Nursing, as a profession, is responsible for care given to clients. Using a specific nursing model or a combination of models can benefit the nurse educator or nurse manager in several ways. First, it provides a common denominator to unify the care given on different shifts or units. Next, it helps to develop standards of care and to ensure that comprehensive care is given to each client. Finally, it provides a basis for orientation and evaluation. However, it is often difficult to get students or staff to accept that a model might be beneficial.
As charge nurse of an adult neurological step-down unit, the author was responsible for orienting students and other nurses assigned to work in that unit. Since neurological clients frequently require complex care, it was decided that a combination of Orem's and Roy's models would be useful in caring for that specific patient population.
To appreciate this combined nursing model, one first needs to be familiar with the concepts inherent in each model. Orem's model addresses four basic concepts of nursing: person, environment, health, nursing practice. The person is described as self-reliant, responsible for self-care and well-being, a functional and integrated biopsychosocial system (Aggleton & Chalmers, 1985; Johnston, 1983). Orem sees the environment as a subcomponent of the person, affecting the needs ofthat person, and which can be modified by the nurse.
Health is defined as a "state of wholeness or integrity of the individual human being, his parts, and his modes of functioning" (Orem, 1971). The model goes on to identify a health-illness continuum with universal self-care and health -deviation self-care as the defining ends. Self-care is part of the western socialization process, a personal and deliberate effort toward health and toward maximizing one's potential, and is aided by curiosity, instruction, and practice (Aggleton & Chalmers, 1985; Orem, 1980). If self-care is not maintained, illness, disease, or death can occur (Orem, 1980).
At one end of the health-illness continuum are universal self-care requisites common to all persons and necessary for structure and functioning. Orem (1980) identifies six categories:
* intake of air, water, and nutrition;
* eliminative function;
* balance of activity and rest;
* balance of time alone and time with others;
* prevention of danger to self; and
* being "normal" as determined by science, culture, and social values.
Next on the continuum are two categories of developmental self-care requisites. One is the prevention of developmental disorders and promotion of development according to potential. The other is the provision of care to prevent or minimize negative effects of conditions that affect development. Finally, on the other end, are six health-deviation self-care requisites that apply to persons who are ill, injured, disfigured, or affected by medical care measures.
The fourth concept, nursing practice, is viewed as a service focusing on the person's need for self-care action on a continuous basis to sustain life, to recover from injury or illness, or to cope with its effects (Orem, 1980). According to what degree the person requires the assistance of the nurse to meet self-care needs, Orem classifies three nursing systems: (1) wholly compensatory, (2) partly compensatory, and (3) supportive-educative. The nurse may perform all necessary self-care activities, share the responsibility with the person, or act as a guide or instructor.
The other nursing model chosen to draw from was developed by Roy. This model also addresses the four basic concepts of nursing, but with slightly different emphasis. Roy's definition of person includes the biopsychosocial aspect as well as that of a living, adaptive system (Aggleton & Chalmers, 1984; Tiedeman, 1983). This concept is discussed in more detail. The environment plays a more significant role in Roy's model. It is the world within and around the person that can stimulate the person to make adaptive responses. Three types of stimuli are identified. Focal stimuli are those immediately present for the person. Contextual stimuli are those that occur along with focal stimuli but are more in the background. Stimuli from the past that may be relevant to the present are referred to as residual stimuli (Andrews & Roy, 1986).
Roy's definition of health is a state of being and a process of reaching one's highest potential. There is also a health-illness continuum representing varying degrees of health or illness that a person could experience at a given time. This concept of health is closely interrelated with that of nursing practice, the application of knowledge designed to assist a person's adaptation to situations of health and illness (Andrews & Roy, 1986; Tiedeman, 1983).
The person, a living, adaptive system, has two mechanisms for adapting to various stimuli. First, there is a biological response known as the regulator subsystem. Second is a cognator subsystem that involves the higher brain functions of memory, information processing, and judgment.
These subsystems are further divided into four adaptive modes. The first is a physiological mode that encompasses oxygenation, nutrition, elimination, activity and rest, skin integrity, the senses, fluid and electrolytes, neurological function, and endocrine function (Galbreath, 1985). Second is the self-concept mode, which refers to tendencies within a person to strive for knowledge of one's self (Andrews & Roy, 1986). Next is the role function mode, which serves to alert the person when external demands fall outside the range of roles the person can adapt to. Finally, in the interdependence mode, persons strive for a relative balance in relationships of friendliness, dominance, and competitiveness (Aggleton & Chalmers, 1984).
The goal of nursing practice is to promote adaptive responses, those that promote health, in relation to the four adaptive modes. Nurses can promote adaptive responses in two ways. First, the nurse can manipulate the focal or contextual stimuli in such a way that adaptive responses are more likely to occur. Second, the nurse can help the person expand his or her adaptation level to tolerate a wider range of stimuli.
Combination of Models
There are both similarities and differences in the two models. The similarities make it easier to combine and understand the models. The differences are useful when one model is more appropriate for a given situation than the other. To combine models, the author used the four phases of the nursing process: assessment, planning, intervention, and evaluation.
The first phase of the nursing process is assessment. There are actually two levels of assessment. The first level determines whether there is a valid need for nursing action. Orem has a well-defined healthillness continuum, while Roy's is more general. For this reason, the first-level assessment uses Orem's continuum to determine whether nursing care is required.
Once this is determined, the nurse assesses the person for the reason he or she is unable to meet his or her needs. Some of the possible reasons for this deficit include a lack of knowledge, skill, or motivation; a limited range of behaviors; or an overload of stimuli in relation to the person's adaptation level. Even if a person can meet his or her own needs, nursing action may still be required if the person is unable to meet those needs safely.
The next phase involves planning. The nurse has assessed the client's needs and abilities, and the reason for the deficit between them. In this phase, the nurse forms a plan of action based on clientcentered goals. When possible, it is desirable to develop these goals based on input from the client or significant others.
Next, the nurse plans the nursing action required to assist the person in meeting these goals. Nursing actions are divided into the three systems used by Orem. However, they also can be evaluated for whether stimuli or adaptation levels will be changed. Nursing action can be wholly compensatory. For example, the nurse acts for the client by adjusting the lighting, the temperature of the room, the noise level, or by coordinating activities that involve the client.
Nursing action can also be partially compensatory, where both nurse and client are involved in the care. In this system, either the stimuli and/or the adaptation level can be manipulated to assist the client in doing his or her own care. For example, if a person can feed himself or herself, but is easily distracted, the nurse can turn off the television, draw the curtain, or close the room door to enable the person to finish the meal. The nurse may also help the client to develop a longer concentration span or teach the client to limit his or her stimuli if unable to complete a task.
Finally, nursing action can be supportiveeducative. The person may be physically able to meet his or her needs, but may have a hard time adapting to new physical limitations, role conflicts, or an altered self-concept. In this situation, the nurse may help the client expand his or her adaptation level through instruction, counseling, or emotional support.
The intervention phase of the nursing process occurs when the nursing action that is based on client-centered goals is put into practice. Depending on which nursing care system the nurse decides is most appropriate to the situation, nursing interventions can take several forms:
* doing or acting for the person;
* guiding or directing the person;
* providing physical support;
* providing psychological support;
* providing an environment that supports and promotes development; or
* teaching the person (Aggleton & Chalmers, 1985).
The final step of the nursing process is evaluation. The nurse must decide if the nursing action and/or the client's new behaviors have been successful in meeting the needs of the client. The desired outcome is for the client to meet successfully his or her own needs without nursing intervention, if possible. Depending on where the client is in relation to this desired outcome, reassessment may be necessary with new goals and interventions being planned. This process will be repeated until the client has reached the maximum potential of independent self-care obtainable for that individual.
There are many conditions of clients in the step-down unit and a high number of client-centered goals that could be developed. Some situations benefit more with emphasis from one or the other of the nursing models used to develop this version of the nursing process. Some brief examples illustrate this.
Patient A suffered a closed-head injury, but had no physical deficits. The only cognitive deficit noted was his disorientation to time, surroundings, and purpose. This individual also had a very short attention span. Some of the planned nursing actions might include manipulating the focal and contextual stimuli. One way would be to decrease distractions and allow the person to complete the assigned tasks, i.e., eating a meal or brushing his teeth. Another way would be to help with the reorientation process by using objects from home, photos of significant others, a clock or calendar, and frequent verbal reorientation.
This nursing system is partially compensatory since both nurse and client are necessary for meeting needs. It is also supportive-educative in the way the nurse instructs the client how to accomplish the task at hand. Individuals with short attention spans very often need step-bystep instructions since they are unable to remember or understand complex commands. Verbal reorientation is also supportive-educative.
Patient B had a craniotomy for an intracranial bleed after a fall. By the time she was admitted to the step-down unit from intensive care, it was determined that she had no significant physical or cognitive deficits. However, she would not do anything to care for herself She made no verbal replies to questions, but when she wanted attention she could call out. In this situation, her husband helped to determine what the goals would be and gave insight into how to provide care. Initially, since the client did no self-care, the nursing actions were wholly compensatory. The nurse was responsible for meeting such universal self-care requisites as feeding the client, bathing and dressing her, and providing range-ofmotion exercises.
The husband suggested that the client had withdrawn because the perceived changes in the client's lifestyle were so drastic. Before surgery, the client had been an outgoing individual, a teacher at a local high school, and a member of many civic groups. Only time would show whether the client could regain all of her previous social abilities. Familiar objects were brought from home to affect the contextual stimuli and to try to motivate the client.
The nurse encouraged the husband to come in whenever possible to assist with meals, bathing, or the rehabilitation program. This was done to help the client is several ways. First, using the husband to provide care ensured that much of the stimuli would be familiar and might help motivate the client to get well and go home. Second, having the husband there to visit and to assist with the client's care promoted maintenance of their relationship. Third, the husband talked to her in such a way as to reinforce for the client that her role as wife and teacher was still intact. Members of her class sent handmade gifts, which supported what the husband said. Finally, the husband brought in clothes from home and colored scarves to cover the client's shaved head to help improve her self-image.
After a few weeks, the client began to respond to the care by doing a few self-care items like eating finger foods and washing her face at bath time. She began to talk more and would ask to get out of bed. As her motivation and strength increased, the nursing action became partially compensatory. The focus shifted to developmental self-care requisites. Nursing care became directed at promoting development and minimizing negative effects from the trauma or surgery. The client was encouraged to do more for herself and to get up for walks. The nurse was still necessary to assist with many activities, from setting up items for the bath and helping the client dress to supervising meals and use of the bathroom. It was apparent that the stimuli were now well within the client's adaptation level. The only time stimuli were manipulated during this part of the client's recovery was at rest times. Noise and activity kept the client from being able to rest adequately. To prevent hall noise from disturbing the client, the nurse closed the door to the unit and tried to coordinate the activities of the other clients in the unit so there were sufficient periods of quiet.
Eventually, the client was able to obtain a balance of activity and rest, became more capable of self-care, and appeared ready to begin the last part of her recovery. Nursing action was still partially compensatory to some degree, but now a part was also supportiveeducative. The focus now was on healthdeviation self-care requisites where care is intended to help the client cope with the effects of the trauma, surgery, and medical care measures. Physical, occupational, and speech therapies were started to assist the client to relearn or to become confident with the skills she had before surgery. During this time, instructions were given to both the client and her husband regarding medications, exercises, and any symptoms that needed to be reported to the physician. This part of the client's care further expanded her adaptation level to cope with the role of a person who needs some degree of continuous medical care.
Using concepts drawn from both models, the author developed a combined model based on the nursing process. While using either model alone in the same situation would probably result in similar care, the combined version was useful in orienting new workers to the neurological step-down unit. As the examples illustrate, there are times when it is easier to look at a situation from the self-care angle and know which nursing action would be most beneficial. However, at other times the adaptation angle proves more useful. When the care for a client is particularly complex, having a similar model on which to base nursing care can be beneficial. It helps in planning continuity of care, assures that comprehensive care is being given, promotes a degree of unity between shifts, and allows orientation and job evaluation to be based on the nursing process. In addition, it helps to make a theoretical model practical to those would-be skeptics.
- Aggleton, P., & Chalmers, H. (1984). The Roy adaptation model. Nursing Times, 80, 45-48.
- Aggleton, P., & Chalmers, H. (1985). Orem's self-care model. Nursing Times, 81, 36-39.
- Andrews, H.A., & Roy, C. (1986). Essentials of the Roy adaptation model. Norwalk, CT: Appleton-Century-Crofts.
- Galbreath, J. G. (1985). Sister Callista Roy. In J. B. George (Ed.), Nursing theories: The base for professional nursing practice (2nd ed.) (pp. 300-318). Englewood Cliffs, NJ: PrenticeHall, Inc.
- Johnston, R.L. (1983). Orem self-care model of nursing. In J. Fitzpatrick & A. Whall (Eds.), Conceptual models of nursing: Analysis and application (pp. 137-155). Bowie, MD: Robert J. Brady, Co.
- Orem, D.E. (1971). Nursing: Concepts of practice. New York: McGraw-Hill.
- Orem, D.E. (1980). Nursing: Concepts of practice (2nd ed.). New York: McGraw-Hill.
- Tiedeman, M.E. (1983). The Roy adaptation model. In J. Fitzpatrick & A. Whall (Eds.), Conceptual models of nursing: Analysis and application (pp. 157-180). Bowie, MD: « Robert J.Brady, Co.