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…