

Study Method

Sample - The setting for the study was a large senior citizen center in a suburban area of Pittsburgh. A sample of 48 retired individuals, aged 65 to 70, volunteered to participate in the study. Subjects signed consent forms approved by the University of Pittsburgh Institutional Review Board. Subjects were randomly assigned by sex to one of three groups by using a table of random numbers. Each group (Roy, Neuman, and control) had 16 members (5 men and 11 women), with similar mean age and length of retirement (see Table 1).

Instruments - The Depression Adjective Check List Form E (DACLE)9 and the Life Satisfaction Index Z (LSiZ)'0 were used to compare effectiveness. The DACLE is composed of 34 selfdescriptive adjectives; its score range is O to 34, with higher scores indicating greater dysphoria. The split-half reliabilities of the DACLE are 0.85 for normals and 0.89 for depressives. The internal consistency of Form E, cornputed from a two-way analysis of variance, is 0.83 for males and 0.88 for females.

Table

TABLE 4ADAPTIVE MODES AND GENERAL INTERVENTION STRATEGIES (ROY MODEL)

TABLE 4

ADAPTIVE MODES AND GENERAL INTERVENTION STRATEGIES (ROY MODEL)

The DACL-E was developed to provide for "brief but reliable measures of state depression, that is, the individual's mood complex"" following certain events, such as retirement. The form is self-administered and can be completed by most persons within ihree to five minutes. It is useful for repeated measurements research and for the evaluation of various types of clinical observations. Moreover, it has been used effectively to measure depression and dysphoria in the elderly in research studies.

The LSIZ is an 18-item scale that measures life satisfaction; its score range is O to 18 with higher scores indicating greater life satisfaction. By using Kendali's Q for factor analyses, reliability coefficient of 0.93 was reported. The LSIZ was developed specifically for use with adults over the age of 50 and is composed of five factors:

1. "Zest versus apathy," which relates to enthusiasm and degree of ego involvement in any activities that constitute daily life;

2. "Resolution and fortitude," which describes the extent to which an individual accepts personal responsibility for his or her life;

Table

TABLES 5LEVELS OF PREVENTION AND GENERAL INTERVENTION STRATEGIES (NEUMAN MODEL)

TABLES 5

LEVELS OF PREVENTION AND GENERAL INTERVENTION STRATEGIES (NEUMAN MODEL)

3. "Congruence between desired and achieved goals," which is the extent to which an individual feels he or she has succeeded in achieving major goals;

4. "Self-concept," which is concerned with whether an individual holds a positive image of self; and

5. "Mood-tone," which relates to the maintenance of optimistic attitudes.

In addition to the DACI^E and LSIZ, a demographic data questionnaire was administered to obtain descriptive information about age, gender, race, religion, marital status, education, residence, and income. It also elicited specific information about retirement, medical problems, loss of significant others, and participation in community activities. The questionnaire was pilot tested for clarity three times on a total of nine individuals between the ages of 65 and 70 who had been retired for up to five years. The individuals who volunteered to complete the questionnaire and to be interviewed were members of a senior citizens' club in another suburban area of the same city and were similar in socioeconomic level to that of the study sample.

Treatment Procedures - Two protocol guides were developed for the treatment groups; one based on the Roy Adaptation Model and the other on the Neuman Health-Care Systems Model. The control group received nursing intervention that was not supported by a theoretical framework. Each protocol involved six group meetings. The principles of group work with the elderly, as suggested by Burnside,12 were incorporated.

Bumside endorses the use of both short- and long-term group work with older adults as effective techniques for handling health-related issues caused by physical, emotional, or other sources. The group leader must take an active role in giving information, eliciting verbal participation from members, and answering questions. It is through discussion among the elderly members that the group work is accomplished.

Table

TABLE 6SCORES FOR EACH TREATMENT GROUP

TABLE 6

SCORES FOR EACH TREATMENT GROUP

The groups received nursing intervention by the same clinical nurse specialist who was instructed in the protocols by the author. Each of the groups met for 90 minutes per week during the same six- week experimental period. The leader and author met before and after each group session to review protocols, goals, and intervention strategies. The groups were audiotaped, and the tapes were subsequently analyzed for accuracy and content validity by two, nonparticipant, master's-level nursing educators who were familiar with both models and with Bumside's principles. The degree of leader adherence to either model was judged to be very high and comparable in both instances.

The DACL-E, LSIZ, and demographic data questionnaire were completed by each of the groups at the beginning of the first group meeting. POsttesting with the DACLE and LSIZ was completed at the conclusion of the sixth session.

The initial session in each treatment cell was devoted to assessment. Firstlevel assessment, identification of adaptive and maladaptive behaviors in each of the four modes, was the focus of the Roy group- Since the variables of depression and life satisfaction in retired individuals were of interest, emphasis was placed on self-concept, role function, and interdependence modes. Sample questions are listed in Table 2. Adaptive and maladaptive responses were summarized by the group. In the Neuman group, assessment was devoted to identification of Stressors, together with intra-, inter-, and extrapersonal factors. Data were collected by using the assessment questions in Table 3.

Stressor identification continued into the second Neuman group session and included the group members' perceptions of Stressors as well as those Stressors perceived by the leader. Problems were identified and goals were set to prevent or minimize the effects of Stressors. During the second session of the Roy group, major adaptive and maladaptive responses were reviewed by members. In addition, second-level assessment, identification of stimulicausing adaptive or maladaptive responses, was performed. Following assessment, nursing diagnoses regarding adaptation strengths and needs were formulated. Goals for changing maladaptive behaviors, manipulating stimuli, and reinforcing adaptive behaviors were planned.

The third, fourth, and fifth sessions in each treatment cell were intervention oriented. The focus in the Roy group was manipulation of stimuli, reinforcement of adaptive behaviors, and encouragement to change maladaptive behaviors (see Table 4). Major emphasis was on self-concept, role function, and interdependence modes. The intervention guidelines for the Neuman group included primary prevention focused on reinforcing and supporting strengths to allay the possible risk factors associated with Stressors, secondary prevention focused on direct symptoms, and tertiary prevention focused on mobilization of the group's existing resources to facilitate reconstitution (see Table 5). Evaluation of goal attainment was performed during the final group session of each treatment cell.

Results

One-way analysis of covariance (ANACOVA) using the DACLE and LSlZ scores, with pretest scores as covariates, was performed to determine significant posttreatment differences among the three groups, while allowing for any pretest differences among groups.

Posttest mean depression scores decreased for both the Roy and Neuman groups, but increased in the controls. ANACOVA of DAt^E scores yielded an overall F ratio (19.34) significant at the 0.001 level (see Table 6). Scheffé post-hoc pairwise comparisons indicated that both the Roy and Neuman groups were less depressed at follow-up than the control group (p<0.001). The Roy and Neuman groups did not differ from each other.

The LSIZ scores for each treatment group (see Table 6) showed a significant increase (p<0.001), which suggests an increase in life satisfaction among individuals in the Roy and Neuman treatment cells. In contrast, the control group showed little increase in mean LSIZ posttest score, suggesting that life satisfaction in the control group did not improve. Scheffé post-hoc pairwise comparisons indicated that both the Roy and Neuman groups had significantly higher life satisfaction scores than did the control group (p<0.001). The Roy and Neuman groups did not differ significantly from each other.

Discussion

The findings of this study suggest the following:

1. The Roy group protocol and the Neuman group protocol are equally effective methods for decreasing dysphoria and increasing life satisfaction in retired individuals, when compared with no planned nursing intervention.

2. Each of the two models is clinically useful in the planning and delivery of nursing care.

The results of this preliminary study support the use of conceptual models in nursing intervention. Both models tested proved useful to the planning and delivery of nursing care. Although this study did not show statistically significant differences between the effects of the two models, it did find that planned, purposeful nursing intervention based on a theoretical framework was more effective in decreasing dysphoria and increasing life satisfaction among retirees than the absence of planned nursing intervention.

There are, however, limitations of study design that need to be considered in interpreting the current data. Generalizability of results may be limited to the population from the one senior citizens' center. It is suggested, therefore, that the study be replicated and include random sampling from a variety of senior citizens' centers in different geographic areas, such as intracity and rural. Also, a study should be conducted using several clinical nurse specialists to determine whether personal characteristics of the nurse are critical to model efficacy.

If the purpose of nursing practice is to enhance well-being, it is suggested that this process be guided by the systematic application of nursing models. The growing arena of gerontological nursing practice and the expanding roles assumed by the nurse (eg, educator, consultant, practitioner, researcher) provide opportunities for studying the application of nursing models to practice.

References

  • 1. Rtehl JP, Roy C: Conceptual Models for Nur sing Practice. New York, Appleton-Century-Crofts, 1974.
  • 2. Riehl JP, Roy C: Conceptual Models for Nursing Practice, ed 2. New York, Appleton-Century-Crofts, 1980.
  • 3 . Roy C: Introduction lo Nursing: An Adaptation Model, ed 2. New York, Appleton-Century-Crofts, 1984.
  • 4. Roy C, Roberts SL: Theory Construclion in Nursing: An Adaptation Model. New Jersey, Prentice-Hal!, 1981.
  • 5. Neuman B: The Neuman Systems Model: Application to Nursing Education and Practice. New York, Appleton-Century-Crofts, 1982.
  • 6. Bumside IM: Nursing and lhe Aged. New York, McGraw-Hill Book Company, 1981.
  • 7. Butler RN, Lewis MS: Aging and Mental Health: Positive Psychosocial and Biomedical Approaches. St Louis, Mo, C.V. Mosby Co, 1982.
  • 8. Larsen K: Thirty years of research on the subjective well-being of older Americans. J Gemntol 1978; 33(1):109-125.
  • 9. Lubin B: Manual for the Depression Adjective Check Lists. San Diego, Educational and Industrial Testing Service, L981.
  • 10. Adams DL: Analyses of a life satisfaction index. J Gerontol 1969; 24(4):470-474.
  • 11. Leviti EE, Lubin B: Depression. New York, Springer Publishing Co, Ine, 1975.
  • 12. Burnside IM: Working with the Elderly: Group Process and Techniques. Massachusetts, Duxburg Press, 1978.

TABLE 1

DEMOGRAPHIC AND WORK-RELATED CHARACTERISTICS OF THE SAMPLE

TABLE 2

ROY ADAPTATION MODEL NURSING ASSESSMENT GUIDE SAMPLE ASSESSMENT QUESTIONS

TABLES 3

NEUMAN MODEL NURSING ASSESSMENT GUIDE

TABLE 4

ADAPTIVE MODES AND GENERAL INTERVENTION STRATEGIES (ROY MODEL)

TABLES 5

LEVELS OF PREVENTION AND GENERAL INTERVENTION STRATEGIES (NEUMAN MODEL)

TABLE 6

SCORES FOR EACH TREATMENT GROUP

10.3928/0098-9134-19870101-05

Sign up to receive

Journal E-contents