Self-Care Dependent-Care Volume 13, No. 1, December 2005 &Nursing The Official Journal of the International Orem Society

Contents Editorial 3 Parting shot Michael J. Morgan 3 Foreword by Guest Editor Violeta A. Berbiglia Original manuscripts 4 A Self-Care Deficit Nursing Theory practice model for advanced practice psychiatric/mental health nursing Victoria T. Grando 9 Development and examination of psychometric properties of Self-Care instruments to measure nutrition practices for English and Spanish-speaking adolescents Jean Moore, Lisa Pawloski, Heibatollah Baghi, Karen Whitt, Claudia Rodriguez, Laura Lumbi, and Adel Bashatah 17 Teaching practically practical nursing science Anna J. Biggs 22 Development and application of the Community Care Deficit Nursing Model (CCDNM) in two populations Serey Shum, Rebecca McGonigal, Barbara Biehler Teaching Strategy Column 26 Show me how Violeta A. Berbiglia IOS News 27 From the president Barbara Banfield 28 In memory of Margarethe Lorensen 29 Concept Formalization in Nursing reprint offer 30 New IOS Web Presentation 2 Author guidelines REVIEW PROCESS Manuscripts are reviewed anonymously. One Self-care, Dependent-care, & Nursing is the author must be clearly identified as the lead, or official journal of the International Orem Society contact, author who must have eMail access. The for Nursing Science and Scholarship. The editor lead author will be notified by eMail of the editor's welcomes manuscripts that address the mission decision regarding publication. of the Journal. INTELLECTUAL PROPERTY MANUSCRIPT PREPARATION Authors submit manuscripts for consideration Use Standard English. The cover page must solely by SCDCN. Accepted manuscripts become include the author’s full name, title, mailing the property of SCDCN, which retains exclusive address, telephone number, and eMail address. rights to articles, their reproduction, and sale. It is So that we may use masked peer review, no the intention of the editor to facilitate the flow of identifying information is to be found on information and ideas. Authors are responsible for subsequent pages. Include a brief abstract checking the accuracy of the final draft. (purpose, methods, results, discussion) followed by MeSH key words to facilitate indexing. SUBMISSION The use of metric and International Units is Manuscripts are to be submitted in MS Word encouraged. Titles should be descriptive but short. format as an eMail attachment to the editor, Karen Full-length articles should not exceed 15 double- Cox, RN, PhD [email protected]. spaced pages. Use of the Publication Manual of Submissions will be immediately acknowledged. the American Psychological Association (5th ed.) is It is assumed that a manuscript is sent for strongly encouraged but not mandatory. When consideration solely by SCDCN until the editor required by national legal or ethical regulations, sends a decision to the lead author. research-based manuscripts should contain a statement regarding protection of human subjects.

M i s s i o n : To disseminate information related to the development of nursing science and its articulation with the science of self-care. V i s i o n : To be the venue of choice for interdisciplinary scholarship regarding self-care. V a l u e s : We value scholarly debate, the exchange of ideas, knowledge utilization, and development of health policy that supports self- and dependent-care. 3

which is nearly every university library in North Parting shots America and dozens across the globe. Self-care, Dependent-care & Nursing continues to be an on- I do not know how well the title of my final ramp to the information highway. Please join me editorial will be perceived by the non-North in wishing the new editor, Karen Cox, RN, PhD as American readership, so I will translate: a parting she gets behind the wheel. Give her the fuel shot is a statement, often acerbic and over the (manuscripts) as she heads the journal into the shoulder, as a person leaves a situation (or tries future. (Please forgive the metaphors, but I do live to get the last word in during an argument). While in Detroit, Michigan, “the Motor City.” I am not engaged in an argument with anyone in particular, I do have a parting shot and hope it Best wishes, stimulates discussion, not ends it. Michael J. Morgan, It has been 5 years since Kathie McLaughlin Editor Renpenning turned the IOS Newsletter over to me with the sage/rueful advice, “You can’t publish About this issue what you don’t receive.” I wish I could say that Dr. Violeta Berbiglia volunteered to be Guest Self-care scholarship has flourished in those 5 Editor for an SCDCN devoted to education. She years, but I would be hard pressed to find the solicited and edited all of the articles contained in evidence. Biennial Congresses notwithstanding, this issue. Her enthusiasm for SCDNT and our scholarship is not being presented to the dedication to excellence in nursing education discipline of nursing. One barrier is the dearth of shines through. scholarship; another is ongoing intradisciplinary FOREWORD FROM THE GUEST EDITOR hostility to nursing theory. I believe it is up to the It has been a pleasure to serve as your guest IOS to fund the development of scholarship, as editor for this issue. This special issue on SCDNT- few others will do it. I implore readers to become based education includes 3 contributors from the part of the process. We have few researchers USA and 1 from Canada. All are known for their funded at significant levels to produce the type of contributions to the IOS and their excellence in scholarship necessary to improve, extend, nursing education. Also, they are interested in expand, and even refute some of the theorized your response to their conceptualizations and in relationships among the various aspects of Self- creating a dialog with you. I have included a care Deficit Nursing Theory. What can we do Teaching Strategy Column that I hope will about that? continue in future issues. Enjoy your reading and We can continue to volunteer to be reviewers plan to attend my Educators' Meeting in for grant applications. We can pressure such Johannesburg. deep-pocket funding sources (National Institute for Nursing Research) to fund theory-based Violeta A. Berbiglia, RN, EdD investigations. We can pressure our colleagues by asking, “What is the contribution of our discipline in that effort?” I am still dismayed that NINR continues to fund proposals with the phrase “self-care” yet give cursory mention of SCDNT. The traditional big grant winners continue to supply the reviewers who continue to fund non- nursing research—all under the umbrella of nursing! NINR continues to fund “nurses who research” rather than nurses doing “nursing research.” The same thing goes for Sigma Theta Tau, International. I have given up bothering to read their journal for nursing research, yet it claims to be the journal of nursing research. (See what I mean about a parting shot?) To paraphrase what I have asked before, “Who is the keeper of the disciplinary flame?” EBSCO has received all the back issues of this Journal, and the articles therein should be available via EBSCO products in the very near future. Our scholarship can now be accessed by people whose library subscribes to EBSCO, 4 A Self-Care Deficit Nursing Theory practice model for advanced practice psychiatric/mental health nursing

Victoria T. Grando

Abstract is twofold. First, it traces the historical background Because advanced practice nurses often use treatment of nurses’ concern for their patients’ ability to care strategies in common with other healthcare providers, controversy continues concerning their role within the health for themselves. And, second, it describes a care delivery system. This is particularly true for practice model based on Orem’s S-CDNT that psychiatric/mental health nurse practitioners whose practice was developed to educate family psychiatric/ overlaps with that of psychiatrists, psycholinguists, social mental health nurse practitioners. workers, and counselors. To address this issue, a practice model based Orem’s Self-Care Deficit Nursing Theory was developed as part of a family psychiatric/mental health nurse Psychiatric/Mental Health Nursing in Transition practitioner master’s specialty program. The practice model Prior to the decline of inpatient psychiatric focuses on minimizing the self-care deficits of patients with services brought about by managed care, the role mental health issues by improving their self-care agency, of psychiatric nurses was unique: managing the meeting their therapeutic self-care demands, and establishing therapeutic self-care systems. This paper provides a valuable round-the-clock therapeutic milieu of psychiatric and timely contribution to the literature on the advancement of units. This included, among other things, nursing discipline-specific knowledge and practice activities by engaging patients in therapeutic communication, presenting a practice model grounded in a nursing conceptual assisting patients in learning new behaviors and model: Orem’s S-CDNT. Key words: Self-care, Orem, Psychiatric/Mental Health Nursing; Advanced Practice identifying feelings, teaching patients to deal with Nursing; practice models stress, improving patients’ social skills, managing medications, helping patients develop and manage their self-care systems, running Nursing leaders continue to wrestle with the psychoeducational groups, and performing parameters that define the scope of advanced psychotherapy. Their role was clearly defined nursing practice. A review of nursing literature whether they based their care on nursing reveals the ongoing dialogue regarding whether conceptual models or not. nurse practitioners are engaged in advanced Today, however, many advanced nursing or delegated medicine (Cody, 2003; psychiatric/mental health nurses work in primary Fawcett, Newman, & McAllister, 2004; Geden & care as psychiatric/mental health nurse Taylor, 1997; Geden, 2001; Grando, 1998; practitioners. In these settings, their practice Watson, 1995). These leaders hold that the role of overlaps that of other mental health professionals. advanced practice nurses needs to be For example, psychiatric/mental health nurse differentiated from the role of other health care practitioners and psychiatrists share prescriptive professionals by clearly delineating nursing’s authority while psychiatric/mental health nurse proper object that is the unique focus of nursing. practitioners, psychiatrists, psychologists, social Indeed, Fawcett (2003) argues that nursing’s workers, and counselors use psychotherapy as future rests in the advancement of nursing their primary treatment strategy. Moreover, the discipline-specific knowledge and practice theoretical frameworks that are the basis for activities grounded in nursing conceptual models psychotherapy are derived from other disciplines. that provide nursing’s distinct perspective on These factors underscore the critical need for phenomena of interest to the profession: human psychiatric/mental health nurse practitioners to beings, environment, health, and nursing. base their practice on conceptual models of Although an important issue for all advanced nursing if they are to have a distinct role. I believe practice nurses, it is especially so for advanced that Orem’s Self-Care Deficit Nursing Theory (S- practice psychiatric/mental health nurses who CDNT) provides a nursing framework for today’s have recently experienced a major shift in their advanced practice psychiatric/mental health practice environment. The purpose of this paper nurses. However, there is a void in the recent 5 literature on the topic of advanced practice introduction of trained nurses (Ashley, 1976; psychiatric/mental health nursing and the use of Grando, 1994) provides evidence of the S-CDNT as a guiding framework. This paper fills effectiveness of these nursing interventions. this void by providing a valuable and timely The writings of another influential nursing contribution to the literature on the advancement leader, Virginia Henderson, echo Nightingale’s of nursing discipline-specific knowledge and views on nursing. Henderson believed that the practice activities by presenting a practice model focus of nursing was to help patients achieve grounded in a nursing conceptual model: Orem’s health by assisting them to perform health related S-CDNT. activities and gain independence. Furthermore, she believed that nurses should focus on daily Historical Background activities such as breathing normally, eating Since the inception of modern nursing in the adequately, getting sufficient rest and sleep, mid-nineteenth century, nurses have assisted avoiding dangers, communicating with others, their patients’ achieve health by providing nursing and learning how to achieve normal development. care that promotes both the body’s healing In her book, The Nature of Nursing (1966), she process and the patients’ ability to care for their provides the following definition of nursing: health related needs. Florence Nightingale articulated these views in, Notes on Nursing: The unique function of the nurse is to What it is and What it is not (1859, 1946). In this assist the individual, sick or well, in the landmark book, she delineates the nature of performance of those activities contributing nursing while making the following three points. to health or its recovery (or to a peaceful First, the role of nursing is distinct from the death) that he would perform unaided if he role of medicine. Nightingale believed that the aim had the necessary strength, will or of both physicians and nurses was to enhance the knowledge, And to do this in such a way as body’s ability to heal itself. Physicians achieved to help him gain independence as rapidly this by intervening surgically and prescribing as possible. (p. 15) medications. Nurses achieved this by preventing Orem’s (2001) beliefs about nursing are complications of poor sanitation, inadequate similar to those of Nightingale and Henderson, but nutrition, prolonged confinements to sick beds, she advanced their views by placing greater and unnecessary emotional stress as well as emphasis on achieving health by focusing on carefully observing the patient’s condition. patients’ ability to care for themselves. According Second, she held that patients and their to Orem, nursing’s proper object is self-care. The environment were the focus of nurses rather than following excerpt from her book, Nursing: physician’s orders. This view was clearly stated in Concepts for Practice (2001), illustrates her Notes on Nursing by the following: views: It (nursing) has been limited to signify Nursing has as its special concern man’s little more than the administration of need for self-care action and the medicines and the application of provision and maintenance of it on a poultices. It ought to signify the proper continuous basis in order to sustain life use of fresh air, light, warmth, and health, recover from disease and cleanliness, quiet, and the proper injury, and cope with their effects. The selection and administration of diet—all condition that validates the existence of a at the least expense of vital power of the requirement for nursing in an adult is the patient. (Nightingale, p. 6) absence of the ability to maintain for himself continuously that amount and Lastly, Nightingale believed that nurses’ role quality of self-care which is therapeutic in was not only to care for the sick, but to teach the sustaining life and health, in recovering proper methods of caring to those who care for from disease or injury or in coping with the health of others. The fact that Notes on their effects. (p. 22) Nursing was not a manual of nursing, but a guide for women on how to care for their family’s health Orem’s S-CDNT and Advanced Practice needs shows her commitment to this belief. Psychiatric/Mental Health Nursing Nursing strategies advocated by Nightingale It is evident from the writings of these were highly effective. The phenomenal success of influential nursing leaders that promoting health Nightingale’s nurses in reducing the mortality rate and the ability to care for self are nurses’ unique in military hospitals during the Crimean war and contributions to health care. Inspired by this the rapid growth of American hospitals after the tradition, I developed a practice model: Treating 6

Self-Care Deficits Related to Mental Health patients’ self-care agency, and helping their Functioning. It is based on Orem’s S-CDNT and is patients’ establish therapeutic self-care systems the foundation of a new family psychiatric/mental (see Figure 1). health nurse practitioner master’s specialty The following examples demonstrate how program. The following assumptions guided the common psychiatric/mental health problems are development of the practice model: (a) nurses viewed from the perspective of this practice have an important role in the process of healing, model. Personal crisis: people experience a crisis (b) psychiatric/mental health nurse practitioners when their established self-care systems are play a distinct role in mental health, (c) self-care is inadequate to cope with a stressful event and the proper object of psychiatric/mental health they are unable to develop new ones that would nursing, and (d) Orem’s S-CDNT (Orem, 1979, address the crisis. Relationship abuse: physical 2001) is an excellent model on which to base the and psychological abuse result in low-self esteem practice of psychiatric/mental health nurse and shame that clouds the abused person’s practitioners. judgment of their ability to engage in self-care From the perspective of this practice model actions needed to protect themselves. Psychosis based on S-CDNT (Orem, 1979, 2001), the – people with schizophrenia have limitations in proper object of psychiatric/mental health nurse self-care agency resulting from disordered practitioners is those persons whose inability to thoughts that hinders their ability to make manage their self-care requirements is related to decisions about appropriate self-care actions their mental health functioning. As primary needed to meet universal self-care requisites. psychiatric/mental health care providers, this Using this practice model, the focus of means that they treat patients with actual or psychiatric/mental health nurse practitioners is potential self-care deficits related to not on the presenting problem, but on finding psychiatric/mental health issues. Accordingly, solutions to self-care deficits. They accomplish their focus is on assessing their patients’ basic this by helping patients identify self-care actions conditioning factors, identifying their patients’ necessary to restore mental health and by helping therapeutic self-care demands, improving their patients enhance their ability to engage in these

Figure 1. Practice Model: Treating Self-Care Deficits Related to Mental Health Functioning.

BASIC CONDITIONING FACTORS Life Events; Family Dynamics; Neurobiological Factors; Peer Relations; Social Support Systems; Developmental Milestones; Current Self-Care Actions, Behaviors, Beliefs, and Feelings.

SELF-CARE DEFICIT Self-care agency inadequate to meet SELF-CARE REQUISITES self-care requisites SELF-CARE AGENCY 1) Changing behaviors 1) Knowledge of self-care 2) Reframing beliefs 2) Judgment, perceptions 3) Managing feelings 3) Foundational capabilities

TREATMENT GOALS

1) Improve self-care agency 2) Meet therapeutic self-care demands 3) Establish therapeutic self-care systems 7 therapeutic self-care actions. The goals of the mornings. Moreover, she feels “down” and treatment include the following: (a) enhancing has lost enjoyment in being at work. The problem self-care agency by strengthening capabilities started a few months after her best friend was and minimizing limitations, (b) determining self- killed in a car accident. The assessment reveals care actions necessary to change behaviors, that the patient’s recent loss has lead to reframing beliefs, and managing feelings; and (c) depression, which has exacerbating her chronic establishing therapeutic self-care systems. problem of getting up in the morning. The focus of Achieving these goals is often difficult treatment is to meet her therapeutic self-care because patients frequently have long demand, which is to get to work on time. The established dysfunctional self-care patterns. treatment goals include treating the depression However, engaging patients in treatment planning that interferes with her ability to perform self-care, facilitates the achievement of their goals. The first helping her identify what actions she is currently step in this process is a comprehensive performing that help her get-up, guiding her psychiatric/mental health history and assessment identifying new actions needed to get her get-up, that focuses on strengths as well as limitations. It and assisting her develop a system of self-care begins by evaluating the patient’s Basic actions that will effectively get her to work on time. Conditioning Factors that influence the current Treatment strategies might include anti- situation such as family dynamics; depressants, teaching the patient cognitive neurobiological factors; peer relations; social reframing skills, and exploring actions that support systems; developmental milestones; effectively wake get her up. current behaviors, beliefs, and feelings; and on A middle aged man has come in to be seen what routine self-care actions are working and because he is afraid that he has an “alcohol those that are not. Next it focuses on determining problem”. The assessment reveals that his intake the patient’s Therapeutic Self-Care Requisites of alcohol has been steadily increasing over the (Universal, Developmental, and Health Deviation) past year and that he is not eating a sufficient and the self-care actions necessary to meet these quantity of protein because of his high alcohol requisites. And lastly, it involves determining the consumption. The focus of treatment would be to adequacy of the patient’s Self-Care Agency by meet the patient’s self-care demands: to reduce assessing the following: (a) the patient’s his alcohol intake and to eat a balanced diet. The knowledge about self-care (empirical, treatment plan would address the addictive experiential, or technical), (b) the patient’s ability behaviors, his eating patterns, and the to make sound judgments and decisions about connections between the two. Treatment self-care, and (c) the status of the patient’s strategies would include joining a treatment group foundational capabilities (such as learning ability, focused on reducing his alcohol dependency, priority systems, attention, perception, and self- identifying the positive aspects of his current diet, understanding), which are necessary to engage in and guiding him to develop a balanced eating deliberate action. plan. After assessing the pertinent patient The Practice Model for Treating Self-care information, psychiatric/mental health nurse Deficits Related to Mental Health Functioning practitioners work with their patients to resolve the provides a treatment orientation that differentiates current situation. Treatment goals are directed at psychiatric/mental health nurse practitioners’ care solutions and not dissecting the perceived from that of other mental health professionals by problem. From a S-CDNT perspective (Orem, focusing on patients’ self-care requisites, 1979, 2001), the solution is achieved by identifying patients’ therapeutic self-care determining therapeutic self-care demands, demands, improving patients’ self-care agency, establishing therapeutic self-care action system, and assisting patients develop self-care systems. and enhancing self-care agency. A self-care orientation is especially appropriate for The following two case examples mental health patients because it focuses on their demonstrate how the practice model can be ability to solve their mental health problems. applied to persons having difficulty meeting the Moreover, helping patients achieve health by therapeutic self-care demands. A young adult managing their own care needs is a longstanding comes to see the psychiatric/mental health nurse nursing challenge. practitioner because she has been cautioned that her continued tardiness at work will result in her Victoria T. Grando, PhD, APRN, BC, is Associate Professor, losing her job. She states that she has always had University of Arkansas for Medical Sciences College of trouble getting up in the morning, but recently she Nursing, Little Rock, AR. Contact Dr. Grando at: is unable get to up on time because she is tired in [email protected] 8

References

Ashley, J. A. (1976). Hospitals, paternalism, and the role of the nurse. New York: Teachers College Press. Cody, W. K. (2003). Scholarly dialogue. Nursing theory as a guide to practice. Nursing Science Quarterly, 16(3), 225. Fawcett, J. (2003). Guest editorial: On bed baths and conceptual models of nursing. Journal of Advanced Nursing, 44(3), 229. Fawcett, J., Newman, D. M., & McAllister, M. (2004). Advanced practice nursing and conceptual models of nursing. Nursing Science Quarterly, 17(2), 135-138. Geden, E., & Taylor, S. (1997). How is nursing expressed by nurse practitioners in the primary health care setting. International Orem Society Newsletter, 5(2), 9. Geden, E. A. (2001). Self-care deficit nursing theory and the nurse practitioner’s practice in primary care settings. Nursing Science Quarterly, 14(1), 29-33. Grando, V. T. (1994). Nurses’ struggle for economic equity: 1945 to 1965. Dissertation Abstracts International, 55(09B), 3815.: (University Microfilms International No. 9504017). Grando, V. T. (1998). Articulating nursing for advance practice nursing. In T. J. Sullivan (Ed.), Collaboration: A health care imperative (pp. 499-514). New York: McGraw Hill. Henderson, V. (1966). The nature of nursing: A definition and its implications for practice, research, and education. New York: The Macmillan Company. Nightingale, F. (1859, 1946). Notes on nursing: What it is and what it is not. Philadelphia: J. B. Lippincott Co. Orem, D. E. (1979). Concept Formalization in Nursing Process and Product. Boston: Little, Brown and Company. Orem, D. E. (2001). Nursing concepts of practice (6th ed.). St Louis: Mosby. Watson, J. (1995). Advanced nursing practice. And what might be. N & HC Perspectives on Community, 16(2), 78-83. 9 Development and examination of psychometric properties of Self-Care instruments to measure nutrition practices for English and Spanish- speaking adolescents

Jean Burley Moore, Lisa Pawloski, Heibatollah Baghi, Karen Whitt, Claudia Rodriguez, Laura Lumbi and Adel Bashatah

Although the researchers had been conducting nutrition The development of healthy nutritional education classes and collecting qualitative dietary information behaviors in childhood and adolescence such as 24-hour dietary recall and usual meal content on girls in Nicaragua for several years, determining dietary change contributes to lifelong health and well-being. and, therefore, program effectiveness, from such information Eating a healthy diet reduces the risk for was very difficult. First, it was not possible to identify specific cardiovascular disease, some cancers, diabetes, nutrition behavior, particularly intellectual behavior, from such and other diseases (U.S. Department of Health information. Further, when changes in the diet occurred, it was unclear whether it was due to a girl’s or her mother’s influence. and Human Services, 1998). Worldwide, many To resolve these issues, the researchers decided to develop a children and adolescents do not meet health quantitative, self-report approach to measure behavior change guidelines for adequate nutrition. For example, for both girls and mothers asking for typical self-care activities research from Latin America has shown that while before and after the nutrition education classes. The following paper relates the process of development of these many countries within this region of the world are instruments. improving economically, a transition has occurred V. Berbiglia, Guest Editor in which fewer children suffer from lack of food, but many are now at risk of overconsumption of Abstract high fat, high calorie, carbohydrate rich foods. There is a need for health professionals to develop nutrition Further, their consumption of nutrient dense fruits education programs that inspire good self-care nutrition and vegetables has decreased (Pena and practices among adolescents and their caregivers, as well as Bacallao, 2000). A survey of eating trends in the instruments to measure the effectiveness of these programs. The purpose of this study was to develop and assess the United States reported that fewer than 15% of validity and reliability of two self-care instruments to measure families with children eat the recommended 5 or nutrition practices in English and Spanish-speaking more servings of fruit and vegetables per day adolescents and their parents. One instrument, the (Produce for Better Health Foundation, 2003). In Adolescent Nutrition Self-Care Questionnaire (ANSCQ), was designed to measure adolescents’ nutrition self-care practices the United States, the nutritional problems of and the second, the Parent Nutrition Dependent-Care adolescents and children are due mainly to poor Questionnaire (PNDCQ), was created to measure parents’ food choices such that children are consuming nutrition dependent-care behavior for their children. The high calorie and low nutrient dense foods. For questionnaires were developed and tested first in English and then translated into Spanish, back-translated, and tested. many United States’ families convenience Orem’s self-care deficit nursing theory was used as the outranks price or nutrition in the importance of theoretical framework for this study. Specifically, Orem’s selecting food (Guthrie, Lin, & Frazao, 2002). In (2001) estimative, transitional, and production self-care developing countries malnutrition among operations were used as the structure for instrument development. The researchers developed and tested the adolescents and children is a major public health instruments using methodology suggested by Evers and by problem and the World Health Organization has Nunnally and Bernstein. The researchers examined the called for the development of nutrition programs psychometric properties of the instruments including content to lower the incidence of malnutrition in these validity, item analysis, and reliability. In general, the experts agreed that the items were clear, represented the nutrition countries (de Onis, Frongillo, & Blossner, 2000). content, and were unbiased. The Adolescent Nutrition Self- Parents and guardians play a critical role in Care Questionnaire (ANSCQ) and the Parent Nutrition Dependent-Care Questionnaire (PNDCQ) can be valuable establishing healthy eating behaviors in their instruments for various investigations, such as describing children. Parents and caregivers are traditionally nutrition practices, comparing adolescents and parents’ the gatekeepers of a child’s food supply and serve behavior, comparing practices in English- and Spanish- as role models for food consumption. Positive speaking populations, examining adolescents’ and parents’ self-care operations, and determining the effectiveness of a parental modeling and involvement significantly nutrition intervention. influence healthy eating behaviors in children and adolescents (Norton, 2003). Key words: nutrition, measurement instruments, self-care, dependent-care, adolescents, Spanish, self-care operations There is a need for health professionals to 10

develop nutrition education programs that inspire requisite “maintenance of a sufficient intake of good self-care nutrition practices among food”, for example, involve more than just eating adolescents and their parents, as well as activities, according to Orem. Acquiring instruments to measure the effectiveness of these information about foods containing specific programs. The intent of this study was to develop nutrients, identifying alternative healthier food, and examine the psychometric properties of two making food-buying decisions, and planning self-care instruments to measure nutrition healthy meals can be among the important practices in English- and Spanish-speaking cognitive antecedent activities for meeting this adolescents and their parents. requisite. Since the researchers’ goal in this study was to design instruments to measure both Theoretical Framework cognitive and psychomotor nutrition-related Orem’s self-care deficit nursing theory (2001; behaviors of adolescents and parents, they used Orem Study Group, 2004) was used as the Orem’s operations as a framework for writing theoretical framework for this study. Specifically, items. Examples of items appear in Table 1. They Orem’s (2001) estimative, transitional, and reasoned that measurement of nutrition-related production self-care operations were used as the operations, both cognitive and psychosocial, is structure for instrument development. Dennis necessary to determine current behaviors, design (1997) defines an operation as “an intellectual or effective education interventions, or measure psychomotor action directed toward a goal” (p.21). outcomes. So operations are practices, activities, or behaviors enacted to perform self-care for oneself Literature Review or dependent-care for one’s dependent. Since formal publication of Orem’s Self-Care Estimative operations are defined as activities that Deficit Nursing Theory in 1971, a number of involve gathering information, acquiring instruments have been developed to measure the knowledge, and identifying alternatives (Orem, concepts and aspects of self-care (Dodd, 2004). 2001; Dennis, 1997). Transitional operations are Most of the self-care instruments that have been behaviors such as considering various options, developed to date are for use in adults. Several making decisions, and planning what action needs self-care instruments have been developed for to be taken (Orem, 2001; Dennis, 1997). use with children, adolescents, and their Production operations involve taking action, dependent caregivers. The Denyes Self-Care identifying resources, and evaluating the results of Agency Instrument (1981) is a 35-item Likert the action to meet the need for self-care or scale instrument that measures the ability of dependent-care (Orem, 2001; Dennis, 1997). adolescents to manage self-care. Deynes (1988) Dennis (1997) describes estimative and also developed a 17-item self-response transitional operations as primarily cognitive instrument to measure general self-care actions activities and production as primarily psychomotor. in adolescents. The Dependent Care Agent Orem’s discussion of operations is instructive Questionnaire (DCAQ) was developed to study when examining self-care practices. Self-care mother’s performances of self-care activities for practices related to the universal self-care children (Moore & Gaffney, 1989). The Child and

Table 1 Operations identified in Self-Care nutrition questionnaires Examples of Operation from Instrument Item Adolescents Parents I encourage my daughter to: Estimative: I suggest healthy foods for my suggest healthy foods for the • Identify Alternatives family to buy family to buy

Transitional: I eat a variety of food eat a variety of food • Make Decisions • Choose Among I choose to drink soda instead of choose to drink soda instead of Alternatives water water • Plan I plan my meals so that they are plan her meals so that they are healthy healthy Productive: I eat breakfast every day eat breakfast every day • Take Action • Evaluate Action I think about whether my diet think about whether her diet has has enough protein enough protein 11

Adolescent Self-Care Practice Questionnaire Vasquez, & Durant, 1998; National Institutes of (CASCPQ) (Moore, 1995) determines children’s Health, 2002; Neumark, et al., 2004; Prochaska & and adolescents’ performance as self-care Sallis, 2004; Rhiderknecht & Smith, 2004; Siega- agents. Adapted versions of the CASCPQ and Riz, Carson, & Popkin, 1998; Stanton, Fries, & DCAQ were created for use with children with Danish, 2003). cancer and their parents, respectively (Moore & Contento, Randell, & Basch, (2002) reviewed Mosher, 1997). instruments used in 265 nutrition education A search for nutrition self-care instruments studies conducted between 1980 and 1999 in six based on Orem’s theory in the CINAHL database population groups: preschool children, school identified only two studies that used nutrition self- aged children, adults, pregnant women, older care instruments. One study used an instrument adults, and professionals. This review noted that to measure self-care/dependent care nutrition there were a wide variety of instruments and knowledge and practices of dependent older methods used to evaluate nutrition education adults and their caregivers (Biggs & Freed, 2000). effectiveness. Measures evaluating nutrition Another study used an instrument to measure knowledge and skills were used to evaluate nutrition self-care behavior of myocardial nutrition education effectiveness in 85% of the infarction patients (Aish & Isenberg, 1996). No studies of school-aged children. Instruments studies were identified that used instruments measuring nutrition attitudes, diet self-efficacy, based on Orem’s Self-Care Theory to measure and intentions to change nutrition behavior were adolescent nutrition self-care behaviors or also used to evaluate nutrition education parents’ nutrition dependent-care behavior for effectiveness in studies of school-aged children. their children. With regard to measuring behavioral outcomes of Regarding the performance of Orem’s self- nutrition education in school-aged children, care operations, only one study has been Contento et al. (2002) reports that direct reported. Moore and Beckwitt (in press) examined observation of actual consumption of school lunch children’s and parents’ performance of operations and snacking practices has been used, as well in a qualitative study, finding that both children as, 24 hour dietary recall, 3-day food records, and and parents reported performing operations in all food selection inventories. three categories. The outcome of choice in measuring the A variety of methods have been used to effectiveness of nutrition education programs is measure nutrition behavior in children and change in dietary behavior (Contento et al, 2002). adolescents. In some studies, the measurement There is no standard definition of nutrition of nutrition behavior in adolescents has been behavior in dietary studies, however, and incorporated into multidimensional instruments measurement of behaviors can range from actual that measure many variables, such as health intake of specific nutrients to actual food related perceptions, safety, lifestyle practices, and dental behaviors. Contento et al. (2002) suggests that health with only a few questions related to food related behaviors and eating patterns are nutrition behavior (Graham & Uphold, 1992; more likely to be correlated with health, rather McCaleb & Cull, 2004). The Youth Risk Behavior than specific nutrients or foods and thus, Survey is an example of a multidimensional instruments that measure food-related behaviors instrument that includes a brief section on dietary and eating patterns are a more effective behaviors (Centers for Disease Control, 2000). evaluation of nutrition education. Contento et al. Neumark-Sztainer, Story, Hannan, & Croll (2002) (2002) identified 10 studies that used instruments noted that instruments used in large, to measure food-related behaviors and eating comprehensive, population-based studies of patterns in adults, but no studies were mentioned adolescent health include very few questions that used food-related behavior or eating pattern assessing eating behaviors and these questions instruments in school-aged children. have been limited in scope and not adequately In general, there is a scarcity of Spanish tested for reliability and validity. The majority of language instruments available for research with instruments used to measure child and Hispanic populations (Carlson, 2000). A search of adolescent nutrition behavior in studies published the Health and Psychosocial Instruments within the past ten years have examined food database from 1985 to 2005 revealed no Spanish consumption only, such as food frequency instruments that measure nutrition self-care questionnaires, 24-hour food recalls, or 3-day behaviors in adolescents and their parents and food diaries (Birnbaum, et al, 2002; Frenn, 2003; very few Spanish instruments that measure Hawks, Merrill, & Madanat, 2004; Lytle, Siefert, nutrition-related variables. Most nutrition-related Greenstein, & McGovern, 2000; Middleman, Spanish instruments are designed for adults and 12 include only a small number of nutrition questions particularly intellectual, as well as describe dietary embedded in large, multidimensional health intake, determine dietary change, compare questionnaires. For example, the Correlates of adolescents’ and parents’ behaviors, and Compliance Measure (Frack, Candelaria, evaluate nutrition intervention effectiveness. Woodruff, & Elder, 1997) is a Spanish instrument, developed for adults, that contains a nutrition- Method related psychological measure section that Sample includes 3-items on nutritional beliefs, 3-items on The instruments were tested with girls ages intention to change nutritional habits, 5-items on 10-18 years old and their mothers. The English nutrition self-efficacy, and a 12-item nutrition versions of the instrument were tested on 32 girls knowledge test. A few nutrition instruments have and 29 mothers. The Spanish versions were been designed for use with Spanish-speaking tested first in the United States on a group of 7 mothers of preschool children. The Nutrition girls and 18 mothers who were native Spanish- Knowledge Questionnaire (Sherman & Alexander, speakers with English as their second language. 1991) is a multiple choice, true-false instrument Then the Spanish versions of the questionnaires designed to assess nutrition knowledge of were given to 88 girls and 29 mothers in Spanish-speaking mothers of preschool-age Nicaragua, to provide a more homogeneous children with questions that focus on elements of group of Spanish-speakers. Girls and mothers a well-balanced diet, food sources for vitamins were recruited from community groups, including and nutrients, consequences of a poor diet, and churches, in the U.S. and from a nursing clinic in the four food groups. Contento et al. (1993) Nicaragua. reported the Mother’s Food Choice Criteria and 24-hour Dietary Recall Measure, which are Procedure Spanish instruments that measure mothers’ This study was reviewed and approved by a attitudes about food choices for preschool-age university human subjects review committee in children that can be correlated with children’s the United States and a school of nursing food intake from the 24-hour food recall. committee in Nicaragua. The girls and their In conclusion, although many measurement mothers gave informed assent and consent instruments exist that determine either nutrition respectively. The researchers developed and intake or knowledge, few exist that measure such tested the instruments in this study using practices for adolescents. None of these are methodology suggested by Evers (2000) and designed to quantify change in behavior. There Nunnally and Bernstein (1994) in the following are no reported English/Spanish equivalent stages. After each stage the researchers revi sed instruments for measuring and comparing the instrument. nutrition self-care behavior in adolescents and 1. Operationally defined variable to be their parents. Likewise, no instruments measure measured. The researchers defined nutrition both intellectual and physical nutrition-related practices as self-care operations related to diet. activities. Finally, no existing instruments base 2. Generated nutrition-related items. All items on Orem’s (2001, pp. 273-277) estimative, researchers developed items based on (a) transitional, and production self-care operations. recommended nutrition content (U.S. Department of Agriculture, 2005) and (b) Purpose Orem’s (2001) operations. The purpose of this study was to develop and 3. Developed the format for the assess the validity and reliability of two self-care questionnaire. Items were written in a five- instruments to measure nutrition practices in choice, Likert-type scale format to measure English- and Spanish-speaking adolescents and frequency of activities. their parents. One instrument, the Adolescent 4. Submitted the questionnaire to a group of Nutrition Self-Care Questionnaire (ANSCQ), was experts to determine content validity. designed to measure adolescents’ nutrition self- Various content experts evaluated the care practices and the second, the Parent instruments for nutrition content, clarity, Nutrition Dependent-Care Questionnaire format, lack of bias, and cultural sensitivity. (PNDCQ), was created to measure parents’ Five researchers determined separately the nutrition dependent-care behavior for their operation that each item represented, and children. The questionnaires were developed and then compared findings until they reached tested first in English and then translated into consensus. Spanish, back-translated, and tested. These self- 5. Pilot tested the questionnaire on a small care measurement instruments can enable group of English-speaking girls and researchers to identify specific nutrition behavior, mothers. The girls and their mothers 13

evaluated the instruments for directions, on the girl’s questionnaire is, “I suggest healthy clarity, format, and time for administration. foods for my family to buy.” Item #6 on the parents’ 6. Translated the questionnaire into Spanish. questionnaire is, with the preface, “Suggest Guidelines for translation, as discussed by healthy foods for the family to buy.” The same 11 Carlson (2000), were followed. These include items are reversed. See Table 1 for additional selection of an expert translator, back- examples of items. translation, pretesting in a field test, and pilot The questionnaires are designed to measure testing. before and after behaviors on the same form at 7. Pretested the questionnaire on a small the same time. For other research they could be group of Spanish-speaking girls and divided into tools that measure behaviors at one mothers. Spanish-speaking girls and time only. mothers in the U. S. suggested many revisions in the Spanish translation. Content validity 8. Consulted a nursing faculty member in Content validity is defined in the Standards for Nicaragua to translate the items into Education and Psychological Testing (American Nicaraguan Spanish. The Nicaraguan Educational Research Association, 1999) as a researcher and another native Spanish- logical analysis of the adequacy with which the speaker suggested changes in the Spanish test content represents the content domain. The translation based on the language and culture researchers developed the items based on the U. of Nicaragua. S. Department of Agriculture guidelines (2005) 9. Pilot tested the questionnaire with girls and Orem’s (2001) operations. To provide further and their mothers in Nicaragua. The content validity evidence, the questionnaires were Spanish versions of the questionnaires were reviewed by a panel of 11 experts including a used with girls and mothers in Nicaragua. pediatric nurse researcher, a nutritional 10. Conducted item analysis on the anthropologist, a psychometrician, a nurse questionnaire. Item analyses were anthropologist, a nutritionist, two native Spanish calculated on both English and Spanish speakers, and four nursing doctoral students. Of versions for girls and mothers. these experts, four had been conducting a 11. Calculated reliability. Reliabilities were nutrition intervention study in Nicaragua for four calculated for both English and Spanish years, one was a native of Nicaragua and a faculty versions for girls and mothers. member at a school of nursing in Nicaragua, two 12. Performed an additional check for had been involved in various nursing projects in evidence of validity. Participants were asked Nicaragua, and one was conducting dissertation whether they could answer the before and research on pediatric nutrition. after questions accurately. The experts made several suggestions for Instruments changes in substance, wording, and format for the The Adolescent Nutrition Self-Care questionnaires that were implemented. One Questionnaire (ANSCQ), designed by the expert questioned whether participants could researchers, is a 37-item questionnaire to remember previous dietary behavior and the measure nutrition self-care practices based on researchers investigated that issue during the pilot Orem’s operations (2001). The questionnaire study. As a check for memory of before and after measures frequency of behavior in a 5-choice behavior, the researchers asked both English and Likert-type scale format with choices of never, Spanish-speaking groups if they could accurately rarely, sometimes, most of the time, and always answer the questions. Participants reported that with higher scores indicating better nutrition they could do so successfully. In general, the practices. Eleven of the items are reversed. experts agreed that the items were clear, represented the nutrition content, and were The Parent Nutrition Dependent-Care unbiased. When the researchers assigned each Questionnaire (PNDCQ) was developed by the item to an operational category, they reached researchers to measure nutrition dependent-care consensus that items represented the three operations that parents perform for their daughters. operational categories as shown in Table 1. It is a 37-item instrument that measures frequency of behavior in a 5-choice Likert-type scale format Findings with the same choices ranging from never to The researchers examined the psychometric always. All items are prefaced with the statement, properties of the instruments including content “I encourage my daughter to…” Its items validity, item analysis, and reliability. The content correspond with the same topics in the same order validity was established using Orem’s (2001) as the girl’s questionnaire. For example, item # 6 operations, U.S. Department of Agriculture 14

guidelines (2005), and content expert evaluation. Discussion The results indicated that there was a Both the Adolescent Nutrition Self-Care correspondence between the questionnaire items Questionnaire and the Parent Nutrition Dependent- and the intended content domain. Care Questionnaire are instruments that were Researchers conducted item analysis on the created to measure nutrition behaviors in English- items, examined the item-total correlations, found or Spanish-speaking populations. Validity and them to be acceptable, and estimated the internal reliability have been examined and established for consistency reliability of the instruments. The these instruments. For construct validity, factor internal consistency method of estimating analysis will be conducted in the future on the reliability focuses on the shared content of the instruments when sample sizes in each group are items or whether the items are homogeneous. In sufficient. this study, estimates of internal consistency were Orem’s (2001) theory was useful in developing determined using coefficient alpha. Methods for items to measure both cognitive and psychomotor estimating reliability differ with respect to the activities. At present the majority of items measure sources of error being addressed. The present operations in the “take action” category, rather than study used coefficient alpha because it being evenly distributed among various addresses errors due to sampling of content or operations. More items should be added to the domain, that is the degree to which the items are instruments reflecting the operations “acquiring representative of the content being measured knowledge”, “making decisions”, and “planning (Pedhazur & Schmelkin, 1991). The coefficients actions.” When compared to other nutrition alpha were estimated and reported for the measurement instruments in the literature, these English and Spanish versions of the before and instruments target areas previously unaddressed: after data for both instruments. Although the matching adolescents and their parents, minimum recommended standard for coefficient English/Spanish equivalent forms, comparison of alpha varies among psychometricians, Nunnally before and after behaviors, and inclusion of both and Bernstein (1994) recommend a threshold of cognitive and psychomotor behaviors. So far these .70. The reliability coefficients for the instruments instruments have been tested only on girls and in this study are shown in Table 2. The mothers and only in the United States and coefficients alpha are above the threshold for all Nicaragua. Nicaraguan Spanish may be somewhat versions, except for the English version of the different than Spanish spoken in other countries. parents’ posttest at .67. If one specific item in that The Adolescent Nutrition Self-Care version were dropped, the coefficient alpha Questionnaire (ANSCQ) and the Parent Nutrition would be.72. Dependent-Care Questionnaire (PNDCQ) can be valuable instruments for various future research Table 2 Reliability Coefficients for the Nutrition investigations, such as describing nutrition Behavior Questionnaires practices, comparing adolescents and parents’ Girls: Nutrition Self-Care Behavior behavior, comparing practices in English- and Questionnaire Spanish-speaking populations, examining adolescents and parents’ self-care operations, Coefficient Coefficient and determining the effectiveness of a nutrition Alpha Alpha intervention. English Version Spanish Version We will be pleased to share the questionnaires Before .8258 .9096 with other researchers. We would appreciate those researchers sharing their results with us so After .8132 .9053 that we can perform further analysis on the questionnaires in the future.

Mothers: Nutrition Dependent-Care Jean Burley Moore, RN, PhD, is Associate Professor, College Behavior Questionnaire of Nursing, Lisa Pawloski, PhD, Heibatollah Baghi, PhD, Karen Whitt, MSN, Doctoral Candidate, Claudia Rodriguez, BS and Coefficient Coefficient Adel Bashatah, MS, Doctoral candidate, all with George Mason Alpha Alpha University, Fairfax, Virginia. Laura Lumbi, MSN, is with Universidad Politecnica de Nicaragua, Managua, Nicaragua. English Version Spanish Version Contact Dr. Moore: Email: [email protected]. Before .7500 .8156 References After .6694 .9419 Aish, A. E., & Isenberg, M. (1996). Effects of Orem-based nursing intervention on nutritional self-care of myocardial infarction patients. International Journal of Nursing 15

Studies, 33(3), 259-270. Lytle, L. A., Seifert, S., Greenstein, J., & McGovern, P. (2000). American Educational Research Association, American How do children’s eating patterns and food choices Psychological Association & National Council on change over time? American Journal of Health Measurement in Education. (1999). Standards for Promotion, 14(4), 222-228. educational and psychological testing, Washington, DC: McCaleb, A., & Cull, V. V. (2000). Sociocultural influences and Author. self-care practices of middle adolescents. Journal of Biggs, A. J., & Freed, P. E. (2000). Nutrition and older adults: Pediatric Nursing, 15(1), 30-35. What do family caregivers know and do? Journal of Middleman, A. B., Vazquez, I., & Durant, R. H. (1998). Eating Gerontological Nursing, 26(8), 6-14. patterns, physical activity, and attempts to change weight Birnbaum, A. S., Lytle, L. A., Story, M., Perry, C. L., & Murray, among adolescents. Journal of Adolescent Health, 22(1), D. M. (2002). Are differences in exposure to a 37-42. multicomponent school-based intervention associated Moore, J. B. (1995). Measuring the self-care practice of with varying dietary outcomes in adolescents? Health children and adolescents: Instrument development. Education & Behavior, 29(4), 427-443. Journal of Maternal Child Nursing, 23(3), 101-108. Carlson, E. D. (2000). A case study in translation methodology Moore, J. B. (in press). Self-care operations and nursing using the Health-Promotion Lifestyle Profile II. Public interventions for children with cancer and their parents. Health Nursing, 17(1), 61-70. Nursing Science Quarterly. Centers for Disease Control and Prevention. (2000). Youth risk Moore, J. B., & Gaffney, K. F. (1989). Development of an behavior surveillance- United States, 1999. MMWR instrument to measure mothers’ performance of self-care Morbidity and Mortality Weekly Report, 49, 1-89. activities for children. Advances in Nursing Science, Contento, I. R., Basch, C., Shea, S., Gutin, B., Zybert, P., 12(1), 76-83. Michela, J. L., et al. (1993). Relationship of mothers’ food Moore, J. B., & Mosher, R. (1997). Adjustment responses of choice criteria to food intake of preschool children; children and their mothers to cancer: Self-care and Identification of family subgroups. Health Education anxiety. Oncology Nursing Forum, 24, 519-525. Quarterly, 20, 243-259. National Institutes of Health, Applied Research Program, Contento, I. R., Randell, J. S., & Basch, C. (2002). Review and National Cancer Institute, (2002). Diet History analysis of evaluation measures used in nutrition Questionnaire, Version 1.0. education intervention research. Journal of Nutrition Neumark-Sztainer, D., Story, M., Hannan, P. J., & Croll, J. Education and Behavior, 34(1), 2-25. (2002). Overweight status and eating patterns among de Onis, M., Frongillo, E. A., & Blossner, M. (2000). Is adolescents: Where do youths stand in comparison with malnutrition declining? An analysis of changes in levels the Healthy People 2010 objectives? American Journal of of child malnutrition since 1980. Bulletin of the World Public Health, 92(5), 844-851. Health Organization, 78(10), 1222-1233. Norton, D. E. (2003). Eating and exercise behaviors in Dennis, C. M. (1997). Self-care deficit theory of nursing. St. preadolescents: Parental influence? Unpublished Louis: Mosby. Dissertation, University of California, San Francisco. Denyes, M. J. (1981). Development of an instrument to Nunnally, J., & Bernstein, I. (1994). Psychometric Theory. New measure self-care agency in adolescents.University of York: McGraw Hill. Michigan, Dissertation Abstracts International, 41(5), Orem, D.E. (2001). Nursing: Concepts of practice (6th ed.). St. 1715B. Louis: Mosby. Denyes, M. J. (1988). Orem’s model used for health Orem Study Group (2004). Working papers. Cloppenburg, promotion: Directions for research. Advances in Nursing Germany: Institute fur Pflegediagnosik & Praxisforschung. Science, 11, 13-21. Pedhazur, E. J., & Schmelkin, L. P. (1991). Measurement, Dodd, M. J. (2004). Measuring Self-Care Activities. In M. design, and analysis. Hillsdale, NJ: Lawrence Erlbaum. Frank-Stromborg & S. J. Olsen (Eds.), Instruments for Clinical Health-Care Research (3rd ed.). London: Jones Pena, M. and Bacallao, J. (2000) eds. Obesity and Poverty: A and Bartlett. new public health challenge. Washington DC: Pan American Health Organization. Evers, G. (2000, February). Measurement of self-care in clinical practice. Paper presented at the 6th International Self-Care Prochaska, J. J., & Sallis, J. F. (2004). A randomized controlled Deficit Nursing Theory conference, Bangkok, Thailand. trial of single versus multiple health behavior change: Promoting physical activity and nutrition among Frack, S. A., Candelaria, J., Woodruff, S. I., & Elder, J. P. adolescents. Health Psychology, 23(3), 314-318. (1997). Correlates of compliance with measurement protocols in a Latino nutrition-intervention study. Produce for Better Health Foundation. (2003). State of the American Journal of Preventive Medicine, 13, 131-136. plate: Study on America’s consumption of fruits and vegetables. Wilmington, DE: Produce for Better Health Frenn, M. (2003). Peer leaders and adolescents participating Foundation. in a multicomponent school based nutrition intervention had dietary improvements. Evidence-Based Nursing, Rinderknecht, K., & Smith, C. (2004). Social cognitive theory 6(2), 44. in an after-school nutrition intervention for urban Native American youth. Journal of Nutrition Education and Graham, M. V., & Uphold, C. R. (1992). Health perceptions Behavior, 36(6), 298-304. and behaviors of school-age boys and girls. Journal of Community Health Nursing, 9(2), 77-86. Sherman, J. B., & Alexander, M. A. (1991). Nutrition Knowledge Questionnaire. Public Health Nursing, 8, 53-58. Guthrie, J. F., Lin, B. H., & Frazao, E. (2002). Role of food prepared away from home in the American diet 1977-78 Siega-Riz, A. M., Carson, T., & Popkin, B. (1998). Three versus 1994-96. Journal of Nutrition Education and squares or mostly snacks—what do teens really eat?: A Behavior, 34, 140-150. sociodemographic study of meal patterns. Journal of Adolescent Health, 22(1), 29-36. Hawks S. Merrill RM. Madanat HN. The Intuitive Eating Scale (IES) (2004). American Journal of Health Education, Stanton, C. A., Fries, E. A., & Danish, S. J. (2003). Racial and 35(2): 90-9. gender differences in the diets of rural youth and their 16

mothers. American Journal of Health Behavior, 27(4), 336-347. U. S. Department of Health and Human Services. (1998). The Surgeon General’s Report on Nutrition and Health. Washington, DC: U. S. Department of Health and Human Services. U. S. Department of Health and Human Services. (2000). Healthy People 2010. Retrieved July 14, 2005, from http://www.healthypeople.gov U.S. Department of Agriculture (2005). MyPyramid.gov: News and Media. Retrieved July 19, 2005, from http://www.mypyramid.gov/global_nav/media.html 17 Teaching Practically Practical Nursing Science, Part I

Anna J. Biggs

We are fortunate to have one of our experienced educators when I was working on my dissertation on relate to us her Self-Care Deficit Nursing Theory (SCDNT)- metaphors of nursing in Orem’s work, I needed to based curriculum experiences. Part I features the initial hermeneutic journey and teaching nursing using Orem’s go back to this first source on Orem, and, to my SCDNT in a baccalaureate degree completion program. Part surprise, found many marginal notes and II will follow in our next issue on Education. The focus of Part underlining and a picture of my infant daughter as II will be on teaching nursing assessment and fundamental a bookmark in the chapter on Orem’s theory. skills and clinical courses for traditional baccalaureate nursing students, including application of SCDNT in a theoretical There were fewer marks in the chapter on Rogers’ nursing assessment and nursing care plan forms used by the theory, which I had thought I should read before program and graduate nursing theory, again emphasizing meeting Martha Rogers! I was surprised because application and use of Orem’s SCDNT. I had no real recollection of having read and V. Berbiglia, Guest Editor marked up the chapter on Orem’s theory! In hermeneutics, this is spoken of as being grasped Background by the theory rather than grasping it (Bleicher, Having taught nursing in two associate degree 1980; Ricoeur 1975, 1976, and 1981). programs in Southwestern and Western United During the PhD Program there was, of States, I began preparations for entering a doctor course, the required course on theory of philosophy (PhD) in a nursing program. I construction, development, analysis and believed I needed further education as the evaluation. I read, studied and used a variety of program where I was teaching developed a two- articles and books on analyzing and evaluating plus-two baccalaureate nursing program. This was theory (Ellis, 1968; Duffey & Mulhenkamp, 1974; at a time when physical assessment was Stevens, 1979; Fawcett, 1978; Fawcett, 1980; becoming a nursing buzzword; and I wanted to Meleis, 1985; Chinn & Jacobs, 1983). Finally, I understand better what a nursing assessment was. focused my attention on Orem’s SCDNT, feeling drawn to the philosophy and theory. Still there was Doctoral Studies dissatisfaction with knowing what the Self-Care Early in my doctoral studies, the director of Deficit Nursing Theory says using the the doctoral program invited newly admitted aforementioned traditional methods of theory students to her home to meet a visiting nurse analysis and evaluation which put questions philosopher and theorist, Martha Rogers. I, (sometimes more than 60 questions!) to the admittedly, did not know much about any nursing theory, looking for the hidden meaning of the theory or nursing theorist, so decided I had better theory. I began searching for understanding the read a book that had come to my office as a desk meaning of the theory using hermeneutic copy for review and possible course adoption. interpretation method (Ricoeur, 1975). This led to The book (Nursing Theories Conference Group, identifying the metaphors of nursing in Orem’s 1980) was a synopsis of several nursing theories, work: Nursing as a Practice Discipline; Nursing as including Martha Rogers’ Science of Unitary Man Deliberate Action; Nursing as a Helping, Human (before the change to Human Being) and Health Service and Science; and Nursing as Dorothea Orem’s Self-Care Deficit Nursing Care—Self-Care of Another Self (Biggs, 1999). Theory, among others. While this first encounter Metaphors carry the meaning of a text or theory with Orem’s theory was in a secondary source, it and are projected upfront and not hidden in the was the beginning of my hermeneutic journey. text or the mind of the author. The identification of I am a scribbler in books, making marginal these metaphors of nursing and the nexus of notes and underlining or highlighting passages of metaphors connected with them and with the the text that stand out to me. A few years later, concepts of the General Theory of Nursing 18

(SCDNT) (Orem, 1985; Orem, 2001) provided the universal self-care requisites. This new found deeper understanding of the world of nursing that ability may not seem tremendous or impressive to I was seeking so that I could better express to those who have been using Orem’s theory, but, students what a nursing assessment would be. for nurses prepared at a technical level, returning for their baccalaureate degree, this is an eye Teaching in a SCDNT- Based Curriculum opening or gestalt experience. Most were After completing my doctorate, I began delighted to have a better appreciation for all the teaching in a baccalaureate completion program things they did to care for patients. They felt that (RN to BSN) in a mid-western United States the nursing care they gave, using Orem’s theory, public university in a major metropolitan area, was actually moving them from a technical level of where Orem’s theory was the conceptual nursing to a more professional level. framework for the curriculum. I was delighted to Students working in pediatrics and obstetrics be assigned to teach an introductory course on also used maturational and situational the dimensions of professional nursing where I developmental self-care requisites, respectively, would be introducing undergraduate nursing in developing appropriate nursing care plans, students (formerly diploma and associate degree along with universal self-care requisites. There registered nurses) to Dorothea Orem’s theory. I was a diabetes nurse educator in one of the recall one semester where, as usual, I had asked classes who exclaimed, regarding the health students why they became a nurse and jotted deviation self-care requisites, “Now, I have a their responses of wanting to help people on the more comprehensive way of looking at and blackboard. I then used that notion of helping teaching diabetes self-care management. With people to begin talking about Dorothea Orem’s Orem’s theory to help my patients understand theory and the metaphors of nursing that had their pathological condition, be aware of and helped me better understand nursing. One attend to the effects of their diabetes and carry out student had her arms crossed and took no notes the prescribed therapy and regulate their during the entire introduction to the course, functioning, modify their self-concept by assignments, and requirements. When I moved accepting themselves as having a pathologic on into talking about helping as one of the condition and needing specific forms of health metaphors of nursing in SCDNT and how we care, all the while learning to live with their would use a practice model (see Figure 1) to condition in a life-style that promotes their examine the dimensions of professional nursing, I continued personal development! This is just what noticed this student writing notes as rapidly as I have needed for a long time!” possible. She came up during a break and asked for some additional references and I thought, Dorothea Orem (1985) noted that nurses often “you’ve been caught as I was!” In fact, she later start at the level of universal and developmental served as a research assistant on some of my self-care requisites and basic conditioning factors. research to test the Biggs’ Elderly Self-Care However, she concluded that there is a need for Assessment Tool (BESCAT) (Biggs, 1990). closer examination of the health deviation self-care One of the activities in this course was to requisites and a thorough description and critically analyze the kardexes and nursing care discussion of “nursing cases” concerning the plans in use in students’ current employment health deviation self-care requisites and the power situations. Students were challenged to see if components of self-care agency. For these there could be connections made to Orem’s beginning professional nurses, I believed their SCDNT. I was impressed with their efforts. Some strides toward a more comprehensive nursing examples of their applications of SCDNT approach to be note-worthy. included: When we examined currently used nursing history forms, students were distressed to see how • Connecting orders for pulse oximetry much of the nursing history was really a repetition readings and oxygen administration to of the medical history and physical examination. “maintaining an adequate intake of air” That led to discussions of the proper object of • Changing the wording regarding parenteral nursing and the domain of nursing (Orem, (IV) fluid administration to “maintaining an 1980,1985, 1995, 2001) as well as how the initial adequate intake of water” nursing history forms could be more relevant to • Altering standardized nursing care plans for nursing care. As we moved into examining the fall prevention to address “prevention of basic conditioning factors (BCF’s) (see Figure 1) to hazards” individualize the universal, developmental and Students were able to reconceptualize health deviation self-care requisites, most of these kardexes and nursing care plans in terms of registered nurses began seeing the need for 19

Figure1. Practice Model of Orem's Self-Care Deficit Nursing Theory

UNIVERSAL DEVELOPMENTAL HEALTH SELF-CARE SELF-CARE DEVIATION SELF- REQUISITES REQUISITES CARE REQUISITES

Self-Care Requisites are individualized by the BASIC CONDITIONING FACTORS

Resulting in the determination of the THERAPEUTIC SELF-CARE DEMAND which is compared with

SELF-CARE AGENCY Assessed by analyzing the ten power components to evaluate development, operability and adequacy for meeting self-care demands and demonstrates or identifies the

SELF-CARE DEFICIT

TSCD - SCA = SCD If TSCD < or = SCA, then no or SCD, and no Nursing TSCD > SCA = SCD System is needed

which determines the

NURSING SYSTEM Wholly compensatory, Partly Compensatory, Supportive-Educative

Implemented by the METHODS OF ASSISTING Acting for/doing for Another, Guiding Another, Supporting Another, Providing an Environment for the development of Self-Care Agency, Teaching Another

Reassess TSCD, Evaluate Outcomes , and Replan/Redesign the NURSING SYSTEM

The Universal, Developmental, and Health-Deviation Self-Care Requisites (SCR's) are individualized by the Basic Conditioning Factors (BCF's) to determine the person's (patient's) Therapeutic Self-Care Demand (TSCD), the total care needed at this point in time. When we compare the Self-Care Agency (SCA, ability to care for self) or the Dependent-Care Agency (DCA, one's ability to care for one's dependents) with the TSCD, we find whether or not the person has a Self-Care Deficit (SCD, inability to care for one's self) or a Dependent-Care Deficit (DCD, inability to care for one's dependents) because of the situation of personal health. A Self-Care Deficit (or Dependent-Care Deficit) is what legitimizes the need for nursing. If there is an SCD or DCD due to the person's or dependent's health state, then a Nursing System is needed and designed. The Nursing System is prescribed as Wholly Compensatory, Partly Compensatory, or Supportive-Educative. The designed Nursing System is implemented by means of the five Methods of Assisting, and is further specified by the nursing actions to be taken within the general method of assisting. The designed Nursing System is evaluated in terms of the development of regained ability to exercise and regulate Self-Care Agency (or Dependent-Care Agency). Reassessment, replanning or redesigning results from this evaluation in the management of nursing care. 20

altering their employer’s nursing history forms to requires understanding of the focus, the address more of the items in the BCF’s because nature, the structure, the content, and the that was truly the information nurses needed to domain of nursing science in relationship provide nursing care. to the focus of and the realities that define Discussions of which nursing system was the domain of nursing practice (Orem, applicable in certain nursing situations were 2004, p. 4). likewise very stimulating. Students posed These positive reflections should not be questions such as: construed to mean that there were never groans • When is a patient in need of a wholly or murmuring and complaining about “having to compensatory nursing system? study Orem.” There was plenty of that, too. • What if there were family members who could Students who did not want to have to read, study make decisions for needed care and and think/reflect about their nursing practice were participate in care? vocal in their preference for continuing their • If patients could do nothing for themselves, atheoretical nursing practice. They preferred their such as in an intensive care unit of sedated- reflexive knee-jerk responses to situations like an ventilated patients, were the patients in a empty IV or a patient’s request for pain wholly compensatory nursing system? medication, or a critical situation such as internal • How did family involvement in decision- bleeding or wound dehiscence and evisceration. making and care fit with definitions of My intent was to foster a reflective (deliberate) dependent care agency? nursing practice where: • How did nursing agency link with self-care • The IV might have been ready before the agency and/or dependent-care agency? current bag was empty (to maintain an Students who were in home health care adequate intake of water). agencies or who were patient educators in • The patient’s pain might be anticipated and hospital settings were very interested in the medications offered to manage pain before it concepts of “multi-person units” of families and became severe (promoting normalcy). populations of patients. They recognized that the • Internal bleeding might have been thought of ultimate basic unit of care was the individual, the as a possibility and assessments made “Another Self” (Orem, 1980, 1985, 1995, 2001), before it became a critical situation who needed self-care; but, because of the (maintaining an adequate intake of air as situation of personal health, was unable to oxygen at the cellular level and the impact of provide care for self. bleeding and shock on air and oxygenation). • A fragile wound might be managed by nursing Students were also able to classify nursing care to prevent or at least find the earliest interventions from the standardized care plans signs before there was evisceration used in their employment situations with the (prevention of hazards). categories of the methods of assisting. They found that much of the focus at that time was on Students who did not want to have to teaching patients, with much less attention to challenge their supervisors and colleagues to a acting for/doing for another, guiding another, higher level of practice were also among those supporting another, and providing an environment who didn’t want to use a theory that might cause in which patients could develop their self-care them to have to rock the boat. It is probably agency. Seeing that nursing was so much more apparent which group of nurses would be than only teaching helped many of them to work preferred for caring for family members of those on expanding the care plans that were in use and ascribing to the use of Orem’s Self-Care Deficit to join practice committees at their employing Nursing Theory! The challenge to faculty was to institutions to try to make some of these changes. try to find the message that would hook the more I believe this change in attitude of technical nurses resistant students or to acknowledge that not in a baccalaureate completion program, as they every student would be able to move into that examined the focus, nature and structure of level of professional thinking and practice. nursing in preparation for becoming professional Change from Teaching in a SCDNT-Based nurses, is an example of what Orem discussed in Curriculum to a Self-Care Systems Model- a recent article on Nursing Practice Science: Based Curriculum Nurses who have or are achieving Sadly, at a curriculum workday in this college, professional status have responsibility for a part-time clinical instructor, who rarely attended the development of nursing science. faculty committees or workdays, asked why we Becoming and being professional had to keep using Orem’s theory because she 21 had not read it and did not plan to and thought we Anna J. Biggs, RN, PhD, is Assistant Professor at St. Louis ought to just drop it. I was nearly speechless and University, St. Louis, MO. Contact Dr. Biggs at: [email protected] spent the lunch time writing about what using Orem’s theory did in terms of helping to structure References and organize the curriculum and nursing practice, using an analogy of lemonade made from powder, Biggs, A.J. (1990). Family caregiver versus nursing or frozen concentrate with lemonade made from assessments of elderly self-care abilities. Journal of Gerontological Nursing, 16(8), 11-16, 36-37. fresh lemons. However, I was one lone voice; and Biggs, A.J. (1999, April). The language of Self-Care Deficit the vote was to change to an undefined (and un- Theory. International Orem Society Newsletter, 7(1), 3-7. definable without using Orem’s SCDNT!) “self- Bleicher, J. (1980). Contemporary hermeneutics: care systems model”. The courses were Hermeneutics as method, philosophy, and critique. subsequently changed and re-titled, so there was London: Routledge and Kegan Paul. no longer a course entitled “Designing Nursing Chinn, P. L., & Jacobs, M. K. (1983). Theory and nursing: A Systems for Families and Groups”, nor a course systematic approach. St. Louis: Mosby on “Teaching and Supporting Individuals and Duffey, M., & Muhlenkamp, A. F. (1974). A framework for Groups” and so forth. The entire curriculum lost its theory analysis. Nursing Outlook, 22(9), 570-574. structure, cohesiveness and organization and Ellis, R. (1968). Characteristics of significant theories. Nursing Research, 17, 217-222. became a listing of required courses for obtaining Fawcett, J. (1978). The relationship between theory and a bachelor’s degree in nursing. research: A double helix. Advances in Nursing Science, Because Orem’s SCDNT pervaded my 1(1), 49-62. nursing practice or my own structure and Fawcett, J. (1980, Nov-Dec). A framework for analysis and organization as an educator, I was able to evaluation of conceptual models of nursing. Nurse Educator, 5(6), 10-14. continue teaching in this program. My teaching Meleis, A. (1985). Theoretical nursing: Development and assignment was changed to teaching a course on progress. Philadelphia: J. B. Lippincott Company. computers in nursing, where students used word The Nursing Theories Conference Group. (1980). Nursing processing to write essays about “self-care theories: The base for professional nursing practice. nursing systems” after reading a description of Englewood Cliffs, N. J.: Prentice-Hall. wholly compensatory, partly compensatory and Orem, D. E. (1980). Nursing: Concepts of practice. (Second supportive-educative nursing systems. Students edition). New York: McGraw-Hill. devised databases to collect information on basic Orem, D. E. (1985). Nursing: Concepts of practice. (Third conditioning factors. They created spreadsheets edition). New York: McGraw-Hill. with narrative and numerical data on maintaining Orem, D. E. (1991). Nursing: Concepts of practice. (Fourth edition). St. Louis: Mosby. an adequate intake of oxygen and hemodynamic Orem, D. E. (1995). Nursing: Concepts of practice. (Fifth monitoring data; or maintaining an adequate edition). St. Louis: Mosby. intake of water and food with IV fluid and total Orem, D. E. (2001). Nursing: Concepts of practice. (Sixth parenteral nutrition (TPN) ingredients or oral food edition). St. Louis: Mosby. intake. When students would ask where I got the Orem, D. E. (2004). Reflections on nursing practice science: ideas for their assignments, I would smile and The nature, the structure and the foundation of nursing then give them the reference to the current edition sciences. Self-Care, Dependent-Care and Nursing, of Orem’s work. Some would respond with “Wow, 12(3), 4 – 11. that is really interesting that all this could come Ricoeur, P. (1975). The rule of metaphor: Multidisciplinary studies of the creation of meaning in language. Toronto: from a nursing theory!” So, even a computer University of Toronto Press. course could be used to fulfill my need to continue Ricoeur, P. (1976). Interpretation theory: Discourse and the to use Orem’s theory in teaching and practice. surplus of meaning. Fort Worth, TX: The Texas Christian When a nursing educator is committed to a University Press. theory-based nursing practice using SCDNT, Ricoeur, P. (1981). Hermeneutics and the human sciences. Cambridge, MA: Cambridge University Press. teaching nursing students to know and perhaps Stevens, B. (1979). Nursing theory. Boston: Little Brown and even understand and appreciate Orem’s SCDNT, Coimpany. will be natural, even in the face of curricular and teaching assignment changes. The second article (Part II) will continue the discussion of using Orem’s SCDNT in a traditional baccalaureate program in a variety of courses: nursing assessment, fundamental skills, clinical practice, and graduate nursing. 22 Development and application of the Community Care Deficit Nursing Model (CCDNM) in two populations

Serey Shum, Rebecca McGonigal and Barbara Biehler

Abstract constructs and explanations related to a The purposes of this paper are to describe the Community phenomenon in one field in order to obtain Care Deficit Nursing Model (CCDNM) and two case concepts and explanations in another field. The applications using the CCDNM in the education of graduate process was modified to use S-CDNT to derive students. The students were able to apply the model to benefit the communities studied. Students derived a holistic new constructs that would be helpful in extending understanding of the communities and the actual Community the theory to describe a community or population Deficits from the perspective of the community members. as the unit of service. The results were the Key terms: Theory, CCDNM, Orem, Community, Public Health, development of a conceptual model of Teaching, Graduate Education Community Care Deficit Nursing extension of S- CDNT and a community diagnosis instrument Orem’s Self-Care Deficit Nursing Theory (S- based on the model. CDNT) has been applied extensively to individuals. A Community Care Deficit Instrument was Fewer applications have been accomplished in developed based on the Community Care Deficit community care when a population is the Model. Both the model and the instrument were multiperson unit of care. The Community Care compared to community health nursing theories Deficit Model (CCDM) and Diagnosis of and community assessment models in terms of Community Care Deficit Instrument (DCCDI) were philosophical underpinnings, assumptions, developed by faculty and graduate students at concepts and propositions. Specifically, Helvie’s West Texas A& M University (WTAMU). Orem’s Energy Theory of Communities (1991) and (2001) Self-Care Deficit Nursing Theory (S-CDNT) Anderson and McFarlane’s Community as Partner is the foundation for all graduate nursing courses, (2004) were chosen to confirm the accuracy and as well as the practice theory for faculty and comprehensiveness of the new model and students at WTAMU. The development of this instrument in relation to current community framework and its utilization were integral parts of diagnosis, population health management and the teaching methodology used in a master’s level community health nursing practice. community health nursing course. The term community is used to indicate the Process multiperson unit of service. In this model Students began the community health course community, as the unit of service, is different from with a review of the community health nursing community as a setting for providing care to an literature. Notably lacking was a full extension of individual, exemplified by a community primary S-CDNT to the population as the multiperson unit care clinic, or a community based home health of care and the recognition that, as a unity of care, agency. It is also different from community as a the population must meet unit health demands. conditioning factor for the individual. As the unit of Therefore, the foundational work of Taylor and service, the community is the care agent and has Renpenning (cited in Orem, 2001; Taylor and conditioning factors that are unique and affect the McLaughlin, 1991) were used as a launching unit’s agency and demands. point from which to begin the process of deriving Community is the type of multiperson unit a theory of population care from S-CDNT. The described by Taylor and Renpenning (cited in principles and process of theory derivation Orem 2001) as a group of persons impersonally described by Walker and Avant (1995) were related who come together for shared purposes, helpful in the process of developing this model. and shared problem resolution. It fits the category Through examining analogous relationships, of a type 2 multiperson care system in that theory derivation stimulates the invention of new members are of a “structured, enduring social 23 group” who have common requisites and work magnitude threatens the existence, health, safety together to meet these requisites. As a type two and/or productivity of the community as a unit. care system, a community is a formally organized Communities, as conceptualized by this model, system and may be a part of a suprasystem. are defined by geographic boundaries and the While there may exist subsystems within the majority of relationships are impersonal. The community devoted to the care of individuals, structure is formal, with formal governance. there must exist subsystems designed to address Figure 1 represents the conceptual model of common requisites that contribute to the Community Care Deficit Nursing. maintenance of the health, integrity and future of the whole, and the diagnosis and solution of Community conditioning factors are an common problems. The public health department, extension of individual conditioning factors. sanitation departments and police department are Examples of these comparisons are listed in examples of community care subsystems. Table 1. These factors condition the agency, Problems, which affect individuals, are addressed demands and deficits of the community. by community care systems only if their Community care agency is viewed as the

Figure 1. Community Care Deficit Nursing Model

Community C Multiperson C Unit of O Service O N N D R R D I I T Community T R I Care Community I Subsystem Demand O Agency O N N I R I N N Community G Care G F Deficit F A A C C T T O Agency: O R Nursing R Collaborators S Partners S Stakeholders

Table 1 Comparison of Conditioning Factors of the community as the Unit of service and the Individual as the Unit of Service

Individual Conditioning Factors Community Conditioning Factors Age and gender Age and gender distribution Residence and its environment Distribution of types and condition of residences. Location of environmental risks and hazards. Family system factors Distribution of family types. Marriage rates, divorce rates, fertility rates. Health State Morbidity and mortality rates Developmental state Community history & current status as a unit Pattern of living General living patterns of unit and subunits Health care system factors Suprasystem factors, economic, political, health Socioculture factors Distribution of socioeconomic groups, cultural and ethnic groups External environmental factors Suprasystem environmental factors 24

ability of the community system and subsystems to diagnosis of community deficits as well as the evaluate and perform the functions needed to planning, implementation and evaluation of maintain the health, integrity and growth of the community care interventions. To the extent that community. The power for community care lies the community care deficit falls within the scope of within its governmental subsystems such as nursing practice, nursing agency may be all that is departments of health, sanitation, recreation, and required to address the community care deficit. public safety. Such power can also be exercised by More commonly nursing partners with care agents less formal subsystems such as volunteer groups, to address the community deficits. non-profit agencies, religious groups, political The Diagnosis of Community Care Deficit groups and influential citizens and citizen groups. Instrument based on this model was developed to The individual has self-care requisites. An guide the student in defining the community extension of this construct is to think of the according to geographic and system boundaries. community as a multiperson unit which has unit The suprasystem(s) are identified, as well as the care requisites. For example, individual universal formal subsystems, which exist to maintain the self-care requisites include air, water and food. A health, functioning and integrity of the community. community requires a safe water source, pollution Community conditioning factors are free air and adequate corporate food supplies. described as well as community requisites and Other examples of community requisites are demands. From these data, an analysis is made control and regulation of communicable disease, as to whether or not requisites and demands are control of safety hazards, reduction of met or not met. From those that are not met, a preventable morbidity and premature death. formal diagnosis is derived. Following this, These requisites place demands on the students can use the program planning process to community and its subsystems; demands, which define agency requirements for addressing the must be met to maintain a functional, integrated community care deficit. Nursing agency unit. The methods and strategies to meet requirements are specified as well as the agency community care requisites are population based requirements of partners of nursing from other with restoration of population health as the goal disciplines and care systems. rather than individual care based with recovery of the individual as the goal. Community Care Deficit Nursing Model When community care demands exceed (CCDNM) Application community care agency, a deficit occurs. This To describe the teaching of the CCDNM in a deficit may be diagnosed through the routine master’s program, we will first describe the monitoring of requisites and demands by course, then course procedures and experiences community care subsystems or by a formal using the model in two clinical settings. The process of community assessment and diagnosis course is a required core course in the master’s or a combination of the two methods. The program and is designed to teach public health diagnosis of a deficit concurrently diagnoses a material according to various accreditation deficit in community care agency. For example, an criteria. It is a didactic/clinical course that builds increase in sexually transmitted disease rates on undergraduate community health concepts. among adolescents is a community care deficit Course Requirements include texts and indicating also an agency deficit for those public health resources, two papers, participation subsystems charged with the management and in classroom discourse, community assessment control of sexually transmitted diseases. When done in small clinical groups, and a formal such a deficit exists there is a need for intervention. presentation to their respective communities. Population based community care is of such a Required materials have included Orem, complex nature that nursing care agency may epidemiology reference, public health resources, require partners, e.g., other disciplines both within and Healthy People 2010. The first or second and outside the community as well as individual week of the semester students divide themselves members of the community, to address the deficit. into small groups for the clinical components. The The outcome of such intervention may result in small group determines the general population adjustments or augmentation of existing they want to work with. community care subsystems or the planning and The focus of the first of the two papers is implementation of new population-based global analysis of a population using the CCDNM. community care interventions. These interventions The second paper focuses on refinement of the are population-based programs with the goal of Community Care Deficit. Resources for the first restoring community care. paper are more generic public health than the Nursing agency may be required in the second in which students refer to information 25 about the specific community deficit. Required Up to this point the clinical component has classroom participation continues throughout the included: l) data gathering from public documents; semester. Discourse focus moves from general 2) survey of the selected communities with public health information to a later specific clinical analysis and discussion at each point using the application focus. During the semester students CCDNM; and 3) interviewing the multi-person units will have reviewed S-CDNT in general, the within their selected communities. The final clinical CCDNM, public health concepts and experience is the student feedback presentations epidemiology. Once students have begun to work to the selected communities. This is the high point with and study their selected populations they of the semester. Students use radio spots and bring these data for class discussion. flyers to invite the community to the forums. They These classroom discussions become the invite community members they have just heart of learning public health concepts within the surveyed and interviewed as well as the model. Each student brings information about a community stakeholders, and any professionals particular Community Care Requisite thinking they can prevail upon to share their expertise to her/his studied requisite is of major importance. help with problem solving. In some cases students Then, through faculty-student debate students had family members that are CPA and attorneys come to recognize that all requisites are important who participated in the forum. Also invited are to a community, but that Community Agency is the members of the class, faculty and other students. determining factor in identifying the Community Each small group selects a time of the day Deficit. Because this is an academic experience, most appropriate to its population and prepares student must also consider what is doable within a presentation media for the event. Information is semester’s time and within the realm of public shared and discussion follows. The dialogues health nursing. These discussions focus on a have resulted in eye opening experiences for the dialectic that involves concepts such as population, clients, the stakeholders and professionals. There setting, multiperson units, and communities. Taylor were often resources available that were not and Renpenning’s work provides the basis for being accessed because of lack of information. these discussions (cited in Orem, 2001). Some stakeholders expressed an interest in For example, students recently studied two continuing the dialogue. Both graduate students southwest communities: one an air force base and community members learned that nursing and another, a low-income community served by agency has an important role in the health of a a nurse practitioner clinic. With discussion of community. Teaching public health concepts community care requisites, the community care within the CCDNM enables graduate students to demands and community agencies, students see that nursing can make a positive difference to discovered that the Community Care Deficit was the health of a community. different than their initial impressions. Discussions related to the air force base Serey Shum PhD, RN, CNS is with West Texas A&M University, began with students’ thinking that the closing of Division of Nursing, Canyon, TX. Rebecca McGonigal PhD RN, is the base hospital forcing patients to use with Brenau University Dept. of Nursing, Gainesville, GA; and : community resources could be the problem. Barbara Biehler, EdD RN PNP lives in Amarillo, TX. Contact Dr. Students also reviewed one year’ retrospective Shum at [email protected] record of emergency room use and interviewed with base parents. These data demonstrated a References lack of primary care resources for pediatric Anderson, E.T. & McFarlane, J.M. (2004) Community as patients. Using the model and focusing their partner. Philadephia: Lippincott, Williams and Wilkins. literature review based on the refinement of data, Helvie, C.O. (Ed). (1998). Community health nursing theory students then looked at available resources for and practice. Thousand Oaks: Sage Publications. parenting, anticipatory guidance and emergency Orem, D.E. (2001). Nursing concepts of practice. St. Louis: care for pediatric families, thus addressing this Mosby Publishing. specific Community Care Deficit. Taylor, S.G. & McLaughlin, K (1991). Orem’s general theory of nursing and community nursing. Nursing Science In the case of the low-income clinic Quarterly 4:153-169. population, students began with a concern for the Walker, L.O. & Avant, K.C. (1995). Strategies for theory ageing population. What the model led them to construction in nursing. Norwalk: Appleton and Lange. was that their specific population’s deficit related U.S. Department of health and Human Services, Healthy to grandparents raising grandchildren. This People 2010: What are the leading indicators? Retrieved 4/16/05 from analysis led them to seeking specific resources http://healthypeople.gov/document/html/objective/14- for aging grandparents with low incomes raising 29.htm their grandchildren. 26 Teaching Strategy Column

SCDNT – Tell Me About It 7. The group answering the question correctly selects the next category and another Game Design: Violeta A. Berbiglia question is asked by the teacher.

The Game Scoring Purpose: To accomplish formative and 1. The scoreboard is posted on a blackboard, summative evaluation on concept attainment of poster, flip chart, etc. Also, the categories are the SCDNT concepts. posted separate from the scoreboard. When correct answers are given, groups receive a Game Content: The questions come directly letter (letters are given sequentially under the from classroom content (lecture, discussion, SCDNT Dorothea E. Orem.) If the answer is handouts, etc.). Only content that students have incomplete, the group will be given a part of a been exposed to in class is used for questions. letter. The following scoreboard shows that all Categories of questions are: history, concepts, 3 groups have answered questions. If groups rationales, trivia, and student-generated questions. are tied at the end of the game, ask a The teacher develops all of the questions (except complex question to break the tie. Upon the student-generated questions) prior to class completion of the game, the group with the time. most correct answers receives a prize.

Rules of the Game S C D N T D o r o t h e a E. O r e m 1. Create 2 or more groups (not over 4 to 6 per Group 1 S N group). 2. Each group selects a leader. Group 2 C D 3. Only the group leader can answer questions. Group 3 T D 4. Groups sit together at a distance from other groups. All course materials must be put Suggestions for a Fun Game Process: away. 5. Select 1 individual to assist the teacher in 1. Just after explaining the rules, ask the groups recognizing group leaders when they stand. if they have any “handicaps” (for example: no 6. Explain the rules and scoring to the groups. males in group, no females in the group, 1 7. Request each group to develop and answer less group member than in other groups, too 2 to 3 questions, write them on separate many younger (or older members), etc. If a sheets of paper, and give them to the group determines they have a handicap, teacher. award the group a letter on the scoreboard. 2. Request the groups to use their own words to Rules for Play paraphrase content – not memorized words. This gives them increased ownership of the 1. The teacher chooses the 1st category for a theory. question. 3. Include humor. 2. The teacher announces the category. 4. Refrain from criticizing individuals/groups. 3. The teacher asks a question from that 5. Don’t play the game too long. The interest category. will lag and fun decreases. 4. Groups confer within the group and agree on an answer. 5. The group leader stands, is recognized and Violeta A. Berbiglia, RN, EdD lives in Helotes, TX. Contact Dr. Berbiglia: provides the answer. [email protected] 6. If several leaders stand, they are recognized in the order of standing. If the 1st standing answers incorrectly, the next standing is recognized, etc. 27

IOS News abstract for the 9th World Congress, volunteer to serve on a committee, volunteer to help with further development of the web site, and/or From the president consider running for an office or for chairperson of a committee. Dear Members of IOS, May you all have a meaningful holiday What a year it has been. The devastation and season and a Happy New Year. suffering resulting from so many natural disasters have been overwhelming. Yet, in all the tragedy Barbara Banfield, President and sadness, there is evidence of the tremendous For your information: capability of human beings to persevere and to The composition of the Board of Directors is: strive to do good. The IOS web site has been moved. The new • Founding Members address is www.scdnt.com. There is still more • President-Banfield-term expires 12/2007 work to be done on the web site. If you have any • VP-Beth Geden-term expires 12/2006 expertise with web site development, please • Secretary-Connie Dennis-term expires consider volunteering to help with this ongoing 12/2007 work. If interested, send me an e-mail. A big • Treasurer-Connie Brooks-term expires Thank You to Gerd Bekel for his work on getting 12/2006 the new web site going. • At Large Members-Violeta Berbiglia-term At the end of this year, Michael Morgan will be expires 12/2006 stepping down as Editor of the journal. During his Kathie Renpenning-term expires 12/2007 time as editor, Dr. Morgan has contributed a great Marcel Sailer-term expires 12/2007 deal, including moving the format of the journal from print to electronic format. Thank You Dr. • Nominating Committee-Barbara Biehler-term Morgan for all the work you have done. expires 12/2006 Karen Cox has been appointed by the Board Sheila Jesek-Hale-term expires 12/2006 of Directors of IOS to serve as Editor for the Monika Lovgren-term expires 12/2006 remainder of the term, ending Dec. 2006. Please Jacqueline Fawcett-term expires 12/2007 see Dr. Cox’s announcement in this journal Jane Ransom-term expires 12/2007 regarding the submission deadlines for next year. • Program Chair-Gerd Bekel-term expires The term for office for the Board of Directors 12/2006 was changed from 4 years to 2 years in the • Public Affairs Chair-Andrea Hintze-term revised bylaws. Beginning in 2006, elections will expires 12/2006 be held yearly. The positions to be filled will • Public Relations Chair-Andrea Hintze-term alternate from year to year so that there is some expires 12/2006 continuity on the board. Think about running for • Publication Chair-Michael Morgan-stepping an office or for chairperson of one of the down 12/2005-replacement is Karen Cox- committees (see below). term expires 12/2006 th The 9 World Congress of SCDNT is • Scholarly Endeavor Chair-Margarethe scheduled for July 20-22 in Johannesburg, South Lorensen-term expires 12/2006 Africa. I encourage you all to attend. Check out the web site at www.worldcongress-scdnt.com for Mission Statement: specific details regarding the conference. Also, The mission of the International Orem Society think about submitting an abstract for the is to advance nursing science and scholarship conference. Information regarding the call for through the use of Dorothea E. abstracts can be found on the web site. Orem's nursing conceptualizations in nursing I am asking each member to take a few education, practice, and research. minutes to look at the mission statement of the IOS as well as the mission statement of the journal. The accomplishment of the IOS mission is dependent on the contributions of individual members. As you think about your New Year’s resolutions, please make a commitment to do something that helps the IOS move toward accomplishment of its mission. There are a number of ways you can contribute; submit an article for publication in the journal, submit an 28

Memorial to Dr. Margarethe Science and Scholarship celebrates the life of Margarethe and pays tribute to her contributions Lorensen, Institute of Nursing to the IOS and to the nursing profession. Science, Oslo University, Dorothea Orem recalls the early contributions of Norway Margarethe and comments: “Her research concerned women and their recovery under certain conditions. She was very active in that she Professor Margarethe Lorensen had the research instruments she developed over 1942-2005 time to study women who were hospitalized or in rehabilitation. She was an interesting woman. Professor Margarethe Lorensen died October Walene and I enjoyed our time with her in 30th 2005, at the age of 63, in her home in Washington. Walene called her ‘the statute of Denmark with her two sons beside her. liberty’.” Dr. Lorensen’s colleague, Dr. Monika Vi Berbiglia also recalls Margarethe’s stature Lovgren, expresses the loss she feels and and strong leadership qualities. She served on provides a translation of the information IOS committees and fostered the use of the concerning Margarethe’s life: SCDNT in many parts of the world. The IOS and Doctor Lorensen began her nursing career in the faculty of the Institute of Nursing Science, 1964 as registered nurse at Sonderjyske Oslo University feel a great loss. Margarethe Sygeplejeskole (Nursing College); and in 1969, continued to meet with her university colleaues she continued her nursing education at until a few days before her death. We all share a Denmark’s School of Nursing, Aarhus University. great appreciation for Dr. Margarethe Lorensen’s contributions and express our sympathy to her Margarethe’s early interest was nursing family. research. She was awarded a scholarship for studies in USA. There, she received a Masters Memorial prepared by: Drs. Monika Lovgren, Dorothea Orem, Degree of Arts in Education (Northern Arizona and Violeta Berbiglia University, 1972) and a Masters Degree in Nursing (University of Colorado, 1973). Margarethe was the first Danish nurse to complete a PhD (Arizona State University, 1976). When she returned to Denmark, she worked as Research Consultant on the Danish Nursing Council (1978). She established the Danish Council’s Nursing Research. Margarethe served as supervisor for 25 years and as the publisher of the journal for Nursing Research for 21 years. In 1983, Margarethe was appointed Vice Director for the Deaconess Foundation (Copenhagen). In 1986, she became the Director . She developed a Somatic Hospital into a Geriatric Center. This was the first time in Denmark that a PhD prepared nurse was appointed a supervisor. She used Orem’s Self- Care Deficit Nursing Theory in her practice in the care of the elderly. Dr. Lorensen was the first nurse to receive a research award in health and nursing care from the Danish Medical Research Council. The award made it possible for her to conduct her project, “Elderly and Self-Care”. From 1987 until her death, Margarethe was a Professor in Nursing Science at Oslo University. She worked very hard to define an autonomous and independent nursing science, nursing research and nursing practice. The International Orem Society for Nursing 29 Concept Formalization in Nursing reprint offer

Reprint of Concept Formalization in Nursing is now availble The IOS has supported the reprint of the 2nd edition of Concept Formalization in Nursing: Process and Product. The book was one of the most selling nursing theory books in 1979. The second edition of CONCEPT FORMALIZATION IN NURSING: PROCESS AND PRODUCT reflects the progress made till 1979. This volume refines previous conclusions and moves on to descriptions of the individual or group dynamics associated with formulation, expression, and acceptance of nursing’s conceptual structure. Orem’s general theory of nursing is used to provide the conceptual framework for research and the structuring of nursing knowledge. Research carried out by Conference members Melba Anger Malatesta, Louise Hartnett Rauckhorst, and the late Joan Backscheider is also presented. Throughout the text, drawings, tables, charts, and graphs are used to illustrate key points. The book is divided into two parts. Part I focuses on nursing as a practice discipline, explains the position of the profession in the world of human affairs, and analyzes 14 concepts of nursing. Part II delves into the Nursing Development Conference Group’s work on the structure of nursing knowledge and applies insights into the conclusions of the first edition. Two chapters explore the implications of the self- care agency. Throughout the text, the skillful integration of a substantial amount of new material serves to provide a complete update of the initial concerns. For more information visit www.scdnt.com- /pub/pub.html or for any order information contact Gerd Bekel ([email protected]). 30

New IOS Web Presentation

• The new IOS Webpage is available to the information you’d like to be presented. public. • We would like to develop two more sections • You will find new information related to S- on SCDNT Research and on International CDNT and IOS. affairs. • Please bookmark our domain and give notice • If you or your students would like to report on to your colleagues, students and friends. your current research work, please contact • You’ll find the webpage at www.scdnt.com Gerd Bekel ([email protected]). • Please Feel free to send us commends and