Human-To-Human Relationship ModelJ o y c e T r a v e l b e e ( 1 9 2 6 - 1 9 7 3 )

“The nurse is responsible for helping the patient avoid and alleviate the distress of unmet needs.” - Travelbee

I n t r o d u c t i o n Joyce Travelbee (1926-1973) developed the Human-to-Human Relationship Model presented

in her book Interpersonal Aspects of Nursing (1966, 1971). She dealt with the interpersonal aspects of nursing. She explains “human-to-human relationship is the means through which the purpose of

nursing if fulfilled” A b o u t t h e T h e o r i s t A psychiatric nurse, educator and writer born in 1926.  1956, she completed her BSN degree at Louisiana State University 1959, she completed her Master of Science Degree in Nursing at Yale University. 1952, Psychiatric Nursing Instructor at Depaul Hospital Affilliate School, New Orleans. Later in Charity Hospital School of Nursing in Louisiana State University, New York University

and University of Mississippi. Travelbee died at age 47.D e v e l o p m e n t o f t h e T h e o r y Travelbee based the assumptions of her theory on the concepts of existentialism by Soren

Kierkegaard and logotherapy by Viktor Frankl. Existential theory believes that that humans are constantly faced choices and conflicts and is

accountable to the choices we make in life Logotherapy theory was first proposed by Viktor Frankel, a survivor of Auschwitz, in his

book Man's Search for Meaning (1963). Logotherapy B a s i c C o n c e p t s Sufferingo "An experience that varies in intensity, duration and depth ... a feeling of unease, ranging

from mild, transient mental, physical or mental discomfort to extreme pain and extreme tortured ..."

Meaningo Meaning is the reason as oneself attributes Nursingo is to help man to find meaning in the experience of illness and suffering.o has a responsibility to help individuals and their families to find meaning.o The nurses' spiritual and ethical choices, and perceptions of illness and suffering, is crucial to

helping to find meaning. Hopeo Nurse's job is to help the patient to maintain hope and avoid hopelessness.o Hope is a faith that can and will be change that would bring something better with it. o Hope's core lies in a fundamental trust the outside world, and a belief that others will help

someone when you need it.o Six important factors charecteristics of hope are: It is strongly associated with dependence on other people.  It is future oriented. It is linked to elections from several alternatives or escape routes out of its situation. The desire to possess any object or condition, to complete a task or have an experience. Confidence that others will be there for one when you need them. The hoping person is in possession of courage to be able to acknowledge its shortcomings

and fears and go forward towards its goal Communicationso "a strict necessity for good nursing care" Using himself therapeutico " one is able to use itself therapeutic."o Self-awareness and self-understanding, understanding of human behavior, the ability to

predict one's own and others' behavior are imporatnt in this process. Targeted intellectual approacho Nurse must have a systematic intellectual approach to the patient's situation.

N u r s i n g M e t a p a r a d i g m s Persono Person is defined as a human being. o Both the nurse and the patient are human beings. Healtho Health is subjective and objective. o Subjective health is an individually defined state of well being in accord with self-appraisal of

physical-emotional-spiritual status. o Objective health is an absence of discernible disease, disability of defect as measured by

physical examination, laboratory tests and assessment by spiritual director or psychological counselor.

Environmento Environment is not clearly defined.  Nursingo "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.”

D e s c r i p t i o n o f t h e t h e o r y 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 encountero Visibility of personal identities/ emerging identities.o Empathyo Sympathyo Establishing mutual understanding and contact/ rapport Travelbee's ideas have greatly influenced the hospice movement in the west.C o n c l u s i o n Travelbee's theory has significantly influenced nursing and health care. Travelbee's ideas have greatly influenced the hospice movement in the west.

H e a l t h A s E x p a n d i n g C o n s c i o u s n e s sM a r g a r e t N e w m a n

=“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. Bachelor’s degree - University of Tennessee in 1962 Master’s 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 MinnesotaTHEORY DEVELOPMENTShe was influenced by following theorists: Martha Rogers - Martha Roger’s 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 ImplicateASSUMPTIONS1. 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

individual3. The pattern of the individual that eventually manifests itself as pathology is primary and

exists prior to structural or functional changes4. 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 PARADIGMSHealth “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 WEAKNESSESStrengths Can be applied in any setting “Generates caring interventions”W eaknesses Abstract Multi-dimensional Qualitative Little discussion on environmentCRITIQUEClarity 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.CONCLUSIONNewman'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”

Comfort Theory

Katharine Kolcaba

INTRODUCTION The comfort theory is a nursing theory that was first developed in the 1990s by

Katharine Kolcaba. Comfort Theory is  middle range theory for health practice, education, and research. Kolcaba's theory has the potential to place comfort once again in the forefront of

healthcare.(March A & McCormack D, 2009).BACKGROUND OF THE THEORIST

Born as Katharine Arnold on December 8th 1944, in Cleveland, Ohio Diploma in nursing from St. Luke's Hospital School of Nursing in 1965 Graduated from the Frances Payne Bolton School of Nursing, Case Western Reserve

University in 1987 Graduated with PhD in nursing and received certificate of authority clinical nursing

specialist in 1997 Specialized in Gerontology, End of Life and Long Term Care Interventions, Comfort

Studies, Instrument Development, Nursing Theory, Nursing Research Currently an associate professor of nursing at the University of Akron College of

Nursing Published Comfort Theory and Practice: a Vision for Holistic Health Care and

ResearchCONCEPTS AND DEFINITIONS ( Kolcaba, 2010)Kolcaba described comfort as existing in 3 forms: relief, ease, and transcendence. Also, Kolcaba described 4 contexts in which patient comfort can occur: physical, psychospiritual, environmental, and sociocultural.

Kolcaba described comfort as existing in 3 forms: relief, ease, and transcendence. If specific comfort needs of a patient are met, for example, the relief of postoperative

pain by administering prescribed analgesia, the individual experiences comfort in the relief sense.

If the patient is in a comfortable state of contentment, the person experiences comfort in the ease sense, for example, how one might feel after having issues that are causing anxiety addressed.

Lastly, transcendence is described as the state of comfort in which patients are able to rise above their challenges. 

Health Care Needs are those identified by the patient/family in a particular practice setting.

Intervening Variables are those factors that are not likely to change and over which providers have little control (such as prognosis, financial situation, extent of social support, etc).

Comfort is an immediate desirable outcome of nursing care, according to Comfort Theory

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 THEORYNursing

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).

The Helping Art of Clinical Nursing E r n e s t i n e W i e d e n b a c h

INTRODUCTION Ernestine Wiedenbach was born in August 18, 1900, in Hamburg, Germany. Wiedenbach's conceptual model of nursing is called ' The Helping Art of Clinical Nursing". Education:

o B.A. from Wellesley College in 1922o R.N. from Johns Hopkins School of Nursing in 1925o M.A. from Teachers College, Columbia University in 1934o Certificate in nurse-midwifery from the Maternity Center Association School for Nurse-Midwives in New York in

1946.. Career:

o Wiedenbach joined the Yale faculty in 1952 as an instructor in maternity nursing.o Assistant professor of obstetric nursing in 1954 and an associate professor in 1956.o She wrote Family-Centered Maternity Nursing in 1958.o She was influenced by Ida Orlando in her works on the framework.

She died on March 8, 1998.CONCEPTS AND DEFINITIONS

 Wiedenbach  defined key terms commonly used in nursing practice.The patient

"Any individual who is recieving help of some kind, be it care, instruction or advice from a member of the health profession or from a worker in the field of health."

The patient is any person who has entered the healthcare system and is receiving help of some kind, such as care, teaching, or advice.

The patient need not be ill since someone receiving health-related education would qualify as a patient.A need-for-help

A need-for-help is defined as "any measure desired by the patient that has the potential to restore or extend the ability to cope with various life situations that affect health and wellness.

It is crucial to nursing profession that a need-for-help be based on the individual perception of his own situation.Nurse

The nurse is functioning human being. The nurse no only acts, but thinks and feels as well.

Knowledge Knowledge encompasses all that has been percieved and grasped by the human mind. Knowledge may be :

o factualo speculative oro practical

Judgment  Clinical Judgment represents the nurse’s likeliness to make sound decisions. Sound decisions are based on differentiating fact from assumption and relating them to cause and effect.

Sound Judgment is the result of disciplined functioning of mind and emotions, and improves with expanded knowledge and increased clarity of professional purpose.

Nursing Skills 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.

Person 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 philosophyo a purposeo a practice ando 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 lifeo Respect for the dignity, worth, autonomy and individuality of each human being ando 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 patient’s need for

help. The Art

The Art of nursing includeso understanding patients needs and concernso developing goals and actions intended to enhance patients ability ando 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 THEORYWiedenbach'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 patient’s need for help through

o observation of presenting behaviors and symptomso exploration of the meaning of those symptoms with the patiento determining the cause(s) of discomfort, ando determining the patient’s 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 patient’s need for help.

From Novice to ExpertP a t r i c i a E . B e n n e r

Introduction Dr Patricia Benner introduced the concept that expert nurses develop skills and understanding of patient

care over time through a sound educational base as well as a multitude of experiences. She proposed that one could gain knowledge and skills ("knowing how") without ever learning the theory

("knowing that"). She further explains that the development of knowledge in applied disciplines such as medicine and

nursing is composed of the extension of practical knowledge (know how) through research and the characterization and understanding of the "know how" of clinical experience.

She coneptualizes in her writing about nursing skills as experience is a prerequisite for becoming an expert.

ABOUT THE THEORIST Patricia E. Benner, R.N., Ph.D., FAAN is a Professor Emerita at the University of California, San

Francisco. BA in Nursing - Pasadena College/Point Loma College MS in Med/Surg nursing from UCSF PhD -1982 from UC Berkeley 1970s - Research at UCSF and UC Berkeley Has taught and done research at UCSF since 1979 Published 9 books and numerous articles Published ‘Novice to Expert Theory’ in 1982 Received Book of the Year from AJN in 1984,1990,1996, 2000

LEVELS OF NURSING EXPERIENCEShe described 5 levels of nursing experience as;

1. Novice2. Advanced beginner3. Competent4. Proficient5. Expert

Novice Beginner with no experience Taught general rules to help perform tasks Rules are: context-free, independent of specific cases, and applied universally Rule-governed behavior is limited and inflexible Ex. “Tell me what I need to do and I’ll do it.”

Advanced Beginner

Demonstrates acceptable performance 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 organizationProficient

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 actions2. Change in learner’s perception of situations as whole parts rather than in separate pieces3. Passage from a detached observer to an involved performer, no longer outside the situation but now

actively engaged in participationSIGNIFICANCE 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 Teacher’s college, Columbia University

King’s Conceptual FrameworkIt 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 systemo Interpersonal systemo Social system

Concepts are given for each systemConcepts 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 King’s 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”

King’s Theory of Goal Attainment Theory of goal attainment was first introduced by Imogene King in the early 1960’s. 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 King’s TheoryFrom 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 Nursing process theory

A system of oriented actions A system of oriented concepts

Assessment Perception, communication and interaction of nurse and client

Planning Decision making about the goals Be agree on the means to attain the goals

Implementation Transaction made

Evaluation Goal attained

N o l a J . P e n d e r ’ s H e a l t h P r o m o t i o n M o d e lI N T R O D U C T I O N

The health promotion model (HPM) proposed by Nola J Pender (1982; revised, 1996) was designed to be a “complementary counterpart to models of health protection.”

It defines health as a positive dynamic state not merely the absence of disease. Health promotion is directed at increasing a client’s level of well being.

The health promotion model describes the multi dimensional nature of persons as they interact within their environment to pursue health.

A B O U T T H E T H E O R I S T Nola J. Pender, PhD, RN, FAAN - former professor of nursing at the University of Michigan The model focuses on following three areas: · Individual characteristics and experiences · Behavior-specific cognitions and affect · Behavioral outcomes

The health promotion model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The set of variables for behavioral specific knowledge and affect have important motivational significance. These variables can be modified through nursing actions. Health promoting behavior is the desired behavioral outcome and is the end point in the HPM. Health promoting behaviors should result in improved health, enhanced functional ability and better quality of life at all stages of development. The final behavioral demand is also influenced by the immediate competing demand and preferences, which can derail an intended health promoting actions.

A S S U M P T I O N S O F T H E H E A L T H P R O M O T I O N M O D E LThe 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 changeT H E O R E T I C A L P R O P O S I T I O N S O F T H E H E A L T H P R O M O T I O N M O D E LTheoretical 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.

Health as an Expanding Consciousness Margaret Newman

Bibliography o Margaret Newman was born on October 10, 1933 in Memphis Tennessee. o In 1954 She earned her first Bachelors degree in Home Economics and English from Baylor University in Waco,

Texas o Margaret Newman felt a call to nursing for a number of years prior to her decision to enter the field. 

o During that time she became the primary caregiver for her mother, who became ill with Lou Gehrig's Disease. 

o Upon entering nursing at the University of Tennessee, Memphis, Dr. Newman knew almost immediately that

nursing was right for her Education 

o In 1962 she received her Bachelors degree in Nursing from the University of Tennessee, Memphis. 

o In 1964 she received her Masters Degree of Medical-Surgical Nursing and Teaching at the University of

California in San Francisco. o In 1971 she completed her Doctorate of Nursing Science and Rehabilitation at New York University 

Employment o 1971 to 1976- She completed her graduate studies at New York University. She also worked and taught

alongside nursing theorist Martha Rogers. Rehabilitation Nursing stemmed her interest in health, movement & time. 

o 1977- Professor in charge of graduate study in nursing at Pennsylvania State. 

o 1984- Nurse theorist at the University of Minnesota. 

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 universeNewman’s 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 nurse’s 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 non-disease can be regarded as the explication of the underlying pattern of person-environment. 

LYDIA ELOISE HALL’s Care, Cure, Core Nursing Theoryo Lydia Hall was born in New York City on September 21, 1906 and grew up in Pennsylvania. o Graduated at York Hospital School of Nursing on1927o Bachelors in Public Health Nursing on 1932, and earns a Master of Arts degree in 1942 at Teacher’s College, Columbia University.o She was an innovator, motivator, and mentor to nurses in all phases of their careers, and advocate

for the chronically ill patient. o She promoted involvement of the community in health-care issues. o She derived from her knowledge of psychiatry and nursing experiences in the Loeb Center the

framework she used in formulating her theory of nursing. These experiences might have given her insight in on the distinct roles of nurses in providing care for the patients and how the nurses can be of utmost importance in caring for these patients.

CARE, CURE, AND COREo Hall enumerated three aspects of the person as patient: the person (core), the body (care), and the

disease (cure). These aspects were envisioned as overlapping circles that influence each other.o Hall clearly stated that the focus of nursing is the provision of intimate bodily care.  She reflected

that the public has long recognized this as belonging exclusively to nursing. Being expert in the area of body involved more than simply knowing how to provide intimate bodily care. To be expert, the nurse must know how to modify care depending on the pathology and treatment while considering the unique needs and personality of the patient.

o 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

CareThis 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.CureThe 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.CoreThe 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.

Understanding Human RelationshipsAuthor: Steve Pavlina

Date: January 29th, 2007 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.

Let’s 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, you’re 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.  You’re 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.  That’s 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 doesn’t 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, you’ll be using an inescapably inaccurate model of reality.  Consequently, the likely outcome is that you’ll frustrate yourself to no end when it comes to human relationships.  You’ll 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 you’ll 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, you’ll have a much easier time relating to people.  It’s 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 it’s all the same thing.

Here’s 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 Erin’s filing cabinet, I once found a file labeled “Stuff I Don’t 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 we’re 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.

Let’s 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, I’m 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.  That’s a very different solution than what we get with the objective model.  To implement this solution, Erin needn’t even be involved.

From the standpoint of the objective model, this subjective solution seems rather foolish.  If anything it will only backfire.  Wouldn’t my working on becoming neater just increase the conflict between me and Erin?

Now here’s 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 wasn’t 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.  I’ve tested this pattern in other ways, and it continues to play out.  My ”external” relationships keep changing to keep pace with my internal relationships.  I’ve seen this effect with other people too, but it’s been most obvious with Erin and my kids, since they’re the people I spend the most time with.  It’s rather spooky at times how strong and immediate the effect is.  However, the subjective model suggests that this is exactly how reality works, so I’m 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 you’re honest you’ll 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 he’s 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 you’ll 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 FutureBy 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 WardMany 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 audience’s 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 couldn’t even sing ‘Happy Birthday.’" The audience applauded wildly. Carroll was stunned at the teacher’s remarks and the audience’s reaction. Clearly, this was more than a teacher. She was a mentor. She inspired.The Need for Nurse MentorsThe nursing profession is in the midst of its longest and most severe shortage. The current shortage has been different from those in past years because of a continuous decline in nursing school enrollments. Causes of this decline include the opening of traditionally male-dominated professions to women, inadequate salary increases in nursing, and nurses speaking out vigorously about their 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 today’s 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.From Novice to ExpertIn her landmark work From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Dr Patricia Benner3 introduced the concept that expert nurses develop skills and understanding of patient care over time through a sound educational base as well as a multitude of experiences. She proposed that one could gain knowledge and skills ("knowing how") without ever learning the theory ("knowing that"). Her premise is that the development of knowledge in applied disciplines such as medicine and nursing is composed of the extension of practical knowledge (know how) through research and the characterization and

understanding of the "know how" of clinical experience. In short, experience is a prerequisite for becoming an expert. Until publication of Benner’s research, which focused on critical care nurses, this characterization of the learning process had gone largely undefined.What Does an Expert Nurse Look Like in the Clinical Setting?Benner used the model originally proposed by Dreyfus4 and described nurses as passing through 5 levels of development: novice, advanced beginner, competent, proficient, and expert. Each step builds on the previous one as abstract principles are refined and expanded by experience and the learner gains clinical expertise.

Instead of seeing patient care as bits of unrelated information and a series of tasks, the expert is able to integrate various aspects of patient care into a meaningful whole. For example, to the novice focusing on mastering the technical aspects of care, an unstable, critically ill postoperative cardiac surgery patient is an urgent to-do list. The vital signs must be noted every 15 minutes, the cardiac rhythm assessed, intravenous drips titrated to keep the blood pressure within a certain range, the lungs auscultated, chest tubes checked routinely, and intake and output recorded.

An expert nurse caring for the same patient would complete the same tasks but not be caught up in the technical details. The expert integrates knowledge of cardiovascular physiology and pathophysiology to assess symptoms and guide patient care; for example, the skin is a little cooler than it should be, the patient is harder to arouse than he was an hour ago, the pulse oximeter shows a decrease in arterial oxygen saturation, and the cardiac monitor shows an irregular heart rhythm. The expert integrates such information and determines that the irregularity is new onset atrial fibrillation and that the cardiac output has probably dropped as a result. The expert knows to watch for emboli, adjust intravenous medications to maintain blood pressure, monitor for other signs and symptoms of reduced cardiac output, and notify the physician about the patient’s change in status. The expert has gone beyond the tasks to read and respond to the whole picture. A potential catastrophe ("failure to rescue" in the lingo of patient safety) is averted.

From Expert to Preceptor

The understanding of what makes an expert nurse has been integral in developing preceptor roles in the intensive care unit (ICU) that help impart this experiential knowledge to nurses new to critical care. The critical care clinician (physician or nurse) makes hundreds of complex decisions each day. It is impossible to teach the myriad circumstances and conditions that a clinician might face daily in the classroom setting or even in a clinical simulation. The clinical expert has a solid technical foundation and the critical thinking skills to adapt to the unique condition of each patient.

Preceptors help new nurses deal with the uncertainty of the clinical setting that is inherent to gaining proficiency. Ultimately, both nursing and medicine are taught in an apprenticeship system, and the role of the "guide at the side" is critical to moving from novice to expert. Imparting knowledge gained by years of experience can be difficult and frustrating for the preceptor and novice alike. The preceptor has learned perceptual distinctions that may be difficult for the novice to understand or the preceptor to teach.

In training experts to be preceptors, facilitators will often use methods that help bring the preceptor back in time to the novice stage. For example, at one local hospital, the instructor responsible for teaching nurses how to be good clinical preceptors brings a musical recorder, an instrument similar to a flute, for each nurse in the class. After giving the class a series of instructions on how to play the recorder, each new clinical preceptor is asked to stand in front of the group and play. This one simple lesson reminds future preceptors what it is like to be a novice and helps them guide new staff nurses skillfully and with empathy.

Inexperienced ICU nurses must deal with a wide variety of complex situations and conditions, many of which they are seeing for the first time. They may feel unsure and vulnerable to being revealed as frauds. Preceptors have to intervene in this potentially lethal 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 WantedThe 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 Homer’s 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, Odysseus’s son, and to guide him

through life’s challenges. Robert Fitzgerald5 correctly refers to Athena’s 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-knowledge—the 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 vision—the 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 creativity—mentors 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.The Future of NursingOur opening premise was that we needed to prepare for the challenge of the influx of new nurses at hospitals around the country. Developing preceptor and mentorship programs within our organizations is one effective way to integrate and support the nurses of tomorrow. We need to create these programs if they don’t exist and encourage our colleagues and administrators to support them and participate in them. The acute need for mentors is not a problem that can be solved by nursing alone. Other disciplines can assist with mentoring, and administrators can incorporate incentives for preceptors and mentors, such as salary compensation and career ladder rewards.

With the current influx of new nurses into the profession, we have an opportunity to shape the healthcare system of tomorrow. We can create a system that values talent and generosity of spirit and that rewards professional commitment. Clinical preceptors and career mentors are key to the growth of the nursing profession.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail,reprints@aacn.org.

REFERENCES1. Carroll J. San Francisco Chronicle. February 20, 2004:D4.

2. 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.

3. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, Calif: Addison-Wesley; 1984.

4. 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).

5. Homer. The Odyssey. Fitzgerald R, transed. New York, NY: Farrar, Straus, Giroux; 1998.

6. 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

IntroductionCongestive 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 patient’s needs because care plans are the essential framework through which nurses work to provide the care a patient needs (Anderson & McFarlane, 2004).Lydia Hall’s 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 Hall’s 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).FrameworkLydia Hall’s 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).

ConclusionNurses 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 Hall’s 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).

ReferencesAsadi-Lari, M., Packham, C., & Gray, D. (2003). Unmet Health needs in Patients with Coronary Heart Disease: Implications and Potential for Improvement in Caring Services. Health Quality of Life Outcomes, 1(26), 1-8. Retrieved January 10, 06, from http:www.pubmedcentral.gov Web Site: http://www.hqlo.com/concent/1/1/26Coelho, R., Ramos, S., Prata, J., Bettercourt, P., Ferreira, A., & Cerqueira-Gomes, M. (2005). Heart Failure and Health related Quality of Life. Clinical Practice and Epidemiology in Mental Health, 1(19), 1-13. Retrieved January 16, 2006, from http://www.pubmedcentral.govLeMone, P., & Burke, K. (2004). Heart Failure. In P. LeMone & K. Burke (Eds.), Medical Surgical Nursing: Critical Thinking in Client Care (3rd ed., pp. 870-888). Upper Saddle River: Prentice Hall, Inc.Paris, M. (2002, February 5). National Quality Management Program. Retrieved July 30, 2005, from http://www.jcaho.org/pms/core+measures.htmQuaglietti, S., Atwood, E., Ackerman, L., & Froelicher, V. (2000). Management of The Patient with Congestive Heart Failure using Outpatient, Home, and Palliative Care. Progress in Cardiovascular Diseases, 43, 259-274.RetrievedRN Central. (2005). RN Central. Retrieved January 10, 06, from www.rncentral.com/careplans/main.htmlTouhy, T. A., & Birnbach, N. (2001). Lydia Hall, The Care, Core, Cure Model. In M. E. Parker (Ed.), Nursing theories and nursing practice (pp.135-137). Philadelphia: F.A. Davis Company.