Integration of Participatory Development and

INTEGRATION of PARTICIPATORY DEVELOPMENT and OREM'S SELF-CARE MODEL for ORGANIZATION- and COMMUNITY-WIDE IMPLEMENTATIONS in the AREA SERVED by an OBSTETRICS/GYNECOLOGY CLINIC (a PATIENT-CENTRIC MODEL) The objective of this work is to examine Orem's Self-Care Model and identify the administrative and issues and problems in this model. This work will design an appropriate nursing management model to include a strategic plan in addressing nursing administrative issues or problems in this model.

This strategy will be justified with appropriate concepts, principles and theories of nursing management and the implications of the newly designed model considered. The work of Donna L. Hartweg entitled: "Dorothea Orem: Self-Care Deficit Theory" states that Orem's self-care model is increasingly used as a framework of practice in specific institutions.

This has significant implications for nursing service administration." (1991) Hartweg relates that the application of Orem's self-care model to "nursing service administration" has been reported in studies including that of Allison (1985) who reported the perspective of an administrator on "structuring of the nursing practice based on Orem's theory of nursing. Elements of the nursing system for a patient with a spinal cord injury were developed. Self-care capabilities and limitations, self-care requirements, and related nursing actions were identified for this patient population.

Using Orem's concept of nursing agency, Allison further identified how the role and function of the professional, technical, and vocational nurse were defined in relationship to each of these components." (Hartweg, 1991) Orem's theory has been applied in various forms in nursing education with curricular content that differentiates the "role and function of the technical and professional nurse in the program at Thornton Community College in South Holland, Illinois." (Hartweg, 1991; paraphrased) it is reported that Orem's theory of nursing was utilized at Georgetown University in its exposure of baccalaureate nursing students to theory early in the program, which is believed to have broadened their perspective of nursing.

(Hartweg, 1991; paraphrased) Orem proposed in 1980 that "self-care systems result from use of knowledge and skills to meet known requisites and that self-care is learned within the context of social groups through human interaction and communication." (Hartweg, 1991) I.

NURSING ADMINISTRATION CONSIDERATIONS in OREM'S THEORY Orem's Self-Care theory is reported in the work of Peeratiyutawong, Hanucharurnkul, and Panpakdee entitled: "A Self-Management Program for Improving Knowledge, Self-Care Activities, Quality of Life, and Gycosylated HbA1c Among Thai Persons with Type 2 Diabetes Mellitus" which relates a study for testing the effectiveness of a self-management program that had been designed to improve cognitive behaviors, knowledge, diabetes self-care activities, quality of life and HbA1c for patients with type 2 Diabetes Mellitus." (2006) the theoretical framework upon which this study was based was the self-care theory of Orem and cognitive behavior therapy.

The self-management group participation was in five sessions: (1) pathology of diabetes mellitus, problem-solving and goal setting skills; (2) dietary control and communication skills; (3) drug self-administration and cognitive restructuring skills; (4) exercise; and (5) foot care and self-monitoring. The methodology used in the five sessions were a supportive educative nursing system comprised of presentation, discussion, and skills training. Noted among the benefits of the self-management program were those of: (1) improved knowledge; (2) improved self -- care activities; and (3) quality of life.

The work of Hanucharurnkul entitled: "Nursing Knowledge Development: An Update" that in the nursing discipline the substance is "nursing knowledge or nursing theory, nursing scholarship, and the essence of nursing." (2006) the development of global or grand theories began in the 1960s and one of these grand theories is that of Orem's self-care deficit nursing theory. These theories are stated by Hanucharurnkul to "provide broad perspectives regarding the nature of outsourcing, the person, and health and the environment. They held to define nursing and nursing research. " II.

EXAMINING the FEASIBILITY of OREM'S MODEL of NURSING The work of Marianne Goodwin entitled: "Is Feasible for the Nursing Division at St. Vincent's Hospital to Adopt Dorothea Orem's Model of Nursing?" relates that centric to Orem's model is "the individual and his/her need for self-care. The model is concerned with the provision of management of self-care.

A requirement for nursing exists when a person is unable to maintain for him/herself self-care action, which is therapeutic in sustaining life and health, recovering from disease and injury or coping with their effects.

(Orem, 187 1: 1; as cited in Goodwin, 1990) Orem emphasizes the complimentary nature of the nurse-patient relationship, which is "the essence of Orem's model." (Goodwin, 1990) and means that the actions of the nurse assist the patient in assuming responsibility for their health-related self-care by: (1) making up for existent health-related deficiencies in the patient's capabilities for self-care; and (2) supplying the necessary conditions for the patients to withhold or maintain or increase their capabilities for self-care in order to maintain, protect and promote their functioning as human beings." (Orem, 1980; 11; as cited in Goodwin, 1990) Orem states that "self-care is a requirement of every person, man, woman, and child.

When self-care is not maintained, illness, disease or death will occur." (Orem, 1980: 6; as cited in Goodwin, 1990) Orem describes self-care deficit by stating: "People can benefit from nursing because they are subject to health-related or health-derived limitations that render them incapable of continuous self-care or dependent care, or that result in ineffective care." (Ore, 1980: 27; as cited in Goodwin, 1990) Orem's model is one that "adopts a 'Development World View' from the identifiable stages she describes in self-care agencies throughout life." (Goodwin, 1990) Orem (1980) states that the conceptual framework of nursing systems "...are formed when nurses use their abilities to prescribe, design, and provide nursing for legitimate patients (as individuals or groups) by performing discrete actions and systems of action.

These actions or systems regulate the value of or the exercise of, individual capabilities to engage in self-care and meet the self-care requirements of the individual therapeutically." (29; as cited in Goodwin, 1990) Orem's model is described by Fawcett (1984) as being one "derived from inductive reasoning." (Goodwin, 1990) The structural and functional components of Orem's model are examined in the work of Goodwin who states that Orem made a clear identification of the "four major nursing metaparadigm concepts..." (1990) the first, or the patient is the model's primary focus.

Secondly, the environment is identified and Orem notes that requirements of self-care "have their origins in human beings and the environmental factors, elements, conditions..." Third, Orem views health "as an ideal, that is, when living things are structurally and functionally whole (1980, 118; as cited in Goodwin, 1990) the fourth, Nursing Actions are defined by Orem as: (1) a creative effort of one human being to help another (1980: 6); and (2) action performed by nurses for the benefit of others." (1980: 92) Within Orem's theory the nursing process is three specific stages: (1) diagnosis and prescription; (2) designing and planning; and (3) production and management.

III. SYSTEM-WIDE IMPLEMENTATION of OREM'S MODEL IS DIFFICULT The work of Marilyn E. Parker entitled: "Patterns of Nursing Theories in Practice" states the senior nursing administrator faces the question of whether nursing theory should be adopted within the agency or organization. In the initiative to adopt a model of nursing, the four primary considerations are stated to be: (1) the environment; (2) the financial resource base; (3) the acquisition of knowledge resources; and (4) development of tools for the implementation.

(Parker, 1993) System-wide theory implementation is acknowledged in the work of Parker (1993) to be "very difficult." Parker reports that development of the philosophy, assessment tools, standards, orientation manual and appraisal tools were done according to the manner in current literature with all tools being adjusted in an ongoing manner.

Parker states that theory provides a frame of reference for nursing practice and provides direction for articulation with other theories and knowledge bases." (Parker, 1993) Parker relates that the view of nursing in an organization guided by the Self-Care Deficit Nursing Theory is demonstrated to go through the integration of theory in the mission/philosophy, the objectives of the nursing department, the orientation program, the staff development programs related to nursing practice, the performance appraisal system, the quality improvement program, and nursing research conducted in the organization." IV.

SELF-CARE SUPPORT REQUIREMENTS of NURSING STAFF The work entitled: "Supporting Self-Care: The Contribution of Nurses and Physicians" relates: "Nursing work in self-care focuses on identifying and assessing self-care needs and abilities, intervening in ways that meet these needs and evaluating the effectiveness of the interventions with clients. The goal of self-care from a nursing perspective is to improve the client's health status, coping and functional abilities.

This is accomplished through the collaboration of clients, their families and support networks with members of the health care team." (Health Care System, Canada, 2007) Additionally stated is: Orem (1991) delineated three possible roles for nurses: (1) to compensate for a person's inability to perform self-care by doing it for her or him; (2) to work together with the patient to meet his or her health care needs; and (3) to support and educate the patient who is learning to perform her or his own self-care in the face of illness or injury or a medical procedure." (Health Care System, Canada, 2007) V.

THEORETICAL BASIS of OREM'S SELF-CARE MODEL Social Learning Theory was developed by Bandura (1987, 1986) who held that behavior results from the individual's personal and environmental factors. It was stated in findings of a study reported by Hyndman et al. (1993) that there is a need to change the individual's environment in order to encourage positive health behavior and that there is a need to correct misperceptions about health. Training and development of skills is necessary in creation of new behaviors and in approaching solutions as well as are role models and self-efficacy.

In Orem's conceptualization of health "the concept of wholeness, soundness and well-being are closely integrated." (Health Care Canada, 2007) Orem's definition of health includes "...psychological, interpersonal and social aspects of living as well as the commonly emphasized physical aspects." (Health Care Canada, 2007) Well-being has been associated with health in Orem's theory that provides a definition of well-being as: "...a state characterized by experiences of contentment, pleasure and kinds of happiness, by spiritual experiences, by movement towards fulfillment of one's self-ideals and by continuing personalization." (Orem, 1995: 101) Orem distinguishes humans from other living beings by their ability for reflection upon themselves and the environment and in being able to symbolize their experiences as well as having the capacity to symbolically create through thought, communication, and in bringing about necessary and beneficial change.

(Orem, 2001: 182) Within the application of Orem's theory interaction takes place between the nurse and the individual, family or groups and an assessment is conducted in order to make a determination of deficit between the needs of self-care and the abilities of the individual to accomplish self-care.

Offerings of nursing are based on (1) the request of the patient; (2) an assessment of the nurse as to how the patient might be assisted through nursing; or (3) how coordination of services and the integration of nursing into the patients daily living activities might be accomplished. (Orem, 1995: 125) Within the framework of Orem's model "nursing is a specific type of human service..." with helping others and self-help as the basis.

Orem (2001) held that a requirement of nursing exists when self-care maintenance makes a requirement of special techniques or applying knowledge of a scientific nature in provision of or design of that care. Furthermore, patient's needs are determined and the role arrangements between the patient, caregivers and family are made "in the context of the interpersonal dimensions of practice." (Health Care Canada, 2007) Within Orem's model are three self-care requisites: (1) universal; (2) developmental and (3) health deviation.

(Health Care Canada, 2007) Universal self-care requisites are those linked with life processes: (1) sufficient intake or air, food, and water maintained; (2) the elimination process; (3) the balance between activity and rest maintained; (4) the balance between solitude and social interaction maintained; (5) prevention of hazards to human life, functioning and well-being (6) the promotion of human functioning and development within social groups in accord with human potential limitations; and (7) the desire to be normal (Orem, 1995:191) Developmental self-care requisites "are either specialized expressions of universal self-care requisites that have been particularized for development processes, or they are new requisites derived from a conditions." (Health Care Canada, 2007) One example of this given is "during pregnancy the expectant mother will adjust her food intake and balance between rest and activity in accordance with her condition." (Zuyderduin, 2004) Health deviation self-care requisites are existing "in conditions of illness, injury or disease but may also result from medical measures required to diagnose and correct a certain condition." (Zuyderduin, 2004) This area of self-care requisites is one in which "the individual will have to seek and secure appropriate medical assistance, and be aware of and attend to the effects and results of pathological conditions and states." (Zuyderduin, 2004) Orem notes that care for the individual is "interpersonal, based on the objective needs of the recipient of care and respecting and accepting the freedom of this recipient to decide upon a course of actions.

Care requires that care agents have sufficient knowledge, both theoretical and experiential to provide care." (Orem, 2001: 27) it is important to note that Orem has cautioned that factors of care situations may either help or harm human beings.

Orem states four critical aspects for self-care and helping others which are: (1) care; (2) responsibility; (3) respect; and (4) knowledge (Orem, 1995:26) the quality of the individual's 'self-care repertoire or the 'quality of the agency" is stated by Orem (2001) to be determined by: (1) what they have learned to do and what they do consistently; (2) what they can and can't do now or in the future (and what their limitations are); and (3) whether what they have learned to do and can do now is equal to meeting all current and projected demands now or at some future time.

(466; as cited in Zuyderduin, 2004) Orem states that 'basic conditioning factors' or the 'internal' and 'external' factors affect the individual in their ability to engage in self-care. Basic conditioning factors include the individual in terms of their age, gender, educational achievement level, and developmental state. Sociocultural and family system factors are those which locate a person within society and factors of health state, health care system factors, patterns of living and environmental factors including resource adequacy and availability are those which describe individuals in their world of existence.

(Orem, 1995; 203) Nursing Agency is a theoretical concept and is defined "as the power that enables nursing interventions." (Zuyderduin, 2004) VI. DEVELOPMENT of a NEW MODEL for SELF-CARE The foregoing research in this study has found that the largest barrier for implementation of Orem's self-care model is the implementation of this theory on an organization-wide basis. This is due to the many changes that must occur within the organization and the role of nursing.

Limitations of Orem's model of are believed by the researcher in this study to be within the ability of the organization to overcome with an added element of participatory modification of Orem's self-care model through active research with the patients of the organization involved in the development of the program.

The work entitled: "Action Research as a Method to Develop a Case Management Tool" states that participatory action research may be defined as "Learning by doing." (Obrien, 1998; as cited by Corbett, 2005) This type of research" has been used by the health sector since the 1980s." (Corbett, 2005) Participatory action research "seeks to empower participants in change." (Corbett, 2005) This type of research is both participatory and collaborative and "arises from the need to clarify a concern generally shared by a group" (Corbett, 2005) and it "done with and for others to improve what they do." (Corbett, 2005) the four basic steps of research within the action research cycle are those of: (1) plan; (2) action; (3) observation; and (4) reflection.

(Corbett, 2005) the aim of participatory actions research is to develop improved systems of service delivery resulting in more effective forms of case management. (Corbett, 2005) The model proposed in this research is a model that is a modified form of Orem's self-care model which has an added feature of participatory action research on the part of the organization's patients - and in this case - obstetrics and gynecology patients.

This modified version of Orem's self-care model is one that has its starting point the first visit of a patient to the clinic.

The patient will be introduced through a short interview with the nurse practitioner in the clinic and followed with a short film describing the participatory action research adaptation of Orem's model of self-care and the necessary participation of the patient to enable this model which will include requirements of the patient to record in a journal their concerns, expected needs, and newly acknowledged self-care needs which will be reviewed at each visit with the nursing staff in the clinic.

The patient/participants in the institution of this model will assist the nursing staff in their development of the modified version of Orem's self-care model through recording in their journals the barriers and challenges faced in the patients attempt to follow self-care guidelines thereby continually informing this study of necessary adjustments to self-care instructions in order that the patient / participants are enabled in establishing self-care regimens which are critically important in this field of nursing administration.

A continuous feedback loop between the patient/participants and the nursing staff of the clinic will serve to inform the practice of the clinic in a manner that enables continuous and ongoing adaptation to the needs of the patient/participants of the clinic.

The basis of the modification of Orem's self-care model is the belief that needs of self-care knowledge of patient/participants in any study are based in environment issues which change geographically dependent upon the location of the obstetrics/gynecology clinic and that in order to meet the needs of the health population in the specific area which the clinic serves that those health needs must be better understood in an individualized and specialized manner.

Information gained from the patient/participant group about the self-care instructions needed by the population the clinic is serving will be reviewed in accordance with the proposed model on a monthly, quarterly and yearly basis with the needed changes or modifications to self-care instructions instituted in the same fashion as these increments of review of the nursing staff provision needs for self-care of patient/participants of the clinic.

The following figures illustrates the conceived modified model of self-care with added elements of participatory research in what is a patient-centric model for distribution of information and knowledge of self-care needs to individuals, throughout the organization and its system and into the community base.